Members of NNOHA's Membership Services Committee have volunteered their time to review articles and studies that may be valuable to safety-net oral health programs. The reviews are listed below. The heading refers to the date of the review and not necessarily when the article was published. If you would like to submit a review for placement in our resources, or are interested in becoming part of the Membership Resources Committee, please send an E-mail to info@nnoha.org. Please note that some of the full articles require subscriptions or payment to view.
April 2012
Preventing Dental Caries Through School-Based Sealant Programs, Updated Recommendations and Reviews of Evidence
Barbara Gooch, DMD, MPH, et al.
Systematic reviews are the highest form of evidence we have. The question of the effectiveness of sealants has been well documented. The main issue is whether the efficacy of the sealant is negatively affected when the placement is not in a traditional setting, such as a school, WIC, YMCA camp, etc. This review is not new, but as school based programs are expanding, their findings remain relevant to the decisions dentists are faced with when treating populations with high caries rates. The utilization rates among Medicaid children and the increasing demand on safety-net dental clinics continue to point to the fact that getting children in for restorative care may not be an adequate intervention to slow the epidemic of dental caries. This review shows School-Based Sealant Programs (SBSP) are an excellent intervention.
This review should be read by anyone utilizing or considering establishing a SBSP. The question may become, why are sealants not being placed in all of our schools?
Effectiveness of Preventive Dental Treatments by Physicians for Young Medicaid Enrollees
Bhavna T. Pahel, BDS, MPH, PhD, et al.
There is an increasing number of models involving medical based practitioners applying cariostatic modalities, such as fluoride varnish to young children at well child checks. There is very little evidence and very few reports which measure the effectiveness of reducing dental caries with these alternative models of early oral health interventions. This is not to say they are not effective; simply, there are few studies measuring the outcomes.
The “Into The Mouth of Babes” (IMB) program in North Carolina started in 2000. This study reports on the efficacy of the North Carolina program from 2000 to 2006. The study revealed that the results were dose dependent. The child had to receive at least 4 doses of fluoride varnish by 36 months to see a reduction in caries related treatment up to 6 years of age. When the child did receive this minimal dose, there was a 17% reduction in caries related treatment.
This study has implications to community health center providers due to the high risk and resulting high caries rate of the populations they serve. The health center dentist should look at models that incorporate methods of applying fluoride varnish on very young children. The model the dentist develops should target minimally 4 to 6 varnish applications by the child’s third birthday for maximum effectiveness.
Development and validation of a measure of pediatric oral health-related quality of life: POQL
Noelle L. Huntington, PhD; Dante Spetter, PhD; Judith A. Jones, DDS; et al
The authors adapted the measure of Pediatric Oral Health-related Quality of Life (POQL) measures to pediatric populations. The POQL was tested for reliability and validity in diverse populations. The children were placed into three categories by age: preschool, school age, and pre-teen. Both the child and their parents to compare the results for consistency answered the initial 20-item assessment. The POQL was tested with a variety of statistical analysis and found to be both valid and reliable. The POQL measured physical results of oral health disease with questions in areas such as pain, ability to chew and if the child cried from any thing associated with their mouth or surrounding areas. It also focuses on social and emotional scales with measures around smiling, laughing, worrying about being attractive and if they are unhappy with their looks. The POQL has potential utility for both clinical assessments and large-scale population studies. The POQL could be useful to dentists practicing in safety-net clinics to gain a better understanding of the ramifications of oral health diseases on their specific patient populations. The POQL could also be useful when seeking support for their dental program.
Supplemental fluoride use for moderate and high caries risk adults: A systematic review
Gretchen Gibson, DDS, MPH; M. Marianne Jurasic, DMD, Carolyn J. Wheeler, RDH, MPH; Judith A. Jones, DDS, MPH, CScD
Multiple systematic reviews have evaluated fluorides for caries prevention in children, but few, if any, exist reviewing the literature regarding supplemental fluoride in adults. An electronic search of the literature produced 305 articles in English and foreign languages. These 305 articles were reviewed at the abstract and study design level. A full text review was completed on 98 articles. The final inclusion criteria resulted in 17 articles being reviewed and their findings used in this article. All of the data demonstrated that the use of supplemental and professionally applied fluoride in moderate and high caries risk adults is effective in preventing and/or remineralizing dental caries. Low dose daily NaF rinses had the most generalized results for adults at risk for caries. The results showed NaF varnish to have a positive effect in controlling root caries. The number of participants in the varnish studies is still relatively low. More studies demonstrating the effectiveness of varnish in adults is needed. This article could be useful to ant Community Health Center oral health provider who is struggling to find prevention interventions for their adult populations. This article could be applied in the establishment of clinical protocols used in their clinic as well as advocating for varnish being included as a third party benefit for adults at risk for dental caries.
Caries preventive effects of xylitol based candies and lozenges: a systematic review.
Andrea Goncalves Antonio PhD, Vivian Santos da Silva Pierro MSD, Lucianne Pople Maia PhD
The article strives to see if xylitol is effective in decay prevention without the mechanical benefit of chewing gum. The question concerning gum is: how much of the benefit is derived from saliva stimulation and its buffering capacity. The approach was through systematic review of the existing literature. Only randomized clinic trials or clinical controlled trails of at least one year were included in this review. The challenge with this study is the examiners only included three studies in their review. Their findings are xylitol is effective in reducing the rate of caries with out the benefit of chewing gum. The benefit was less significant on the proximal tooth surfaces. As with chewing, adequate amounts of gum compliance is also an issue with the candies and lozenges. To be optimally effective 6g or more of the xylitol needed to be used per day. This is significant in the safety net due to the high caries rate seen in the patient populations served by health centers. It is unfortunate but three studies are inadequate to draw major conclusions.
Topical fluoride as a cause of dental fluorosis in children
Wong MCM, Glenny AM, Tsang BWK, Lo ECM, Worthington HV, Marinho VCC
Strong evidence exists to support the use of toothpaste containing fluoride can prevent dental caries in both adults and children. Twenty-five studies were reviewed to determine the significance and prevalence of fluorosis or tooth mottling of the permanent teeth due to swallowing when toothpaste with fluoride was utilized on young children with developing teeth. The review showed the risk of fluorosis is much higher and more common when the fluoride in the toothpaste was equal to or higher than 1000ppm. The higher risk and prevalence of change in the permanent teeth was also related to when the toothpaste was first used. Higher fluorosis occurred when the toothpaste was utilized prior to 12 months and it dramatically reduced if the toothpaste was introduced after 24 months. The evidence supporting the increased association of mottling with use prior to 12 months is weak and unreliable. The studies had no definitive data related to the amount of toothpaste being used on the brush. They failed to quantify a pea-sized amount, or a rice-sized amount of toothpaste with the presence or absence of fluorosis. The frequency of brushing was not a factor in the development of fluorosis. The participants in all of the selected studies brushed a minimum of once per day, but the frequency over 7 times per week was not accounted for in most of the studies. The authors concluded in children considered to be at high risk for tooth decay the benefit to health of preventing decay may outweigh the risk of fluorosis. This article is important to any dentist working with populations at high risk for dental caries. It is a helpful article in determining when the benefit is worth the risk.
The Seventh Element of Quality: The Doctor-Patient Relationship
MendozaM.D., Smith S.G., Eder M., Hickner J.
Though National experts have defined the elements of quality health care, community-based physicians have not been systematically asked their opinions on quality. This study explored primary care clinicians’ beliefs about the elements of quality of care. Structured interviews were conducted with twelve primary care clinicians and open-ended comments in a subsequent survey of 85 clinicians, all employed by a large urban federally qualified community health center. Their responses constituted the study’s data. Responses were coded independently by two researchers and analyzed for major themes.
After it was discovered that the themes resembled the six elements advanced by the Institute of Medicine (effective, patient-centered, timely, efficient, equitable, and safe), the data were recoded to identify additional perceptions about quality. Findings included that clinicians believed that the relationship with patients is a core element of quality healthcare. They also reconfirmed the elements of quality advanced by the Institute of Medicine. The clinicians also emphasized the importance of focusing on preventive care. The authors concluded that while primary care clinicians’ beliefs about quality are generally consistent with experts’ definitions, i.e., the Institute of Medicine report, they also emphasize relationships and rarely mention safety.
