Teledentistry Knowledge and Attitudes: Perspectives on the role of dental hygienists

Purpose. The first statewide teledentistry (TD) Summit in North Carolina (NC) was convened by the University of North Carolina (UNC) at Chapel Hill in 2018. The purpose of this analysis is to compare Summit participants' understanding of TD, its benefits, challenges, solutions and the role of dental hygienists, pre- and post-Summit.Methods. Summit invitees included leaders in related policy, education, advocacy, legislation, technology and UNC dental hygiene and dental students. Descriptive analyses and exact McNemar's matched pair tests compared proportions of participants' responses to pre- and post-Summit surveys.Results. Response rates were pre-Summit 75.3% (n= 58) and post-Summit 70.1% (n= 47); matched pre-post survey pairs (n=42). Pre-Summit respondents reported their primary role in administration (48.0%), teaching and mentoring (21.0%), patient care (12.0%) or as a student (19.0%). Among respondents, overall self-reported TD knowledge increased from 38.1% to 92.9%, p< 0.001. Their reported extent TD should be developed in NC increased from 78.6% to 95.2%, p = 0.07; the extent hygienists should have a role in TD services increased from 83.3% to 88.1%, p = 0.73. The most frequently mentioned challenge was state practice acts requiring direct supervision of dental hygienists, limiting their TD use in community settings, which increased in the pre- to post-surveys from 33.3% to 59.5% respectively, p = 0.01.Conclusion. Among attendees at the statewide TD Summit, self-reported knowledge was high and attitudes favorable for moving forward with TD in NC. However, state dental practice act barriers restricting dental hygienist participation in TD was the first challenge respondents thought needed to be addressed.

Development of a Silver Diamine Fluoride Protocol in Safety Net Dental Settings

Purpose: In the United States, silver diamine fluoride (SDF) is a new method to arrest dental caries. Protocols for using SDF are under development as the research evolves and experience is gained with different populations and settings. The purpose of this study was to develop a comprehensive SDF protocol for young children tailored to safety net dental clinics (SNDCs).<br/> Methods: We developed the SDF protocol for SNDCs through a two-step process: (1) an expert panel of pediatric dentists reviewed, modified, and expanded existing SDF protocols including clinical, pre- and post-clinical components; and (2) the new SDF protocol was implemented in three SNDCs in North Carolina with on-site didactic training, clinical observations and discussion. We obtained feedback from SNDC dentists, staff, and administrators to further refine the SDF protocol.<br/> Results: The SDF protocol was tailored to SNDCs based on recommendations from SNDCs themselves. Suggested improvements were primarily non-clinical in nature, such as the provision of laminated SDF information with color pictures of staining in each operatory, a timer for SDF procedure, and templates for documentation, coding, and billing.<br/> Conclusion: To facilitate SDF use in SNDCs, we developed an expert-consensus protocol that incorporated the clinical experience of SNDCs that implemented the protocol. (J Dent Child 2019;86(1):32-9)<br/> Received September 17, 2018; Last Revision November 7, 2018; Accepted November 7, 2018.

Providers' preferences for pediatric oral health information in the electronic health record: a cross-sectional survey

BACKGROUND

The majority of primary care physicians support integration of children's oral health promotion and disease prevention into their practices but can experience challenges integrating oral health services into their workflow. Most electronic health records (EHRs) in primary care settings do not include oral health information for pediatric patients. Therefore, it is important to understand providers' preferences for oral health information within the EHR. The objectives of this study are to assess (1) the relative importance of various elements of pediatric oral health information for primary care providers to have in the EHR and (2) the extent to which practice and provider characteristics are associated with these information preferences.

METHODS

We surveyed a sample of primary care physicians who conducted Medicaid well-child visits in North Carolina from August - December 2013. Using descriptive statistics, we analyzed primary care physicians' oral health information preferences relative to their information preferences for traditional preventive aspects of well-child visits. Furthermore, we analyzed associations between oral health information preferences and provider- and practice-level characteristics using an ordinary least squares regression model.

RESULTS

Fewer primary care providers reported that pediatric oral health information is "very important," as compared to more traditional elements of primary care information, such as tracking immunizations. However, the majority of respondents reported some elements of oral health information as being very important. Also, we found positive associations between the percentage of well child visits in which oral health screenings and oral health referrals are performed and the reported importance of having pediatric oral health information in the EHR.

CONCLUSIONS

Incorporating oral health information into the EHR may be desirable for providers, particularly those who perform oral health screenings and dental referrals.

Changes in the intestinal bacterial community, short-chain fatty acid profile, and intestinal development of preweaned Holstein calves. 1. Effects of prebiotic supplementation depend on site and age

Digestive disorders are common during the first few weeks of life of newborn calves. Prebiotics are nondigestible but fermentable oligosaccharides that modulate growth and activity of beneficial microbial populations, which can result in enhanced gut health and function. Galactooligosaccharides (GOS) have demonstrated such prebiotic potential. In this study, the effect of GOS supplementation on intestinal bacterial community composition and fermentation profiles; intestinal health, development, and function; and growth was evaluated in dairy calves fed for high rates of growth. Eighty male Holstein calves were assigned either to a control treatment consisting of commercial milk replacer or to a GOS-rich (i.e., 3.4% of dry matter) milk replacer treatment. After 2 and 4wk, 8 calves per treatment were slaughtered at each age. Samples of intestinal digesta and tissue were collected for assessment of bacterial communities, short-chain fatty acid concentrations, in vitro measurement of nutrient transport and permeability, histomorphology, and gastrointestinal organ size. The remaining 48 calves continued to wk 8 to measure body growth, nutrient intake, and fecal and respiratory scores. Calves fed GOS displayed greater Lactobacillus and Bifidobacterium relative abundance and more developed intestinal epithelial structures, but also had greater fecal scores presumably related to greater colonic water secretion. Control calves showed slightly better growth and milk dry matter intake. Size of intestinal organs, intestinal nutrient transport, and epithelium paracellular resistance were not affected by treatment. Excessive GOS supplementation had both prebiotic and laxative effects, which led to slightly lower growth performance while promoting commensal bacteria population and greater intestinal epithelium growth.