Successful efforts to promote quality in primary care should be consistent with clinician’s beliefs about what constitutes high quality. For the most part, “quality” has been defined in primary care as compliance with a number of care processes, mostly focusing on prevention and care of chronic diseases. Primary care clinicians’ level of agreement with quality indicators, and the clinical guidelines that incorporate these indicators, is highly variable. Experts and national quality organizations have promulgated definitions of quality with little input from primary care physicians and other clinicians who provide day-to-day patient care. One study of hospital-based physicians and nurses found their perceptions of quality bore little resemblance to experts’ definitions. Other work focusing on palliative care clinicians in acute care settings and nurses show little agreement on what constitutes quality in these settings. The authors concluded that primary clinicians, who are far removed from the level of national policy, identify many of the same elements of quality as the experts who formulate national health care policy. Importantly, these clinicians place greater emphasis on relationship, a feature of quality that is highly valued in primary care yet not reported among the six characteristics of high quality identified by the Institute of Medicine in 2001.
Towards Building the Oral Health Care Workforce: Who Are the New Dental Therapists?
Blue C.M., and Lopez, N.
This paper looks at the Minnesota Experience. In 2009, Minnesota’s governor signed into law a bill approving the creation of a new dental team member: the dental therapist. The intent of the legislation was to address oral health disparities by creating a dental professional who would expand access to dental care in Minnesota.
The study aimed to describe the characteristics of the first class of dental therapy students at the University of Minnesota’s School of Dentistry and to ascertain the values and motivations that led them to choose a career in dental therapy. Four surveys were used to create the composite profile of the ten students in this first dental therapy class: 1) The California Critical Thinking Skills Test, 2) The Learning Type Measure, 3) The Attitudes Towards Healthcare Survey, and 4) The Values and Motivations survey that included demographic data.
The results of the surveys revealed interacting influences of the students’ background, personal self-concept, and environment leading to a career decision to pursue dental therapy. What is not mentioned is that the University of Minnesota’s program was created in response to the development of an oral health therapist program by Normandale Community College and Metro State University. That program is training hygienists with additional clinical skills so that they will resemble medical nurse practitioners.
Evaluation of Knowledge, Attitudes, and Self-Reported Behaviors Among 3-5 Year Old School Children Using an Oral Health and Nutrition Intervention
Grant J.S., Kotch J.B., Quinonez R.B., Kerr J., and Roberts M.W.
Ninety 3-5 year old children, 43 in the control group and 47 in the intervention group, participated in this study. An age and developmental appropriate prop-based oral health and nutrition intervention program was used. Subjects in the intervention group received a pre-test, an 8-10 minute prop-supported intervention followed by an immediate post-test. The same test was repeated two weeks later. The control group received a pre-test and post-test two weeks later but no intervention. The intervention improved scores in the immediate post-test but these improvements were not sustained two weeks later. The only positive relationship found for the entire group between pre- and two week post-test scores was for oral health knowledge. There were no significant findings when adjusted for race, intervention type or group. The authors concluded that changing oral health and nutrition knowledge, attitudes and behavior may require intense and repetitive interventions to have a significant change in this age cohort.
Performance of Atraumatic Restorative Treatment (ART) depending on operator-experience
Rainer A. Jordan, Peter Gaengler, Ljubisa Markovic and Stefan Zimmer
The purpose of this prospective observational study, conducted in Africa, was to evaluate the performance of atraumatic restorative treatment (ART) in comparing those placed by supervised trainees, Community Oral Health Workers (COHW), and dentists. A year later, no clinically significant differences were detected on evaluation by a blinded examiner between restorations placed by the COHW and dentists. Value to safety-net oral health programs: In the US, ART is considered an interim therapeutic restoration (ITR). According to the American Academy of Pediatric Dentistry policy on ITR, the procedure “may be used to restore and prevent further decalcification and caries in young patients, uncooperative patients, or patients with special health care needs or when traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed”. ITR placement by dental auxiliaries may merit consideration by US policy-makers working to strengthen the dental safety-net.
The dental safety net, its workforce, and policy recommendations for its enhancement
Burton Edelstein, DDS, MPH
The purpose of this overview of the dental safety-net is to identify options and opportunities for policy changes to enhance oral health professional workforce in the safety-net. The author considers dental education, licensure, scope of practice for allied dental personnel, federal and state financing of public insurance, and efforts to engage more private practitioners in care of the underserved. The best approach is to dramatically reduce need and demand for treatment by preventing and managing disease. Expansion of safety-net facilities, providers and payment streams is critical. Value to safety-net oral health programs: The article considers immigration policy, training opportunities for foreign-educated dentists, potential of minority dental students to provide more “care to the underserved”, and development and evaluation of new kinds of dental providers. The author states that “recruitment and retention to safety-net facilities may be enhanced by improving their efficiency and staffing and by increasing compensation”.
This article describes the goals and successes of a public-private oral health collaboration in central Massachusetts. Initial funding was provided by a private state-level foundation; later leveraged to including national foundations. The initial catalyst for the initiative was the local dental society, and the initial steering committee included two local Health Centers, hygiene program, medical school and others. The five goals included: advocating for changes in oral health policy, increasing access to oral health care, providing school-based dental services, establishing a dental residency in the area and educating medical professionals. During the first eight years the initiative has made progress in all these areas, and the collaborative partners have grown to include local school districts, health departments, additional Health Centers and state legislators. Significance to Health Center Practice: Along with our primary purpose of delivering clinical care, Health Centers should be vital partners in any local efforts to improve oral health status. Structured long-term collaboration with other partners can lead to greater results for the communities we serve than working alone.
Water consumption beliefs and practices in a rural Latino community: implications for fluoridation.
Scherzer T, Barker JC, Pollick H, Weintraub JA.
Focus groups and structured interviews were used in this study to explore beliefs about tap water among Latino parents of young children in a rural California community. The majority of the respondents were not born in the U.S., but had lived in the community over six years. There is a Health Center and private practice dentists serving the community. The vast majority of residents avoided drinking unfiltered tap water, and felt it was unsafe based on taste appearance and smell. Additionally, long-time residents spoke of documented history of poor water quality, which was transmitted to newer residents. Significance to Health Center Practice: Although the particular community in which the study was conducted does not have fluoridated drinking water, the beliefs and perceptions stated by the participants, may have applicability to other urban or rural communities that are fluoridated. Health Center dental programs should be aware of any documented current or past issues with local water supplies, and be prepared to engage caregivers of young children in discussions about their drinking water preferences.
Fluoride varnishes for preventing dental caries in children and adolescents
Marinho VCC, Higgins JPT, Logan S, Sheiham A
Many states are faced with cutting Medicaid costs, translating to lower reimbursement to providers. In Colorado they are considering cutting the limit of Fluoride Varnish applications from 4 per year to 3 per year. This type of potential policy change raises the question about the evidence supporting the caries-reducing efficacy of varnish. This systematic review was completed in 2009 answering the question of fluoride varnish efficacy. After an extensive electronic search of the literature and databases, nine studies involving 2709 were included in this review. This review has some limitations due to the small number of studies they included. The review does not include statements in the areas of any reported adverse effects or the acceptance of the varnish by the children. The review does report on the caries reduction seen and attributed with 2 to 4 applications per year of fluoride varnish. The D(M)FS pooled prevented fraction estimate was 46%. The pooled d(e/m)fs prevented fraction was 33%. The Confidence Intervals have a large range indicating more studies are needed. This review strongly suggests that the application of fluoride varnishes two to four times a year is associated with a substantial reduction in caries increment in both the permanent and deciduous dentition.
Assessing the Relationship Between Children’s Oral Health Status and That of Their Mothers
Bruce A. Dye, DDS, MPH, et al.
This article used data from the Third National Health and Nutrition Examination Survey to compile a sample of 1,184 mother/child pairs. The children’s ages ranged from 2 through 6 years. The results showed children of mothers who had untreated caries were more than three times as likely to have higher levels of caries experience compared with children whose mothers had no untreated caries. The implication to the safety net dentist is the oral health of the mother should be considered in the caries risk assessment of the child. The deeper implication of this study is by the time we have the child in our offices it may be too late. If we are treating the child with out first addressing the oral health of the mother, while she is still pregnant, we have missed a major opportunity to influence the oral health of the child. Caries elimination, periodontal interventions and oral hygiene instruction while a woman is pregnant is a pathway to healthier children. Dentistry’s historic hesitancy to treat women during pregnancy is changing. This article gives more evidence of why the change is needed. It does affect the oral health of two generations.