Inhibitory Effects of Methylcellulose on Cellulose Degradation by Ruminococcus flavefaciens

Highly methylated, long-chain celluloses strongly inhibited cellulose degradation by several species of cellulolytic bacteria of ruminal origin. Specifically, the inhibitory effects of methylcellulose on the growth of Ruminococcus flavefaciens FD1 were concentration dependent, with complete inhibition at 0.1% (wt/vol). However, methylcellulose did not inhibit growth on cellobiose or cellulooligosaccharides. Mixtures of methylated cellulooligosaccharides having an average degree of polymerization of 6.7 to 9.5 inhibited cellulose degradation, but those with an average degree of polymerization of 1.0 to 4.5 did not. Similar inhibitory effects by methylcellulose and, to a lesser extent, by methyl cellulooligosaccharides were observed on cellulase activity, as measured by hydrolysis of p-nitrophenyl-beta-d-cellobioside. R. flavefaciens cultures hydrolyzed cellulooligosaccharides to cellobiose and cellotriose as final end products. Cellopentaose and cellohexaose were cleaved to these end products, but cellotetraose was also formed from cellohexaose. Methylcellulose did not inhibit hydrolysis of cellulooligosaccharides. These data are consistent with the presence of separate cellulase (beta-1,4-glucanase) and cellulodextrinase activities in R. flavefaciens.

The Relationship Between Cardiovascular Xerogenic Medication Intake and the Incidence of Crown/Root Restorations

OBJECTIVES

This retrospective, longitudinal cohort study quantified the strength of the association between xerogenic cardiovascular medication use and dental restorations, using the latter as a proxy measure for dental caries experience.

METHODS

Study data were collected from 11 years of electronic clinical/pharmacy records in two large dental group practices associated with managed care organizations (MCO). Records were extracted for all members who were at least 55 years old at the end of the 11 year window, and had at least 48 months of concurrent dental, medical, and pharmacy coverage. The authors identified 4448 individuals whose only xerogenic medication exposure was to drugs treating a cardiovascular condition. This group was compared to a group not taking any medications (n=1183), and a group taking medications with no known xerostomic side effect (n=5622). Poisson regression compared restoration incidence and mean restoration rates among the three groups.

RESULTS

MCO members taking cardiovascular or nonxerogenic medications had higher restoration incidence and mean restoration rates than individuals taking no medications. A small difference in mean restoration rate between the non-xerogenic medication group and the cardiovascular drug group was observed; no significant difference in restoration incidence was seen between these two groups.

CONCLUSIONS

This study provides objective quantification of cardiovascular medication's long-term effects on increased restorations in older adults. When grouped under a single category labeled "cardiovascular", drugs with effects targeting the cardiovascular system did not appear to unequivocally lead to higher restorative experiences.

Root Canal Filled Versus Non-Root Canal Filled Teeth: A Retrospective Comparison of Survival Times

OBJECTIVE

This matched cohort study used data from a large dental HMO in the Pacific Northwest to evaluate the degree to which pulpal involvement and subsequent endodontic therapy affects tooth survival. Root canal filled (RCF) teeth were used as an indicator of pulpal involvement. Our hypothesis was that RCF teeth would be extracted sooner than non-RCF teeth matched within subjects, controlling for tooth-level variables of interest.

METHODS

The HMO's treatment databases and a subsequent chart audit were used to identify 202 eligible subjects, each of whom had one tooth endodontically treated in 1987-88 and a similar contralateral tooth that was non-RCF at that time. Both teeth were followed from the endodontic access date through the extraction date, the endodontic access date (for initially non-RCF teeth), or 12/31/94, whichever was earliest. Time-to-event analyses were carried out, with Kaplan-Meier curves generated and multivariable marginal proportional hazards regression models fitted to describe the effect of RCF status on tooth survival. All statistical analyses accounted for the complex sampling strategy used in generating the dataset.

RESULTS

Teeth were followed for up to eight (median = 6.7) years. RCF teeth had substantially worse survival than their non-RCF counterparts (p < 0.001), with a greater effect of RCF status evident among molars than non-molars. Adjusted hazard ratios (95% confidence intervals) for loss of RCF versus non-RCF molars and non-molars were 7.4 (3.2-15.1) and 1.8 (0.7-4.6), respectively.

CONCLUSION

Though endodontic therapy can prolong tooth survival, pulpal involvement still may hasten tooth loss, underscoring the importance of caries prevention and prompt restorative care.

Use of Clinical Services Compared with Patients' Perceptions of and Satisfaction with Oral Health Status

OBJECTIVES

To examine the relationship between rates of clinical service use and self-reported perception of and satisfaction with oral health status.

METHODS

Dental services provision rates were calculated using health maintenance organization electronic data for members 55 years of age and older with at least four years of eligibility between 1990 and 2000. A mail survey yielded 986 responses (response rate = 65.7%). Poisson regression was used to examine the relationship between service utilization rates and self-reported perception of and satisfaction with oral health status, controlling for age, education, sex, and marital status.