Language and Literacy Related to Lack of Children’s Dental Sealant Use
Mejia GC, Weintraub JA, Cheng NF, Grossman W, Han PZ, Phipps KR, Gansky SA
The purpose of the study was to determine the percent of California’s third grade public school children who lacked sealants as a function of child and family factors, and to measure the social disparities that may be associated with absence of sealants. The study analyzed data from the California Oral Health Needs Assessment of 2004-2005. This assessment represented a complex stratified cluster sample of 10,450 children from 182 randomly selected public elementary schools in California. The dependent variable was the absence of sealants on first permanent molars. The independent variables included the child’s race/ethnicity; socio-economic position (SEP); measured as the child’s participation in the free or reduced-price lunch program at the individual and school level; acculturation of the family measured as language spoken at home and school level percent of English language learners; and parent functional health literacy measured as correctly following questionnaire instructions. Absolute differences, and health disparity indices (e.g., Slope Index of Inequality, Relation Index of Inequality-mean, Absolute Concentration Index) were used to measure absolute and relative disparities. The investigators showed that the percent of children without sealants was high in all racial/ethnic groups; no child or school level SEP differences were seen amongst those who lacked sealants but significant differences existed by acculturation (child and school level) and parental functional health literacy. The investigators concluded that non-English speaking language and poor parental functional health literacy are potential barriers that need to be addressed in an effort to overcome disparities in the utilization of sealants.
The purpose of the study was to address the perceived inadequacies in the current U.S. oral health care system in better preventing oral diseases, eliminating oral health disparities, and ensuring access to basic oral health services. The authors sought to articulate the attributes that an ideal oral health system would possess which would be consistent with the principles of the leading authorities on the public’s health. The authors reviewed policy statements and position papers of the World Health Organization, the Institute of Medicine, the American Public Health Association, Healthy People 2010 Objectives for the Nation, and the American Association of Public Health Dentistry. The authors concluded that, consistent with leading public health authorities, an ideal oral health system would have the following attributes: it would be integrated with the rest of the healthcare system; it would emphasize health promotion and disease prevention; it would monitor population oral health status and needs; it would be evidence-based, effective, cost-effective, sustainable, equitable, universal, comprehensive and ethical; it would offer continuous assessment and assurance, be culturally competent and empower communities and individuals to create conditions conducive to health. The authors concluded that though there are some attributes of an ideal oral health system on which the United States has made initial strides, it falls far short in many areas. The authors are of the opinion that the development of an oral health care delivery system that meets the characteristics described above is possible but it would require tremendous commitment and political will on the part of the American public and its elected officials to bring it to fruition.
Efficacy of Silver Diamine Fluoride for Arresting Caries Treatment
R. Yee, et al.
Arresting Caries Treatment (ACT) has been proposed to manage untreated dental caries as early as 1999. Silver Diamine Fluoride (SDF) has been used to arrest dental caries since 1969. Studies around the world have suggested SDF to be significantly more effective in arresting caries and preventing new caries than fluoride varnish applications applied in three-month intervals. This study compares the effectiveness of a single spot application of two concentrations of SDF, 38% or 12%, with or with out tannic acid as a reducing agent. The study was designed and carried out in Kathmandu, Nepal. The study design is flawed and the results are questionable. This article would not be the best choice to use if you were deciding to use or not use SDF. Significance to HC dental practice: This article, in spite of its design, does have bearing to all dentists working on patient populations with a high incidence of dental caries. The FDA is now considering SDF for use in the United States. When and if SDF is available in the U.S. all Health Center dentists will be faced with the question of whether or not they are going to use it in their Center. This article and others like it will become a resource for their decision making about SDF.
The Impact of Visible Dental Decay on Social Judgments: comparison of the effects of location and extent of the lesion
A. Somani et al.
Previous research has shown people make social judgments about someone else based on the condition of that person’s teeth. Dentists and dental hygienists know this through experience but it has not been the subject of extensive investigation. This study sought to determine whether the position of the decay and the extent of the lesion are determining factors in such social judgments. One hundred young people were randomly divided into four groups of 25 per group. Each group was shown a differently computer-modified photograph of the same person. The location and extent of a lesion were varied systematically. Participants were asked to rate the person in the photograph with respect to intellectual ability, social competence and psychological adjustment. The data confirms previous studies that poor dental condition is highly correlated with perceived poor social performance and intellectual ability. The study also showed the more central position of the caries is more predictive of poor social judgments.
Significance to HC dental practice: In Health Centers where oral health care has the potential to become more rationalized, this data supports the social impact of dental decay. It supports the need to treat decay to assure patients have an equal chance for success.
A Comparison of the Effects of Toothbrushing and Handpiece Prophylaxison Retention of Sealants
Shellie Kolavic Gray, DMD, MPH et al.
This article evaluated studies that looked at the effects of different tooth surface cleaning methods on sealant retention. Direct evidence revealed no difference in complete sealant retention between sealed teeth cleaned with a handpiece with pumice or prophy paste and those cleaned with an air-water syringe or dry toothbrushing. Additionally, indirect evidence suggested that tooth sealant retention using a toothbrush prophy as the surface preparation was equal to or greater than sealant retention rates that utilized a handpiece prophy for tooth surface preparation.
Significance to Health Center dental practice: The dental caries prevention benefit of sealants is well understood. As Health Centers expand sealant activities to reach high risk children in non-traditional dental settings, equipment access becomes an issue. Use of a handpiece for tooth sealant preparation requires additional equipment that may prohibit sealant outreach efforts. This article provides evidence that sealants can be successfully placed using a toothbrush prophy for tooth preparation when handpieces are unavailable.
The Effects of Occlusal Loading on the Margins of Cervical Restorations
Luciana Fávaro Francisconi, DDS, MS, et al.
This research article determined the effects of occlusal loading forces on the margins of resin based composite restorations used to restore cervical wedge shaped abfraction lesions. The research found that occlusal loading forces on the buccal cusp, lingual cusp or central fossa in extracted premolars lead to a significant increase in marginal gap formation of the cervical restoration versus cervical restorations placed in extracted premolars not subject to occlusal forces. Significance to Health Center dental practice: Many patients present with non carious abfraction lesions so severe that restorative treatment is indicated. Many times, these restorations fail for no obvious reason and this article reveals that failure of the restoration may be due to the occlusal forces. Although not specifically addressed in this article, one can assume that occlusal forces may also contribute to failure of Class V restorations completed due to caries. The research suggests that identifying and treating the occlusal forces will result in better outcomes reducing the time and cost of restoration replacement.
A Comparison of a Refrigerant and a Topical Anesthetic Gel as Preinjection Anesthetics
Amar Kosaraju, DMD, MSEd and Kraig S. Vandewalle, DDS, MS
This study compared the effectiveness of a five second application of a refrigerant with a two minute application of a topical anesthetic gel in reducing the pain experienced during a posterior palatal anesthetic injection. The authors concluded that use of a refrigerant as a preinjection anesthetic was more effective in reducing the pain experienced during a posterior palatal anesthetic injection compared to the use of a topical anesthetic gel. Significance to Health Center dental practice: Many patients delay restorative dental treatment due to the anxiety associated with the anesthetic injection. Use of preinjection techniques to reduce the pain of a dental injection many result in better patient compliance for completion of restorative treatment plans and reduce no-show rates. The article also reports the additional benefits of using a refrigerant as being: decreased application time, ease of application, and avoidance of displeasing taste.
Do School-Based Dental Sealant Programs Reach Higher-Risk Children
Siegal, M.D., and Detty, A.M.R.
The report compares sealant prevalence by caries risk status among third graders at Ohio schools with or without school-based dental sealant programs (S-BSPs) and estimates the percent of children receiving sealants in S-BSPs who are higher-risk for dental caries. Data were analyzed from a state-wide open-mouth oral health survey of Ohio third graders for sealant prevalence by S-BSPs availability and caries risk classification. Children were classified as higher or lower risk for dental caries based on school lunch program enrollment and other non-clinical access-related indicators. At schools with no S-BSPs, higher-risk children were less likely to have dental sealants than lower-risk children (28.7% v. 42.7%, P < 0.001). At schools with S-BSPs, sealant prevalence for both risk categories was equivalent for higher and lower risk children (59.4% v. 63.4% P=0.428). Higher risk children at schools with S-BSPs were more than twice as likely to have a sealant as higher-risk children at non-S-BSP schools (59.4% v. 28.77%, P < 0.001). Of higher-risk children with at least one sealant, 61% attended a school with an S-BSP compared with 12.3% of lower risk children with at least one sealant. Higher-risk children accounted for at least 75% of children receiving sealants at S-BSPs. The authors concluded that targeting S-BSPs by family income-based school-level criteria was effective in reaching higher-risk children.