RESULTS

Perceptions of oral health status and levels of satisfaction with oral health status generally were closely associated. Greater dissatisfaction with oral health status and perception of poorer oral health status were associated with higher usage of nonpreventive dental services. Less satisfaction with oral health status was associated with higher restorative services usage and lower preventive services usage and slightly associated with periodontal service usage. Perception of a less favorable oral health status was strongly associated with higher restorative and periodontal services usage, but had only a weak association with preventive services usage.

CONCLUSIONS

Dental plan members' service use is associated with their perception of their oral health status and their level of satisfaction with it. Future work should seek to clarify whether opinions on oral health status and satisfaction are a result of clinical experiences over time or whether the behavior and the values associated with seeking and obtaining care instead shape opinions on status and satisfaction.

Issues regarding insurance and other third-party reimbursement for behavioral management procedures

Issues related to reimbursement for time and effort expended in providing behavior management services for children often result in confusion and frustration for the parent and practitioner. Multiple medical and dental insurance plans within a state or region frequently lack a common set of definitions that are fundamental in interpreting and applying contract language. Ambiguities and inconsistencies in state and federal programs and regulatory structures, as well as budget concerns, only exacerbate the problem. This paper reviews issues of third-party payment associated with dental care for children requiring behavioral management. An environmental assessment of the health care system identifies individual and societal challenges. A model that identifies stakeholders involved in third-party reimbursement is discussed, noting the incentives faced by each stakeholder and expected behaviors based on those incentives. Strategies for effecting change based on a thorough understanding of each stakeholders' concerns are discussed.

Oral disorders and chronic systemic diseases in very old adults living in institutions

This study evaluated whether oral disorders were associated with chronic systemic diseases in 532 Canadian adults who are old and very old and living in institutions. A brief oral examination documented tooth retention, caries, and periodontal and gingival health. Medical records provided information about chronic systemic conditions. A history of stroke was associated with a higher experience of caries, a higher ratio of decayed-to-present teeth, and more gingival and periodontal problems. Participants with high blood pressure, osteoporosis, or diabetes were more likely to be edentulous or to have fewer teeth than participants who did not have these conditions. Participants who had arthritis retained more teeth with age. Participants who had more diseases also tended to have poorer gingival or periodontal conditions, fewer teeth, and higher risk of edentulousness. The associations between systemic diseases and more severe oral disorders may be direct or may be mediated by underlying factors such as health behaviors.

Making clinical decisions for dental care: concepts to consider

Clinical decisions are often made with incomplete information, yet patient care decisions are made every day. Patients vary clinically, uncertainty exists in diagnostic and prognostic information, and many preventive and treatment alternatives have not been formally assessed for their effectiveness. Because scientific information will never answer all clinical questions, clinical decisions are partially based on probabilistic information. This paper describes how to apply clinical decision making to diagnosing and managing dental caries and periodontal diseases. By using explicit information to quantify probabilities and outcomes, clinical decision making analyzes decisions made under uncertain conditions and the uncertain impact of clinical information. Clinical decision making incorporates concepts for preventing, diagnosing and treating dental caries and periodontal diseases: risk assessment, evidence-based dentistry, and multiple oral health outcomes. This information can serve as a tool for clinicians to augment clinical judgment and expertise.

Differential protein phosphorylation-dephosphorylation in response to carbon source in Ruminococcus flavefaciens FD-1

AIMS

The aims of this study were to study the effect of cellobiose or cellulose as a carbon source on the differential protein phosphorylation-dephosphorylation of cytoplasmic and membrane-associated proteins from Ruminococcus flavefaciens FD-1.

METHODS AND RESULTS

SDS-PAGE analysis was used to compare in vitro labelled proteins (32P-ATP) isolated from R. flavefaciens FD-1 grown on either cellobiose or cellulose as the carbon source. Distinctly different protein phosphorylation patterns were detected depending on carbon source and cell fraction. Analysis of the nature of the phosphorylated proteins indicates that phosphorylated proteins from cellobiose grown cultures are phosphorylated on serine residues, whereas phosphorylated proteins from cellulose grown cultures are phosphorylated on threonine residues.

CONCLUSIONS

The results of this comparative analysis show a shift from serine phosphorylation of proteins to a threonine phosphorylation when R. flavefaciens FD-1 cells are grown on cellulose as opposed to cellobiose. There appears to be a role for these phosphorylation events in sensing the carbon source for growth and regulating co-ordinated metabolism in R. flavefaciens FD-1.

SIGNIFICANCE AND IMPACT OF THE STUDY

We have demonstrated that there is a protein phosphorylation system in R. flavefaciens FD-1 that may be the primary sensing system for carbon source by R. flavefaciens FD-1 and the further regulation of gene expression related to cellulose degradation.

Expression pattern and role of a 60-kilodalton progesterone binding protein in regulating granulosa cell apoptosis: involvement of the mitogen-activated protein kinase cascade

Progesterone (P4) inhibits both granulosa cells and spontaneously immortalized granulosa cells (SIGCs) from undergoing apoptosis. P4 does so through a plasma membrane-initiated event. It appears that P4's membrane-initiated actions are mediated by a 60-kDa P4 binding protein (P4BP), which is detected by an antibody directed against the ligand binding domain of the nuclear P4 receptor (i.e., C-262). Immunohistochemical analysis revealed that a C-262-detectable protein was first observed in the periphery of a few granulosa cells within early antral-stage follicles. In nonatretic antral follicles, this protein was detected at the periphery of virtually all granulosa cells. In contrast, granulosa cells of atretic follicles lost the distinct peripheral localization of this C-262-detectable protein. This reduction in the membrane localization was also observed by Western blot analysis. To assess the temporal changes in this 60-kDa P4BP during apoptosis, studies were conducted using SIGCs. That this 60-kDa protein is important in mediating P4's action was confirmed by the observation that C-262 but not IgG attenuated P4's antiapoptotic action. Interestingly, the membrane localization of this 60-kDa P4BP was maintained but the ability of P4 to prevent apoptosis was lost within 20 min of initiating the apoptotic cascade. In addition, Erk-1 and -2 phosphorylation (i.e., activity) increased within 20 min of P4 withdrawal. Further, P4 suppressed the increase in the Erk-1 phosphorylation if administered within 5 but not 20 min of initiating the apoptotic cascade. Moreover, the mitogen-activated protein kinase kinase (MEK) inhibitor, PD98059, reduced the percentage of SIGCs undergoing apoptosis in the absence of P4. Because MEK phosphorylates Erk, these observations suggests that 1) the increase in Erk-1 activity is an important part of the apoptotic cascade, 2) P4 promotes granulosa cell viability by modulating the activity of Erk-1, and 3) P4 becomes "uncoupled" from its antiapoptotic signal transduction mechanism within 20 min of initiating apoptosis, even though the membrane localization of the 60-kDa P4BP is maintained.

On translating new biologic-based interventions into dental practice

Prudent change is a professional responsibility. Four forces will influence the incorporation of the new biology into dental practice--and their individual application in various settings will lead to a range of practice characteristics. These forces include our vision of what it means to be a professional, health consequences of the new biology, infrastructure features, and incentive structures.

A review of complementary and alternative medicine use for treating chronic facial pain

BACKGROUND

The authors compiled information on the prevalence of complementary and alternative medicine, or CAM, use, as well as on reports of randomized clinical trials of CAM modalities used to treat chronic facial pain.

TYPES OF STUDIES REVIEWED

The authors searched several databases for reports of clinical trials randomizing patients who had facial pain to a CAM intervention or to a control or comparison group. Search terms included "complementary," "alternative," "acupuncture," "biofeedback," "relaxation," "herbal," "meditation," "massage," "yoga," "chiropractic," "homeopathic" and "naturopathic."

RESULTS

Three acupuncture trials, eight biofeedback trials and three relaxation trials met the authors' inclusion criteria. Across studies, results suggested that acupuncture, biofeedback and relaxation were comparable to conservative treatment (for example, an intraoral appliance) and warranted further study. The authors did not locate any randomized clinical trials that tested the effects of homeopathy, naturopathy, chiropractic, massage, meditation, yoga or herbal remedies for chronic facial pain.

CLINICAL IMPLICATIONS

Significant gaps in the scientific knowledge base limit the accuracy with which dental professionals can guide their patients regarding CAM approaches used to treat chronic facial pain.

Membrane-initiated events account for progesterone's ability to regulate intracellular free calcium levels and inhibit rat granulosa cell mitosis

It has been proposed that the antimitogenic action of progesterone (P(4)) is mediated through a membrane receptor that has GABA(A) receptor-like characteristics. To test this hypothesis, studies were designed to compare the antimitogenic effects of P(4) with its gamma amino butyric acid(A) (GABA(A)) receptor-activating metabolite, 5alpha-pregnane-3alpha-21-diol-20-one (5alpha3alpha). These studies revealed that P(4) was more effective than 5alpha3alpha in blocking mitogen-dependent mitosis of both small granulosa cells (GCs) and spontaneously immortalized granulosa cells (SIGCs). Ligand binding studies illustrated that P(4) bound to SIGCs with an apparent dissociation constant (K(d)) of 0.32 +/- 0.09 microM, whereas 5alpha3alpha bound with an apparent K(d) of 40 +/- 19 microM. Further, the GABA(A) antagonist, bicuculline, did not attenuate P(4)'s antimitotic action in SIGCs. Finally, reverse transcriptase-polymerase chain reaction (RT-PCR) studies demonstrated that none of the 6 known alpha chains of the GABA(A) receptors to which bicuculline binds were detected in SIGCs. Taken together, these studies suggest that P(4) does not mediate its action via a GABA(A)-like receptor. Additional studies revealed that P(4) regulated intracellular free calcium levels ([Ca(2+)](i)) as part of its antimitotic action. Specifically, P(4) maintained a basal [Ca(2+)](i) level that was slightly lower than normal. Increasing extracellular calcium not only increased basal [Ca(2+)](i) but also attenuated P(4)'s antimitogenic effect. P(4)'s actions appeared to be initiated at the membrane, since horseradish peroxidase conjugated-P(4) (HP-P(4)), which is cell impermeable, was as effective in blocking mitosis as P(4). Progesterone receptor (PR) mRNA was not detected in SIGCs by RT-PCR analysis, which is consistent with the findings in GCs. However, a 60-kDa protein was detected within crude membrane fractions of both GCs and SIGCs using an antibody directed against the ligand binding domain of the PR (C-262). This antibody was also used in immunocytochemical studies to detect a protein that was associated with the plasma membrane of SIGCs. It is proposed that this 60-kDa protein mediates P(4)'s membrane-initiated actions.