A meta-analysis was performed to determine the relative effectiveness of fluoride toothpastes of different concentrations in preventing dental caries in children and adults, and to examine the potentially modifying effects of baseline caries level and supervised toothbrushing. The primary effect measure was the prevented fraction (PF), the caries increment of the control group minus the caries increment of the treatment group, expressed as a proportion of the caries increment in the control group. Seventy-five studies were included of which 71, comprising 79 trials, contributed data to the network meta-analysis, network meta-regression, or meta-analysis. For the 66 studies (74 trials) that contributed to the network meta-analysis of D(M)FS in the mixed or permanent dentition, the caries preventive effect of fluoride toothpaste increased significantly with higher fluoride concentrations of 1000, 1055, 1100 and 1200 ppm. D(M)FS PF compared to placebo was 23% for those concentrations, rising to 36% for toothpastes with concentrations of 2400, 2500, and 2800 ppm. The concentrations of 440, 555 ppm, and below showed no statistically significant effect when compared to placebo. The effect of fluoride toothpaste also increased with baseline level of D(M)FS and supervised brushing, although this did not reach statistical significance. Six studies assessed the effects of fluoride concentrations on deciduous dentition with equivocal results dependent upon the fluoride concentrations compared and the outcomes measured. The authors concluded that the review confirmed the benefit of using fluoride toothpaste in preventing caries in children and adolescents when compared to placebo but only significantly for fluoride concentrations of 1000 ppm and above. The relative caries preventive effects of fluoride toothpaste in different concentrations increased with higher fluoride concentrations. The decision of what fluoride level to use for children under 6 should be balanced against the risk of fluorosis.
The Path to Physician Leadership in Community Health Centers: Implications for Training
Markuns, J.F., Fraser, B., Orlander, J.D.
With community health centers facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs, community health centers require more well-trained physician leadership to succeed with the above-described expansion. The objective of this study was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs. Data were collected by means of recorded interviews and focus-group with community health center medical directors. From these data, patterns and themes were identified through cross-case content analysis to determine leadership training needs in underserved settings. Results showed that medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Clinical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship and formal degree training. Many directors interviewed expressed a desire for additional training, preferring flexibility in curriculum and hands-on components. The authors conclude that additional leadership training opportunities for active and future medical directors are needed. Academic medical centers and other training sponsors should consider innovative ways to develop effective physician leadership to provide quality care to underserved communities. The authors found that medical directors entered leadership roles motivated by a desire to make improvements in community health center care. However, many quickly found themselves unprepared and unable to achieve the improvements they desired. General medical directors claimed that additional training programs would be useful, especially if programs included longitudinal project work with direct application, components of peer-networking, mentorship, flexibility and interacting with curriculum. The authors conclude that their research has important implications for medical education as well as public policy. It is the authors’ opinion that government, health centers, and academic and post-graduate training institutions will need to work together to generate adequate funding and develop and coordinate this important leadership training to provide the highest quality healthcare to all.
Though “pay-for-performance” is an incentive system that has been gaining acceptance in the practice of medicine, it has only recently begun to be considered for implementation in dentistry. However, it is unclear whether pay-for-performance can effect significant and lasting changes in provider behavior and quality of care. The authors identified the dental insurance market, the dental profession, the organization of dental practice, and the dental-patient involvement as structural factors influencing the way dental care is practiced and paid for. After considering variations in dental care in the early stage of development for evidence-based dentistry, the scarcity of outcome indicators, lack of clinical markers, inconsistent use of diagnostic codes, and scarcity of electronic dental records, the authors conclude that for pay-for-performance programs, to be successfully implemented in dentistry, should 1) expand the evidence base, 2) create evidence-based performance measures tied to existing clinical practice guidelines, and 3) create evidence-based performance measures tied to existing clinical practice guidelines. The authors conclude, after exploring factors that would influence the adoption of value-based purchasing programs in dentistry, that none of these factors was an essential deterrent for the implementation of pay-for-performance programs in medicine, the aggregate seems to indicate that significant changes are needed before this type of program could be considered a realistic option in dentistry. The authors conclude that dentistry may follow medicine by implementing pay for performance programs to improve dental quality.
Single dose oral ibuprofen for acute postoperative pain in adults
Christopher Derry, et al.
This article was a review of a study to assess the analgesic efficacy of ibuprofen in single oral doses for moderate and severe postoperative pain in adults. The study found that that ibuprofen is an effective analgesic in treating postoperative pain and that there were no more adverse effects then with a placebo. Significance to Health Center dental practice: Abuse of prescription narcotic pain medication is a significant problem throughout the country. Health Center oral health providers many times are faced with the challenge of weighing the risk of use of a narcotic pain medication against the risk of abuse or unintended non-medicinal uses. This study gives practitioners the confidence to use ibuprofen as it provides evidence that this non-narcotic analgesic medication is effective and safe for use in controlling post-operative dental pain.
The challenge to delivering oral health services in rural America
Susan M. Skillman, MS, et al.
This article begins by listing some of the reasons why the oral health status of rural populations in America is poorer than their urban counterparts. The article goes on to identify the challenges to improving oral health in rural America and describe some of the potential solutions. Significance to Health Center dental practice: Many Health Centers are located in rural areas and the oral health staff witness many of the issues described in this review. Understanding the causes of poor oral health status in rural America as well as possible solutions allow the practitioner to become an effective advocate for oral health with community leaders well as state and federal governmental agencies.
Preventing Dental Caries through School-Based Sealant Programs: Updated Recommendations and Reviews of Evidence
Barbara F. Gooch, DMD, MPH, et al.
This article describes a systemic review of the effectiveness of sealants in managing caries. The review found that the evidence supports the use of visual assessment to detect surface cavitation and to seal sound surfaces and noncavitated lesions (after toothbrush or handpiece prophy) even if there is no assurance of a follow-up visit. Significance to Health Center dental practice: Many Health Centers provide limited (exam, prophy, sealant services) school based oral health services. One of the challenges that Health Centers must overcome is the perception that providing sealants in a school based health center setting where fixed traditional dental equipment is not accessible and follow-up is not assured results in bad outcomes. This article rebuts this argument and may help Health Centers expand school based oral health sealant services.
Improving oral healthcare delivery systems through workforce innovations: an introduction
Elizabeth A. Mertz, PhD, MA ; Len Finocchio, DrPH
This article serves as the introduction to a special issue of the Journal of Public Health Dentistry. The title of the special issue is Improving Oral Healthcare Delivery Systems through Workforce Innovations. This paper describes the purpose, rationale and key elements of the special issue. The background for this article as well as the special issue is a conference held by the Institute of Medicine in 2009. This article establishes the background information and sets the parameters for the remaining articles in the journal. The entire journal is of interest to any oral health practitioner serving in the safety net. The current problems are articulated and potential solutions are posed.
Oral health disparities and the workforce: a framework to guide innovation
Irene Hilton, DDS, MPH ; Arlene M. Lester DDS, MPH
It is a fact oral health disparities exist in the U.S. The authors of this article examine workforce changes as a strategy to address these disparities. The article establishes a framework to apply to workforce innovations, followed by applying examples of workforce innovations to the established framework. The framework is used to define expected outcomes from workforce models. The workforce models discussed in the article include dental therapists, community dental health coordinators and advanced dental hygiene practitioner. The workforce innovations are looked at in the context of reducing or eliminating oral health disparities. This article adapts a framework to be used as a guide the planning process for workforce innovations. The areas of planning include: needs assessments; current infrastructure; analysis of delivery systems; financial resources and appraisal of the landscape. This article is articulate, well presented and contains information every dentist in a safety net setting should read. It establishes language to be used with non oral health practitioners. It articulates the problem and proposes a framework to analyze potential solutions to the disparities we see every day. The reviewer highly recommends this article.
Envisioning success: the future of the oral health care delivery system in the United States
Raul I. Garcia, DMD, MMedSc ; Ronald E. Inge DDS ; Linda Niessen, DMD, MPH, MPA ; Dominick P. DePaola, DDS, PhD
The authors are all members of a nonprofit organization committed to serving as a catalyst for innovations in health care. In this article they examine existing oral health disparities. The authors highlight the fact the current workforce has failed to enhance access or improve oral health outcomes. The article clearly states, “successful implementation of workforce innovations must include: reducing resistance to change by organized dentistry”. This article looks at some of the underlying issues that may need to change before significant changes in the workforce can be made. The topics include payment reforms, educational systems reforms, and policy issues. This article is included with several other articles examining workforce issues in the special issue of the Journal of Public Health Dentistry.Oral health providers currently in the safety net should have an interest in this entire set of articles. The oral health disparities we see everyday will not be changed with out workforce innovations. This article examines the problems and looks into potential solutions. The solutions must include the existing safety net. This makes this article and the entire special issue of high interest to anyone who wants to improve access to oral health care.
Remembering and repeating childhood dental treatment experiences: parents, their children, and barriers to dental care.
Smith PA, Freeman R.