Development, validation, and application of PCR primers for detection of tetracycline efflux genes of gram-negative bacteria

Phylogenetic analysis of tetracycline resistance genes, which confer resistance due to the efflux of tetracycline from the cell catalyzed by drug:H(+) antiport and share a common structure with 12 transmembrane segments (12-TMS), suggested the monophyletic origin of these genes. With a high degree of confidence, this tet subcluster unifies 11 genes encoding tet efflux pumps and includes tet(A), tet(B), tet(C), tet(D), tet(E), tet(G), tet(H), tet(J), tet(Y), tet(Z), and tet(30). Phylogeny-aided alignments were used to design a set of PCR primers for detection, retrieval, and sequence analysis of the corresponding gene fragments from a variety of bacterial and environmental sources. After rigorous validation with the characterized control tet templates, this primer set was used to determine the genotype of the corresponding tetracycline resistance genes in total DNA of swine feed and feces and in the lagoons and groundwater underlying two large swine production facilities known to be impacted by waste seepage. The compounded tet fingerprint of animal feed was found to be tetCDEHZ, while the corresponding fingerprint of total intestinal microbiota was tetBCGHYZ. Interestingly, the tet fingerprints in geographically distant waste lagoons were identical (tetBCEHYZ) and were similar to the fecal fingerprint at the third location mentioned above. Despite the sporadic detection of chlortetracycline in waste lagoons, no auxiliary diversity of tet genes in comparison with the fecal diversity could be detected, suggesting that the tet pool is generated mainly in the gut of tetracycline-fed animals, with a negligible contribution from selection imposed by tetracycline that is released into the environment. The tet efflux genes were found to be percolating into the underlying groundwater and could be detected as far as 250 m downstream from the lagoons. With yet another family of tet genes, this study confirmed our earlier findings that the antibiotic resistance gene pool generated in animal production systems may be mobile and persistent in the environment with the potential to enter the food chain.

Relationship of clinical depression to periodontal treatment outcome

BACKGROUND

Depression has been associated with periodontal disease; however, its relationship to periodontal treatment outcome (PTO) has not been investigated.

METHODS

Data were obtained by chart abstraction and computer databases on 1,299 health maintenance organization (HMO) patients aged 30 to 64 who had concurrent medical, dental, and pharmacy benefits, and who had an initial periodontal examination during 1996, 1997, or 1998. Depression (yes/no) was the main independent variable and was determined by presence of any diagnosis code for depression on the patient record. PTO was determined by the difference in percent of sites with probing depth (PD) > or = 5 mm between the initial and 1-year post-treatment periodontal exams. Sub-median periodontal treatment outcome (SMPTO) was defined as a reduction in fewer than the median percent of sites (7.33%) with PD > or = 5 mm. Information on sociodemographics, periodontal therapy, calculus and plaque, number of remaining teeth, smoking, antidepressant medications, and diabetes were collected.

RESULTS

A total of 697 patients had a periodontal exam at both baseline and follow-up. Of these, 12.2% had depression. In a multivariable logistic model, depression (odds ratio [OR] 2.16, 95% confidence interval [Cl] 1.12 to 4.16) and 4-month recall treatment (OR 2.34, Cl 1.46 to 3.75) were associated with SMPTO, while percent of sites at baseline with PD > or = 5 mm (OR 0.93, Cl 0.91 to 0.94), number of remaining teeth at baseline (OR 0.94, Cl 0.89 to 0.99), and number of teeth lost during the study period (OR 0.75, Cl 0.58 to 0.96) were negatively associated. Periodontal surgery, age, gender, smoking, plaque, calculus, diabetes, and antidepressant medication were not significant in the model.

CONCLUSION

Clinical depression may have a negative effect on periodontal treatment outcome in this group model HMO population.

Movement of teeth adjacent to posterior bounded edentulous spaces

Bounded edentulous spaces (BES)-a missing posterior tooth with intact adjacent teeth-are thought to lead to arch collapse resulting from the movement of adjacent teeth. To determine the rate of change in distance between teeth adjacent to a BES, we examined three successive measurable radiographs of 116 untreated posterior BES cases. The distance between the teeth (DBT) adjacent to the space was measured, and change in DBT (delta DBT) between pre-extraction and follow-up radiographs was calculated. We used linear spline regression to construct models for tooth movement and to identify factors associated with delta DBT. The mean delta DBT was < 1 mm during the first year post-extraction, and the DBT continued to decrease at a successively slower rate each following year. Overall and for each tooth type, the greatest rates of decrease in DBT were seen in the zero to two-year period. In a multivariable model, time since extraction and tooth type were significantly associated with delta DBT. These findings suggest that movement of teeth adjacent to a posterior BES after the first two years is usually gradual and minor within the time frame of this study.

Clinical decision-making for dental caries management

Scientific information on diagnosis, prevention, and management of dental caries and associated indicators of risk continues to increase rapidly. Patients vary in clinically important ways, however, and uncertainty affects our understanding of risk; diagnostic and prognostic information; efficacy and effectiveness of many preventive, diagnostic, and treatment alternatives; and outcomes associated with clinical strategies. Consequently, challenges abound for clinicians to identify, evaluate, and incorporate new information, patient preferences, and uncertainties into clinical practice. Clinical decision-making--an analytical approach that makes explicit use of information to quantify probabilities and outcomes to analyze decisions under conditions of uncertainty--can provide a framework to analyze the impact of uncertainty of clinical information. Diagnostic, effectiveness, and outcome information is quantified and combined in an explicit way to serve as a tool for clinicians, not as a replacement for clinical judgment or experience. Such an approach has the potential to improve clinical practice and help dentists do their jobs better by structuring the decision problem and assessing probabilities and utilities. Clinical decision-making also helps dentists communicate with each other by identifying clinical controversies, thereby characterizing how and why disagreements may arise and what additional data may be needed to address a clinical question.

State of the evidence base for medically necessary oral health care

OBJECTIVE

The purpose of this article was to highlight the recent call for an evidence-based approach to public policy decision making with respect to funding dental services and the need this creates for enhanced clinical research activities.

STUDY DESIGN

Systematic reviews on topics of importance to oral health care practitioners are being conducted and published by various national and international groups. Recent activities to assess evidence to support medically necessary dental services were reviewed.

RESULTS

An Institute of Medicine Committee on Medicare Coverage Extensions found little published scientific evidence that directly assessed the effectiveness of dental services in preventing or managing systemic health outcomes for patients with head and neck cancer, lymphoma, leukemia, organ transplantation, and heart valve repair or replacement.

CONCLUSIONS

The scientific community must strive to meet the challenge of conducting well-designed randomized, controlled trials that test the impact of dental treatment interventions on systemic health to meet the growing need for evidence to support or refute widely accepted dental treatment protocols for medically complex patients.

Extending Medicare coverage to medically necessary dental care

BACKGROUND

Periodically, Congress considers expanding Medicare coverage to include some currently excluded health care services. In 1999 and 2000, an Institute of Medicine committee studied the issues related to coverage for certain services, including "medically necessary dental services."

METHODS

The committee conducted a literature search for dental care studies in five areas: head and neck cancer, leukemia, lymphoma, organ transplantation, and heart valve repair or replacement. The committee examined evidence to support Medicare coverage for dental services related to these conditions and estimated the cost to Medicare of such coverage.

RESULTS

Evidence supported Medicare coverage for preventive dental care before jaw radiation therapy for head or neck cancer and coverage for treatment to prevent or eliminate acute oral infections for patients with leukemia before chemotherapy. Insufficient evidence supported dental coverage for patients with lymphoma or organ transplants and for patients who had undergone heart valve repair or replacement.

CONCLUSIONS

The committee suggested that Congress update statutory language to permit Medicare coverage of effective dental services needed in conjunction with surgery, chemotherapy, radiation therapy or pharmacological treatment for life-threatening medical conditions.

PRACTICE IMPLICATIONS

Dental care is important for members of all age groups. More direct, research-based evidence on the efficacy of medically necessary dental care is needed both to guide treatment and to support Medicare payment policy.

Identification of patterns of transmission of Salmonella within swine production systems using pulsed field gel electrophoresis (PFGE) and repetitive sequence polymerase chain reaction (REP-PCR): a quantitative analysis

Pulsed field gel electrophoresis (PFGE) using 3 enzymes (Spe I, Xba I, Avr II) and repetitive sequence polymerase chain reaction (REP-PCR) with 3 primers (BOX, ERIC, REP) were compared with respect to their validity as a method for identifying transmission of Salmonella on swine farms. Sixty-eight isolates of Salmonella were obtained from feces of swine, cats, mice, and birds, insect body parts, water and floor samples, and boot scrapings collected on 9 swine farms in Illinois USA. Genetic distances between isolates were calculated using the Dice matching coefficient. Cluster analysis of distance matrices was conducted using the UPG-MA algorithm. There was no significant difference between PFGE and REP-PCR in the genetic diversity detected; however, REP-PCR differentiated between 14 pairs of isolates which PFGE identified as identical. There were no significant differences between PFGE and REP-PCR in identifying all or most close genetic links as isolates from the same farm, the same building, and from the same sampling visit, suggesting ecological validity for both methods. Thus, REP-PCR should be considered as an acceptable and perhaps preferable alternative to PFGE as a genotyping method for studies of Salmonella transmission.

Clinical factors related to noncompletion of root canal therapy

OBJECTIVES

This study identified clinical factors related to noncompletion of root canal therapy (RCT) among patients in a dental health maintenance organization (HMO) based in Portland, OR.

METHODS

A secondary analysis of a case-control study was conducted using data from 303 individuals enrolled continuously in the HMO from January 1, 1987, through December 31, 1994, who received endodontic access on a permanent nonwisdom tooth in 1987 or 1988. Person- and tooth-level characteristics were evaluated to compare patients whose accessed tooth was obturated by December 31, 1994, with patients whose accessed tooth was not obturated by that date. Written and electronic records were reviewed to ascertain study variables, and multivariate logistic regression models were developed to describe differences between the two groups.

RESULTS

Incomplete RCT was more common among patients who were symptomatic prior to access and had more missing first molars at access. It also was more common among teeth that were decayed, had more pockets > or = 5 mm, and had fewer decayed or filled surfaces at access.

CONCLUSIONS

Because patients with greater evidence of past and current oral disease were less likely to have completed RCT, they may require additional counseling about the importance of carrying through with prescribed treatment.

Health care utilization and cost among health maintenance organization members with temporomandibular disorders

AIMS

Little has been reported on the use of health care services and consequent costs among persons with temporomandibular disorders (TMD). This project compared the use and cost of medical and dental care services for TMD patients and matched comparison subjects.

METHODS

Patients were continuously enrolled members of Kaiser Permanente Northwest Division who had at least 1 TMD Clinic visit or TMD-related procedure between January 1990 and December 1995 (n = 8,801). An equal number of comparison subjects were identified electronically and matched on 14 variables, including age and gender. Utilization and cost estimates were determined and compared for selected medical and dental services.

RESULTS

For both groups, the mean age was about 40.5 years, and approximately 80% were female. The TMD subjects used significantly more services than did comparison subjects and had mean costs that were 1.6 times higher for all services. Outpatient visits accounted for about 40% of the difference in mean costs. About 10% of TMD subjects and comparison subjects accounted for about 40% and 47% of the costs in each group, respectively. Female TMD subjects and comparison subjects had higher costs than their male counterparts, and male TMD subjects had higher costs than female comparison subjects.

CONCLUSION

Patients with TMD used more of all types of services and had higher costs. A small proportion of the subjects accounted for a large proportion of the costs. Gender was an important factor in utilization and cost. Utilization and cost differences were consistent over a wide range of service categories and could not be explained by TMD alone.