This article examines the effect that a parents' negative childhood dental experience may have on their children. This study included 19 parents of various ages and backgrounds, with children seeking emergency care. The study found that parents with fear of dental care, based on their childhood experiences, were more likely to delay seeking care for their child until the child was in pain. By continuing a reactive approach to accessing care rather than a proactive approach of prevention, tooth loss and significant dental care needs become a self fulfilling prophecy. Significance to Health Center dental practice: Parents who present with their child only when a child has urgent needs, should be queried to determine the parents’ previous dental experiences. A parent with a history of negative emergency care and delay of care should be counseled to attempt to break the cycle of the potential negative feelings associated with urgent care.
Traumatic Intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study.
Altun C, Cehreli ZC, Acikel C.
A 7 year prospective study was done in order to examine the developmental disturbances of permanent teeth attributed to intrusive injury of their primary predecessors. A total of 78 children (ages 12-48) months presenting with intrusive trauma to 138 primary incisors showed that maxillary incisors (93.5%) were the most common primary teeth that were intruded. In 74 permanent successors (53.6%) of the following developmental disturbances were observed: enamel hypoplasia (28.3%), crown and/or root deformation (16.7%) and ectopic eruption (16.7%). There was no significant correlation between age of intrusion and frequency of subsequent developmental disturbances. The clinical significance for health center practice: The majority of intruded primary incisors where immediate extraction is not indicated will re-erupt if it is just observed.
The Effect of Dentin-Cleaning Agents on Resin Cement Bond Strength to Dentin
Duygu Saraç, DDS, PhD, Bilinc Bulucu, DDS, PhD, Y. Sinasi Saraç, DDS, PhD and Safak Kulunk, DDS, PhD
This article examines the effect of dentin cleaning agents on resin cement bond strength to dentin. The three products compared were Sikko Tim, Cavity Cleanser, and ConsepsisScrub. The study found that the use of an effective dentin cleanerbefore cementation with resin cement can increase bond strength. In particular, significant differencesamong the different dentin-cleaning agents and etching systemswere found. Sikko Tim andConsepsis Scrub had higher shear bond strength valuesthan did specimens in the Cavity Cleanser and the control groups. No significant differences between theone- and two-step self-etching adhesive systems were found. Significance to HC dental practice: Many practices utilize resin cements for the cementation of fixed prosthetics in cases where retention many be problematic. This study provides evidence that treating the dentin with a dentin cleaning agent after removal of temporary cement increases bond strength which may lead to less fixed prosthetic failure. The entire article can accessed at: http://jada.ada.org/cgi/content/full/139/6/751
Exploring Four-Handed Delivery and Retention of Resin-Based Sealants
Susan O. Griffin, PhD, Kari Jones, PhD, Shellie Kolavic Gray, DMD, MPH, Dolores M. Malvitz, DrPH and Barbara F. Gooch, DMD, MPH
This article examines data about the retention rate of sealants placed by a dental professional with (four-handed delivery) and without (two-handed delivery) the assistance of a dental assistant. The analysis of the data indicates increased sealant retention when sealants are placed utilizing a four-handed delivery technique. Significance to HC dental practice: Many of our CHC patients are at high risk for caries and sealants are an important arsenal in the prevention of dental caries. Many of the public insurance programs place a limit on the frequency of placement of sealants for reimbursement thus making sealant retention critical. Therefore, proper sealant placement is essential for long term caries prevention and this article provides evidence of the critical role of proper staffing (utilizing four-handed delivery) in sealant placement. The entire article can be accessed at: http://jada.ada.org/cgi/content/full/139/3/281
Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw: An institutional inquiry
Parish P. Sedghizadeh, DDS, MS, Kyle Stanley, BS, Matthew Caligiuri, BA, Shawn Hofkes, BS, Brad Lowry, BS and Charles F. Shuler, DMD, PhD
This article outlines the first large institutional study in the UnitedStates to investigate the relationship of osteonecrosis of the jaw (ONJ) and oral bisphosphonate (BP) use. A study of electronic medical records at the University of Southern California was used to identify the number of active patients who had a history of oral bisphosphonate (BP) use with alendronate sodium as well as patients being treatedfor active osteonecrosis of the jaw who currently were receiving oral BP or had a past history of oral BP use.
The findings from the study indicate that even short-term useof oral BP can lead to ONJ in a subset of patientsafter dental extractions. The authors conclude that furtherstudies will be needed to more clearly establish the relationship betweenoral BP use and ONJ. Significance to HC dental practice: These findingshave important therapeutic and preventive implications as many CHCs provide a significant amount of oral surgery on a daily basis. Many of these patients have significant medical histories and are poly-pharmacy with oral BP use. A clear understanding of the relationship of oral BP use and the risk of ONJ is vital to risk management and good patient outcomes. The entire article can be accessed at: http://jada.ada.org/cgi/content/full/140/1/61
April 2010
An Examination of the Advances in Science and Technology of Prevention of Tooth Decay in Young Children Since the Surgeon General's Report on Oral Health.
Milgrom P, Zero DT, Tanzer JM.
This paper looks at the new and emerging science and technology that has been discovered and developed in the 10 years since the Surgeon General’s report in the area of dental caries prevention. The paper finds that many of the discoveries have not been translated into routine clinical practice. The infectious nature of dental caries has been well established, yet strategies for preventing or delaying transmission have not been universally adopted. The majority of resources and training still focuses on end-stage surgical treatment and repair of dental caries. Examples of preventive strategies include caries risk assessment and early detection of incipient caries lesions. Remineralizing interventions such as fluoride varnish have not been universally adopted in the private practice sector. Lack of focused long-term research has delayed the determination of the most effective anti-bacterial chemotherapuetics such as chlorhexidine, polyvinylpyrrolidone iodine, diamine silver fluoride and xylitol. Significance to HC dental practice: Health Centers can and should be at the cutting edge of implementing evidence-based preventive interventions for our high-risk populations. HC dental providers must remain up-to-date on prevention research.
An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part I. Timing of pulp extirpation.
Hinckfuss SE, Messer LB.
The principles of evidence-based dentistry were used to assess the proper time interval for pulp extirpation (PE) following reimplantation of an avulsed permanent tooth. After an initial literature search, potential studies for inclusion in a meta-analysis has their abstracts reviewed. Further inclusion criteria were applied resulting in 6 studies being selected for the meta-analysis. These studies included a total of 236 teeth. Results showed that PE more than 14 days after reimplantation was associated with inflammatory resorption, therefore the optimal time to perform PE was within 14 days of reimplantation. Some of the studies had PE performed within 10 days of reimplantation and others within 14 days. There was no significant difference in outcomes between the two time intervals. Significance to HC dental practice: PE should be performed on a reimplanted permanent tooth within 14 days for the best outcome. This is in agreement with current American Association of Endodontists’clinical guidelines recommandation of 7-14 days.
The Role of Children’s Tooth Decay in a Public Health Program to Encourage Low Income Pregnant Women to Utilize Dental Care
Milgrom P, et al.
In an effort to show that dental care to mothers has a positive impact on caries rate in their offspring, a study was instituted in Klamath County, Oregon involving a community-based public health program which provides a dental home for women covered by the Oregon Health Plan. The study’s long-term goal was to promote preventive oral health care for mothers and their new infants provided by dental managed care companies. The children were examined in the second year of life and it was determined that children whose mothers participated in the intervention had significantly fewer caries than those children from comparable non-program counties in Oregon. Intervention subjects’ children were found to be one and a half times more likely to be caries free. Klamath County had a population of 66,425, of which 82.7% were white, non-Hispanic. The local water supply was not fluoridated and there was little natural-occurring fluoride. Mothers received counseling and dental care during pregnancy or within two months of delivery. The comparison counties were also in rural Oregon with similar levels of birth to women served by the Oregon Health Plan. Equal percentages of the intervention and control group mothers were primiparous. All of the mothers in the intervention group received dental care and about half of the mothers in the comparison group received dental care during pregnancy or in the two-month window post-partum. The intervention included education materials intended to promote dental visits for the offspring in the second year of life. The authors conclude that the intervention during pregnancy likely has benefits for the child.
Case Study of Linking Dental and Medical Healthcare Records
Theis MK, et al
The objective of the study was to link the administrative data of a large dental carrier in Washington State (which provides comprehensive dental insurance to more than 2 million adults and children) and an integrated health plan (which provides care to approximately 570,000 residents in Washington State and northern Idaho) to conduct an observational study of diabetes and periodontal disease. The authors selected social security number, date of birth, first name and last name to test reliability as linking variables among a population with dual dental and medical insurance. The authors showed that with a success match rate of more than 96% with the 4 test variables, it was possible to link the data to assess the impact of oral disease on overall health. For over 20 years, the medical carrier has collected monthly administrative, financial, and clinical data formatted in SAS. The authors showed that a relatively deterministic approach, within a narrow time frame and with demographic variables commonly collected by dental and medical insurance carriers, results in high-quality record linkage.