Characterization of a putative membrane receptor for progesterone in rat granulosa cells

Progesterone (P(4)) inhibits granulosa cell apoptosis in a steroid-specific, dose-dependent manner, but these cells do not express the classic nuclear P(4) receptor. It has been proposed that P(4) mediates its action through a 60-kDa protein that functions as a membrane receptor. The present studies were designed to determine the P(4) binding characteristics of this protein. Western blot analysis using an antibody that recognizes the P(4) binding site of the nuclear P(4) receptor (C-262) confirmed that the 60-kDa protein was localized to the plasma membrane of both granulosa cells and spontaneously immortalized granulosa cells (SIGCs). To determine whether this protein binds P(4), proteins were immunoprecipitated with the C-262 antibody, electrophoresed, transferred to nitrocellulose, and probed with a horseradish peroxidase-labeled P(4) in the presence or absence of nonlabeled P(4). This study demonstrated that the 60-kDa protein specifically binds P(4). Scatchard plot analysis revealed that (3)H-P(4) binds to a single site (i.e., single protein), which is relatively abundant (200 pmol/mg) with a K(d) of 360 nM. (3)H-P(4) binding was not reduced by dexamethasone, mifepristone (RU 486), or onapristone (ZK98299). Further studies with SIGCs showed that P(4) inhibited apoptosis and mitogen-activated protein kinase kinase (MEK) activity, and maintained calcium homeostasis. These studies taken together support the concept that the 60-kDa P(4) binding protein functions as a low-affinity, high-capacity membrane receptor for P(4).

Ten-year survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces

STATEMENT OF PROBLEM

Failure to replace a single missing posterior tooth may lead to a variety of dental problems, which may ultimately result in tooth loss. However, little is known about the fate of the adjacent teeth if a missing posterior tooth is not replaced.

PURPOSE

This retrospective study evaluated the survival of teeth adjacent to treated and untreated posterior bounded edentulous spaces.

MATERIAL AND METHODS

Data were obtained from electronic treatment records from the Kaiser Permanente Dental Care Program, Portland, Ore. A final sample of 317 patients who met the study inclusion criteria was identified. Each bounded edentulous space was placed in 1 of 3 treatment categories: untreated, restored with a fixed partial denture, or restored with a removable partial denture. Subsequent treatment and the status of the teeth adjacent to the bounded edentulous space were followed through December 1999. Ten-year Kaplan-Meier survival estimates were generated for each treatment group, and differences in survival were evaluated with the log-rank chi-square test (alpha=.05).

RESULTS

There was a significant difference in survival among the 3 treatment categories (P=.005). Spaces restored with a fixed partial denture had longer 10-year survival estimates (92%) than those that remained untreated (81%). Spaces restored with a removable partial denture had the poorest 10-year survival rate (56%).

CONCLUSION

Under the conditions and selection bias associated with this retrospective study, the survival of teeth adjacent to a single posterior edentulous space was negatively associated with removable partial denture placement compared with no treatment or the use of a fixed partial denture.

Characterization of two novel saccharolytic, anaerobic thermophiles, Thermoanaerobacterium polysaccharolyticum sp. nov. and Thermoanaerobacterium zeae sp. nov., and emendation of the genus Thermoanaerobacterium

Two anaerobic, thermophilic, Gram-positive, non-spore forming bacteria with an array of polysaccharide-degrading enzymes were isolated from the leachate of a waste pile from a canning factory in Hoopeston, East Central Illinois, USA. The results of 16S rDNA sequence homology indicated that their closest relatives belong to the saccharolytic, thermophilic and anaerobic genera of Thermoanaerobacterium and Thermoanaerobacter. Although, the evolutionary distances between these bacteria and their closest relatives are greater than 11%, there is no defining phenotypic characteristic for the creation of a new genus. It is proposed that these bacteria should be placed in the genus Thermoanaerobacterium, which requires emendment of the genus description with regard to the reduction of thiosulfate to sulfur, because neither isolate is capable of this reduction. Thermoanaerobacterium polysaccharolyticum reduces thiosulfate to sulfide, whereas Thermoanaerobacterium zeae is unable to reduce thiosulfate. The cells of both isolates are rod-shaped and exist as single cells or sometimes in pairs. Cells are motile by means of flagella. Growth occurs between 45 and 72 degrees C, with optimum temperature of 65-68 degrees C at pH 6.8. The pH range for growth is from 4 to 8 at a temperature of 65 degrees C. Both organisms ferment glucose, arabinose, maltose, mannose, rhamnose, sucrose, trehalose, xylose, cellobiose, raffinose, melibiose and melezitose. The major end products of fermentation with glucose are ethanol and CO2, with lesser amounts of acetate, formate, lactate and hydrogen. The DNA G+C contents of Thermoanaerobacterium polysaccharolyticum sp. nov. and Thermoanaerobacterium zeae sp. nov. are 46 and 42 mol%, respectively. The type strains are KMTHCJT (= ATCC BAA-17T = DSM 13641T) and mel2T (= ATCC BAA-16T = DSM 13642T), respectively.

Identification of adult populations at high risk for dental caries using a computerized database and patient records: a pilot project

OBJECTIVES

The purpose of this study is to test the usefulness of dental insurance claims history, supplemented with radiographic caries diagnoses, as a means of identifying caries-active and caries-inactive working adults, as determined by bacterial levels. Computerized identification of at-risk groups may facilitate subject selection for clinical trials designed to test caries-preventive strategies.