Educating Pediatricians and Family Physicians in Children’s Oral Health
Douglass AB, Douglass JM, Krol DM.
The 2000 Surgeon General’s Report on Oral Health in America alerted the public and health professionals to the importance of oral health and the disparities in oral health and access to care for vulnerable populations. The National Call to Action to promote oral health called for revamping health professional education to address these issues. In response, the American Academy of Pediatrics, the American Academy of Family Physicians and the Society of Teachers of Family Medicine have supported training programs designed to increase physician’s engagement in oral health, particularly for underserved children. This paper reviews advances in oral health training of pediatricians and family physicians and makes recommendations for future efforts, including that oral health should be a required component of graduate and continuing medical education for pediatricians as it is currently for family physicians and should be included in Board Certification and re-certification activities. Existing new curricula programs and oral health projects should be evaluated for their effectiveness in changing knowledge, attitudes and behaviors. The content of oral health education programs should be consistent in content and be of high-quality, reflecting the latest science, safe and effective clinical techniques, and appropriate anticipatory guidance. Closer relationships between physicians and dentists need to be fostered at each level of the educational continuum to promote the development of high-quality, evidence-based educational content as well as to assure favorable referral environments.
Evidence that Fluoride in the Infant Formula Causes Enamel Fluorosis Weak
Maura Edwards
Data from PubMed, the Cochrane Library, the Web of Science, Controlled Trials, Clinical Trials, ProQuest UMI, National Institute for Health and Clinical Excellence, Virtual Health Library, Bireme-PAHO-WHO, and the Latin America and Caribbean Centre on Health Sciences Information were reviewed. Twenty-seven of 41 studies evaluating the effect of infant formula on enamel fluorosis risk were included. These 27 papers reported the results of 19 observational studies, one prospective cohort study, five retrospective cohort studies, six case-control studies, four cross-sectional studies and three historical-control studies. Seventeen of the 19 studies reported odds ratios and, among these, infant formula consumption was associated with a higher prevalence of enamel fluorosis in the permanent dentition. The authors concluded that infant formula consumption may be associated with an increased risk of developing at least some detectable level of enamel fluorosis, as a function of the level of fluoride in the water supply. The evidence that the fluoride in the formula per se caused enamel fluorosis was weak.
How information systems should support the information needs of general dentists in clinical settings: suggestions from a qualitative study.
Mei Song, Heiko Spallek, Deborah Polk, Titus Schleyer, Teena Wali
The authors attempted through an interview process to identify the information needs of general dentists. The number of dentists participating in the interview was 18. The interviews process was specific to 105 patient cases. All of the participating dentists practice in the private sector. The article identifies the fact information is needed in a quick and timely manner due to the hectic scheduled dentists keep. The information needs are grouped into four categories based on functions: clinical information, administrative tasks, patient education and professional development. The article does not address sharing of information from a medical provider to a dental provider. The article is lacking in the fact it does not address electronic information could include health data such as current medications, allergies, or other heath history information that could be exchanged and be very useful to the practicing dentist. This article does not contain much content that is easily useable or applicable in most safety net settings.
Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a metaanalysis of randomized trials
Nikolaos P. Polyzos, MD, et al.
The authors state they have applied metaanalysis to, “all up-to-date randomized controlled trials” looking at periodontal treatment during pregnancy and the effect of the treatment on low birth weight (LBW) and preterm birth (PTB). The authors considered periodontal treatment to include root planning and scaling but not surgical interventions. Their findings are treatment resulted in significantly lower PTB (odds ratio 0.55: confidence level 95%), borderline significantly lower LBW ( OR 0.48, CL 95%) and no difference for spontaneous abortion/stillbirth. The article includes a discussion of what might cause the relationships they found through their analysis. This article would be useful to any dentist who treats women during pregnancy. It establishes statistically the fact periodontal treatment can have a positive influence on birth outcomes.
Tern Stillbirth Caused by Oral Fusobacterium nucleatum
Yiping W. Han, PhD, et al.
This article shows the bacteria (F. nucleatum) isolated from the placenta and the fetus was the same clone of bacteria found in the mother’s subgingival plaque. Intrauterine infection is recognized as a cause of adverse pregnancy outcomes. The debate often centers on whether or not oral bacteria can be a source of the intrauterine infection. This study shows that the oral environment can be the source of the infection. This case sheds more light on oral health management being an important component of care during pregnancy. The patient did report excessive gingival bleeding during her pregnancy. The authors conclude, “We speculate that a certain portion of the unexplained stillbirths may be caused by previously unrecognized oral bacteria translocated to the uterus independent of the ascending vaginal route”. This article gives the dentist another reason to treat women during pregnancy. It should be of interest to all oral health providers who treat women during pregnancy. In addition, and perhaps more importantly, it should be read by all oral health practitioners who are not treating pregnant women during pregnancy.
This report is in depth and complete. The report is 67 pages long. This means it takes some time to go through the entire report. If you have a desire to know how your state measures up to other states in meeting and providing oral health care to vulnerable children this report is an excellent resource. The report establishes what most of us know, but it does an excellent job of giving us new language, statistics and materials to support our efforts and the costs associated with meeting the needs we set as a priority. In chapter 1 the report established the significance of the dental health challenges children face. In chapter 2 some potential solutions are put forth. Chapter 3 grades each state. The report uses eight policy benchmarks needed to build a strong state position on children’s oral health as the basis for their grade. The report concludes with an explanation of their methodology. The report is worth looking at and keeping on hand as a resource for supporting our programs. It clearly establishes the need and the severity of the need.
This report explores the idea of developing mid-level providers, such as dental therapists, to increase the availability of dental care for underserved populations in the United States. These new primary care dental providers deliver services that were previously delivered in the U.S. only by dentists. Introducing successful cases of implementing these mid-level providers, this report clarifies the roles and training of existing and proposed dental providers, examines international experience with alternative dental providers, and explores a range of policy issues related to instituting dental therapists in the U.S. Relevance to Health Centers: The author states that instituting dental therapy would strengthen the dental safety net through addressing vacancies and unmet needs for dental services throughout the country.
Adding Dental Therapists to the Oral Health Care Team to Improve Access to Oral Health Care for Children
David A. Nash, DMD, MS, EdD
This article states several arguments in support of the use of dental therapists to increase access to oral health care for at risk populations. The article uses the declining workforce, the current economics, and the current access issues as arguments in support of “midlevel” oral health providers. Models where dental therapists have been used with success are examined. Educational models for the training of therapists are postulated in the article. Relevance to Health Centers: This article has applications to any dentist or administrator in a safety net clinic. It is a possible model currently being discussed to increase access to care. NNOHA supports the evaluation of pilot models attempting to increase access to oral health services. This includes but is not limited to the use of dental therapists. This article as an excellent source of information on the potential use and education of dental therapists and contains valuable information that can be applied to our current knowledge base. If nothing else the article provides us with excellent talking points about the potential future of oral health care systems and provision.
Addressing Children’s Oral Health in the New Millennium: Trends in the Dental Workforce
Elizibeth Metz, MA; Wendy Mouradian, MD, MS
The dentist to population ratio is declining. This is coupled with the fact that shortages of dentists continue to rise in rural and underserved areas. Fewer than 1 in 5 children with Medicaid receive preventive dental care. Recent surveys indicate increasing levels of caries experience in young children with the continuing disparities seen by ethnicity and income levels. Relevance to Health Centers: This article looks at the potential for new roles for dental providers. These could include enhanced training for the general practitioner to see young children. Another change considered is an expansion of the scope of services for dental assistants and dental hygienists. The article’s conclusion includes the following statement, “a significant expansion of community health center dental services.” This article is applicable and important because it projects the future of oral health disparities and possible models to decrease these disparities.
Laetitia Bonifat, DEA, Fatiha Chandad, PhD, Daniel Grenier PhD
The question is ‘can the use of probiotics help in the maintenance and treatment of dental caries and periodontal disease?’ Probiotics are defined in this article and the specific bacteria with potential benefits are identified. The existing clinical studies are few, but the results are summarized here. The conclusion drawn in this article is the studies to date are too few to draw sound clinical recommendations and more studies are needed. Relevance to Health Centers: The articles interest is an exploration of future treatment modalities which may become part of the treatment offered to our patients. As our patient populations continue to suffer with severe oral health conditions anything we might be able to offer them is of interest.
Periodontal Disease – The Overlooked Diabetes Complication
Tisha Dunning, Med, PhC, AM, RN
Periodontal disease is referred to as the “sixth diabetes complication in this article. The association between oral health specifically periodontal problems and diabetes maintenance has been bantered about studied and talked about for quite awhile. This article makes the point in spite of this association it is still overlooked in routine diabetes medical management and complication screening processes. The author examines the relationship between diabetes and periodontal disease, possible underlying causal factors, and suggested management strategies. One of the statistics used to support medical and dental collaboration in the management of the patient with diabetes is the fact that 85% to 90% of these patients have been found to have periodontal disease. Once periodontal disease and diabetes occur together, a vicious cycle develops: diabetes predisposes the individual to periodontal disease, which in turn contributes to hyperglycemia, which affects other tissues and organs, including the oral cavity. This article has application to all dentists but of special interest to dentists that are collocated with medical providers due to the fact both medical and dental providers are necessary to adequately care for the patient with diabetes.
Nephrology Nursing Journal – September – October 2009, Vol 36, No. 5
Effect of Adhesive Agent and Fissure Morphology on the in vitro Microleakage and Penetrability of Pit and Fissure Sealants
Derek Marks, DDS/Barry M. Owens, DDS/William W. Johnson, DDS, MS
This article evaluates the effect of adhesive agents and fissure morphology on the microleakage and penetrability of pit and fissure sealants. The study found that application of sealants using phosphoric acid as an enamel conditioning agent had the best results and the use of adhesives prior to sealant placement provided no benefit in terms of microleakage and penetrability. The study also found that fissure morphology was not a significant factor affecting microleakage but the fissure type did significantly impact penetrability. There was no correlation between the extent of sealant microleakage and extent of sealant penetrability. Significance to HC dental practice: Sealants are an effective preventive measure in our daily practices. This article’s finding that adhesives provide no benefit in terms of microleakage and penetrability can make placement more cost effective and clinically effective by eliminating the additional cost of applying an adhesive and reducing risk of contamination by eliminating the adhesive step.
The entire article can be accessed at Quintessence International, Volume 40, Issue 9, October, 2009, pages 763-772: http://www.quintpub.com/journals/abstract.php3?iss2_id=412&article_id=5145
Serum Inflammatory Mediators in Pregnancy: Changes after Periodontal Treatment and Association with Pregnancy Outcomes
Bryan S. Michalowicz, M. John Novak, James S. Hodges, Anthony DiAngelis, William Buchanan, Panos N. Papapanou, Dennis A. Mitchell, James E. Ferguson II, Virginia Lupo, James Bofill, Stephen Matseoane, Michelle Steffen, and Jeffrey L. Ebersole
This article describes a study whose purpose was to determine if periodontal treatment in pregnant women before 21 weeks of gestation alters levels of inflammatory mediators in blood serum and if changes in these mediators are associated with birth outcomes. The study found that non-surgical periodontal treatment (scaling and root planning) delivered before 21 weeks of gestation in pregnant women did not reduce blood serum markers of inflammation. In pregnant women with periodontitis, levels of these markers at 13 to 17 weeks and 29 to 32 weeks of gestation were not associated with infant birth weight or a risk for preterm birth. Significance to HC dental practice: Understanding the current knowledge surrounding this issue will assist in efforts when providing care educate to our pregnant patients and outreach to our medical colleagues.
Journal of Periodontology, Volume 80, No. 11, November, 2009 Pages 1731-1741: http://www.joponline.org/toc/jop/80/11?cookieSet=1 (Subscription or payment required for full article)
September 2009
Effects of periodontal therapy on rate of preterm delivery: a randomized controlled trial. Offenbacher, et al.
This article contains the long-awaited results of the MOTOR clinical trials. This study started with 1,806 multi-ethnic patients in 3 states with periodontal disease, which is the largest number of participants in any study looking at periodontal disease and adverse birth outcomes. Women were routed into two treatment arms: those who received scaling & root planning during the second trimester and those who received treatment after birth. The primary outcome was delivery at gestational age less than 37 weeks. The rate of preterm delivery for the treatment group was 13.1% and 11.5% for the control group. Given the large number of participants, the difference was NOT statistically significant. Significance to Health Center dental practice: The flip side of this is dental treatment with anesthesia is safe during pregnancy and does not result in an increase in adverse birth outcomes. Some day discovery of the biological mechanisms will explain the associations seen in other studies and the lack of results in this study. In the meantime, active periodontal disease in pregnant women can and should be treated.
Beyond the dmft: The Human and Economic Cost of Early Childhood Caries.
Casamassimo PS, Thikkurissy S, Edelstein BL and Maiorini E.
This very interesting article looks at Early Childhood Caries (ECC) and its associated costs in a different way: As a pyramid with the most common, frequent costs at the bottom and the least frequent negative effects, such as death, at the top of the pyramid. Some of the costs may not be obvious to those with infrequent exposure to ECC. At the top death can occur from dental infection or treatment itself. Directly below that, high-level surgical interventions in the hospital, ER, or under GA and sedation use up disproportionate resources and add morbidity. At the very large, wide base of the pyramid you have all the costs and burdens associated with treatment and/or delayed or non-treatment such as pain, missed school hours and work hours for caregivers, missed sleep, eating dysfunction, lower academic performance, inappropriate use of OTC medications and many others. Significance to Health Center dental practice: Implementing perinatal & early infant intervention programs in the HC setting, as piloted in the Oral Health Disparities Collaborative, is the only possible way to prevent and reduce the costs detailed in this article. J Am Dent Assoc 2009;140;650-657.
Xylitol pediatric topical oral syrup to prevent dental caries: a double-blind randomized clinical trial of efficacy.
Milgrom P, Ly KA, Tut OK, Mancl L, Roberts MC, Briand K, Gancio MJ
This article evaluates the effectiveness of xylitol pediatric topical syrup in reducing the incidence of dental caries in very young children between the ages of 9 and 15 months. The study found that xylitol oral syrup administered topically two or three times daily at a total daily dose of eight grams was effective in preventing ECC. Significance to Health Center dental practice: ECC continues to be a problem in our patient population. This article provides evidence that the xylitol is an important tool in the prevention of ECC/dental caries. Additional work is needed to develop strategies for the public health application of xylitol. The entire article can be accessed at: Archives of Pediatrics and Adolescent Medicine 2009; Volume 163, Number 7, July 2009, pages 601-607
Body Mass Index of Children with Severe Early Childhood Caries.
Sheller B, Churchill SS, Williams BJ, Davidson B.
This article discusses a retrospective case study by the authors that sought to describe the body mass index (BMI) of children with severe early childhood caries (ECC) receiving dental treatment under general anesthesia and determine if there was a correlation between the two. The study found that the BMI percentile was not correlated with ECC even after adjusting for cofounding factors. Significance to Health Center dental practice: ECC is a multi faceted problem and this article shows that other factors in addition to diet and high caloric intake contribute to ECC and that we must address them all to solve the problem of ECC. The entire article can be accessed at: Pediatric Dentistry 2009; Volume 31, Number 3, May/June 2009, pages 216-221
Cardiovascular Disease Parameters in Periodontitis.
Andréa M. Monteiro, Maria A.N. Jardini, Sarah Alves, Viviana Giampaoli, Elisete C.Q. Aubin, Antônio M. Figueiredo Neto, and Magnus Gidlund
The aim of this study is to investigate the association between chronic periodontitis and cardiovascular risk markers. The results confirmed and further strengthened the suggested association between coronary artery disease and periodontitis. Significance to HC dental practice: There are common risk factors for periodontal disease and cardiovascular disease. Understanding that relationship allows the clinician to counsel patients on the relationship between oral health and cardiovascular health. The entire article can be accessed at: Journal of Periodontology 2009, Vol. 80, No. 3, Pages 378-388
Dental Workforce
E.S. Solomon
This articles tracks and projects the dental workforce from 1970 to 2020. The bulk of the article is a series of tables and graphs characterizing the makeup of the dental workforce and project what it might look like in the coming years. The article suggests the number of dentists peaked in 2005 and will decline moving forward. Another graph shows the number of dentists per 100,000 people in the United States will also drop as we approach 2010 and move forward toward 2020. Significance to Health Center oral health programs: This projected dental manpower decline could have effects on Health Center recruitment and access to populations who all ready have access to care issues.
Giving Policy Some Teeth: Routes to Reducing Disparities In Oral Health
Susan A. Fisher-Owens, Judith C. Baker, Sally Adams, Lisa H. Chung, Stuart A.
Gansky, Susan Hyde, and Jane A. Weintraub
Despite improvements oral health is not accorded the same importance in health care policy as general health. Oral health concerns are not well addressed in strong oral health policies. This article highlights examples of oral health discrepancies between policy and needs and gives examples of successful interventions. This article is full of language which may be useful when talking to policy makers or medical providers. It urges and argues for oral health as essential for systemic health and quality of life. This article has strong language and strong arguments for oral health care to always be in the discussion of overall or general health. This type of information and argument is always of use to a dental director or any dentist who finds themselves in the role of an apologist for oral health.