METHODS

Two groups of subjects were initially selected from an insurance database based upon their dental service utilization during a one-year period: a "low restorative" group of individuals defined as persons who had received no restorative treatment, and a "high restorative" group comprised of individuals who had received at least three multisurfaced restorations. A chart review confirmed a diagnosis of caries in the high restorative group and an absence of caries in the low restorative group. Subjects were then approached for saliva collection. The low and high restorative groups were compared for salivary mutans streptococci and lactobacilli levels, stimulated flow rate, and buffer capacity (n = 48).

RESULTS

The high and low restorative groups differed in mutans streptococci levels, but not on other measures.

CONCLUSIONS

A group of subjects who had recently received multisurfaced restorations that were placed for reasons of caries had significantly higher levels of mutans streptococci and potential for continued caries activity when compared to a group of subjects who had received no restorations and were caries free.

The dentogingival epithelial surface area revisited

Recent studies implicating periodontitis as a cause of systemic diseases have reported that the surface area of periodontal pockets exposed to bacterial biofilm ranges from 50 cm2 to 200 cm2. Since the root surface area of the typical human dentition (excluding 3rd molars) is 75 cm2, these estimates appear too large. The goal of this study was to relate linear periodontal probing measurements to the dentogingival surface area (DGES). The DGES comprises both the sulcular and junctional epithelium, present in health, as well as any intervening pocket epithelium present in periodontitis. Formulas to estimate the DGES from clinical measures were derived from a meta-analysis of root surface areas, published values of root length, and a study that related the percent remaining root surface area to the percent remaining root length. These formulas were applied to a survey of the adult US population, the Veterans Affairs (VA) Dental Longitudinal Study, and a population of individuals visiting a periodontist. Individuals without periodontitis had a typical DGES of 5 cm2. Among individuals with periodontitis, the mean DGES in the three samples ranged from 8 cm2 (ranging from 1 cm2 to 29 cm2) to 20 cm2 (ranging from 2 cm2 to 44 cm2). It was concluded that the mean DGES among individuals with periodontitis ranges from 8 cm2 to 20 cm2, considerably smaller than the range of 50 cm2 to 200 cm2 currently assumed.

The consequences of not replacing a missing posterior tooth

BACKGROUND

Failure to replace a missing posterior tooth is assumed to result in host of adverse consequences, which include shifting of teeth and loss of alveolar bone support.

METHODS

A retrospective longitudinal study (median follow-up period 6.9 years), using the radiographs of 111 patients who had an untreated bounded edentulous space, or BES, was conducted to determine the extent to which these adverse outcomes occurred.

RESULTS

The majority of patients lost 1 millimeter or less of the distance between teeth adjacent to the space, extrusion of the opposing tooth was < or = 1 mm in 99 percent of the cases, and the amount of alveolar bone loss next to the adjacent teeth was < or = 1 mm in 83 percent of the cases.

CONCLUSIONS

Within the follow-up time in this study, this group of patients did not exhibit the expected adverse consequences with either the frequency or severity generally assumed to be associated with nonreplacement of a single posterior tooth.

CLINICAL IMPLICATIONS

These findings suggest that for the large majority of patients who experience a single-tooth posterior BES, immediate treatment may not be critical to the maintenance of arch stability. Instead, regular follow-up assessments to monitor change in stability and periodontal health may be warranted.

Non-surgical periodontal therapy and tooth loss. A cohort study

BACKGROUND

No reliable evidence is available regarding the effect of periodontal therapy on major disease endpoints such as tooth loss, edentulism, or quality of life. The primary objective of this study was to assess the association between tooth loss and the non-surgical periodontal treatment history of 1,021 members of the Kaiser Permanente Dental Care Program.

METHODS

Tooth loss rates were estimated using Poisson regression models, adjusting for some of the potentially confounding variables such as initial disease severity and extent.

RESULTS

Continuous non-surgical therapy (one or more non-surgical procedures performed during 3 successive years), as opposed to no therapy during such a 3-year period, reduced the subsequent tooth mortality rate by 58% (relative rate, 0.42; 95% confidence interval, 0.29-0.61). Intermittent non-surgical therapy reduced the tooth mortality rate by 48% (RR = 0.52; 95% confidence interval, 0.34-0.80). As the number of non-surgical procedures increased, tooth loss rates decreased.

CONCLUSIONS

These findings suggest that non-surgical periodontal therapy may be associated with a substantial reduction in tooth mortality. Different study designs and populations are needed to confirm these findings.

Development of effectiveness of care and use of services measures for dental care plans

OBJECTIVES

Standardized measures to assess clinical aspects of the performance of managed dental care plans are not available. This project sought to develop and evaluate measures for effectiveness of care and use of services that could be calculated using a plan's administrative data.

METHODS

Two panels of stake holders representing dental plans, purchasers, and dental providers participated in a modified Delphi process to refine initial sets of effectiveness of care and use of services measures modeled after HEDIS measures for medical care. The refined measures were then pilot tested in two dental health maintenance organizations.

RESULTS

The development process resulted in specification of seven effectiveness of care measures assessing disease activity classification, and prevention and outcomes for caries, periodontal disease, and tooth loss. Six use of services measures focusing on prophylaxes, third molar surgery, preventive, restorative, prosthetic, surgical, and endodontic care also were specified. Pilot testing of the measures indicated reasonable reliability and sensitivity, but also demonstrated the need for supervision or auditing of the process.

CONCLUSIONS

These standardized measures for dental care plan performance are available for immediate use. However, because the measures depend on diagnostic information (periodontal probing data and diagnoses associated with restorative treatments) in the administrative data set, their adoption will require changes in most plans' data systems and data collection policies.