Strength of Evidence relating Periodontal Disease and Atherosclerotic Disease
Kaumudi Joshipura, BDS, MS, ScD; Juan Carlos Zevallos, MD, and Christine Sell Ritchie, MD, MSPH
This article reviews the literature to assess the evidence supporting the link between periodontal disease and atherosclerotic disease. The authors attempt to asses if periodontal disease is an independent causal risk factor atherosclerotic disease and especially for ischemic stroke. The conclusion ultimately drawn is there is not enough evidence to support a causal relationship at this time. The authors to believe the evidence is fairly strong for a causal relationship wit stroke but not for all atherosclerotic diseases. This article is important because it is another link between oral health and systemic disease.
Family Income Gradients in the Health and Health Care Access of U.S. Children.
Larson, K. and Halfon, N.
Purpose: To determine the relationship between family income (defined in terms of percent of FPL) and U.S. children’s overall health, access to medical care, and use of available services
Findings: Data on 32 health and healthcare indicators from the 2003 National Survey of Children’s Health (telephone survey of 102,353 parents of children 0-17 years of age) were analyzed by income level (<100%, 100-199%, 200-299%, 300%-399%, > 400% FPL). For 15 health outcomes, quality of health increased as a function of family income. When health insurance coverage and socio-demographic confounders were controlled for, odds ratios >2 comparing the lowest to the highest income groups were noted for health conditions across both physical and developmental domains. Steeper gradients were noted for parent-reported global child health status, activity limitations and oral health status than for specific chronic and acute conditions. Ten measures of health care access and utilization were associated with family incomes. Income gradients are pervasive across many health indicators at an early age.
Value for Health Centers: Study underscores the need for social and health policy interventions to address the many factors which can affect children’s health and initiate disparities in development.
Flores, Tomany-Korman. Racial and ethnic disparities in medical and
dental health, access to care, and use of services in US children.
Pediatrics 2008; 121(2):e286-e298.
Data from the National Survey of Children’s Health was analyzed to examine racial/ethnic disparities in medical and oral health, access to care and use of services. Relating to oral health, more white, Asian/Pacific Islander, and multiracial children’s teeth were described as being in excellent or very good condition compared with African American, Native American and Latino children. Poor or fair teeth condition was described most frequently in Latino children. Native American and Latino children were least likely to have dental insurance, compared with other racial/ethnic groups. Nonwhite racial/ethnic groups of children had greater unmet dental care needs than white children. Parents most frequently attributed their unmet dental care need to their dentist not knowing how to provide care, lack of dental insurance coverage, parents not knowing where to go for treatment and dental health plan problems. Latino and multiracial children had the highest risk of never having seen a dentist. Significance to HC dental practice: Minority children experience multiple disparities in oral health status, access to care, and use of services. Certain disparities are particularly marked for specific racial/ethnic groups. These are the populations we serve in Health Centers. To read the full article, visit http://www.ncbi.nlm.nih.gov/pubmed/and search by title.
Kingsley, O'Malley, Ditmyer, Chino. Analysis of oral cancer epidemiology in the US reveals state-specific trends: Implications for oral cancer prevention. BMC Public Health 2008; 8(1):87.
Analysis of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program reveals that while oral cancer incidence and mortality rates have been declining over the past thirty years, these declines have reversed in the past five years among some demographic groups, including black females and white males. Sorting of data by state revealed that eight states exhibited increasing rates of oral cancer deaths: Nevada, North Carolina, Iowa, Ohio, Maine, Idaho, North Dakota, and Wyoming, in contrast to the national downward trend. Furthermore, detailed analysis of data from these states revealed increasing rates of oral cancer among older white males, also contrary to the overall national trends. Significance to HC dental practice: Localized geographic areas exist where the incidence and mortality from oral cancers have been increasing. These areas represent locations where Health Centers can collaborate to focus education and prevention efforts to target specific populations in an effort to improve health outcomes and reduce disparities. It is important to be up to date on local statewide cancer incidence rates. To read the full article, visit http://www.ncbi.nlm.nih.gov/pubmed/ and search by title.
Battrell, Gadbury-Amyot, Overman. A qualitative study of limited access permit dental hygienists in Oregon. J Dent Educ 2008; 72(3):329-343.
This qualitative study was designed to evaluate the impact of the Limited Access Permit (LAP) legislation in Oregon and to understand the relationship between dental hygienists and dentists within this delivery system. The LAP-DH was created in 1997 and legislatively authorized dental hygienists to provide services in a variety of health care settings without the supervision of a dentist. The LAP-DH was legally allowed to “examine the patient, gather data, interpret the data to determine the patient’s dental hygiene treatment needs, and formulate a patient care plan.” Collaborating dentists were identified to whom the LAP dental hygienists can refer patients needing services (e.g., restorative) beyond the LAP scope of practice. Seven LAP dental hygienists and two collaborating dentists participated in the study. LAP dental hygienists practice in Head Start programs, Health Centers and other community settings, providing direct clinical services, but also acting as case-managers and educators. The full impact of the LAP legislation is still unknown due to the limited numbers of LAP dental hygienists and early nature of the LAP practice. Significance to HC dental practice: Health Centers may be ideal locations to pilot alternative and/or expanded dental workforce personnel. There is precedent for early success in this Oregon experience.To read the full article, visit http://www.ncbi.nlm.nih.gov/pubmed/ and search by title.
June 2009
Benefits of Periodontal Therapy When Preterm Birth Threatens
Radnai M., Pal A., Urban E., Eller J., Gorzo I.
This article attempts to determine the effect of periodontal treatment on the pregnancy outcome in women at risk for pre-term birth. The study followed a total of 83 women who were hospitalized due to a threatened pre-term delivery. Forty-one received periodontal exam and treatment. Forty-two women received periodontal exam but no treatment. All 83 women had periodontal disease. The average birth weight of the babies born to the women who received treatment was 3079.0 grams. The average birth weight without periodontal treatment was 2602.4 grams. All of the women were the same ethnic group, none smoked, took drugs, consumed large amounts of alcohol, and all were free of systemic medical problems. All were followed in the same hospital. The sample size is low. Originally 429 women were assessed. Of the 429 only 83 met the inclusion criteria and has periodontal disease. When sample sizes are larger the birth weight differences are not significant. This study eliminates some of the ethnic differences, socioeconomic differences and risk differences in the high participant studies. It is the similarity of the women’s condition and control of the study that makes the study interesting. Follow the link to read the entire article:Journal Of Dental Research 88(3):280- 284, 2009
This article compares the various products available for the management of incipient caries: resin-based sealant (sealant), a fluoride-containing sealant (F-sealant), a fluoride varnish (F-varnish), and a glass-ionomer cement (GIC). The most effective material in reducing the carious areas was GIC, followed by F-varnish, F-sealant, and sealants. GIC followed by F-varnish was most efficient in inhibiting new caries lesions. The article discusses how the different materials may aid in theremineralization effects of saliva. Significance to Health Center dental program: This article provides evidence based methods for the management of incipient caries. Almost daily, in practice we are faced with the dilemma of incipient caries which previously would be labeled with a "watch" and monitored until penetration through the DEJ and then restored. We now know that observation of incipient caries is not an adequate treatment option or accepted standard of care.
The entire article can accessed at: http://tinyurl.com/cariesmgmt
The Effect of Dental Sealants on Bacteria Levels in Caries Lesions: A Review of the Evidence
Ella M. Oong, DMD, MPH, Susan O. Griffin, PhD, William G. Kohn, DDS, Barbara F. Gooch, DMD, MPH and Page W. Caufield, DDS, PhD
This article reviewed six published studies that examined the effects of sealants on bacteria levels and bacterial cultivability within carious lesions under dental sealants. The authors found that sealants were effective in reducing total bacteria counts in carious lesions as well as reducing bacterial cultivability. There were no findings of significant increases in bacteria levels under sealants. The results were the same regardless of the sealant material. Significance to Health Center dental program: This article addresses one barrier to sealant placement, the concern about inadvertently sealing over caries. This concern has become an obstacle to implementation of school-based sealant programs. Sealant prevalence among high caries risk lower income children is around 30% well below the Healthy People 2010 objective of 50%. The reported findings do not support concerns about poorer outcomes associated with inadvertently sealing caries and suggest that when sealants are retained, bacterial access to fermentable substrates is blocked and bacteria do not appear capable of carrying out their cariogenic activity.
The entire article can accessed at: http://jada.ada.org/cgi/reprint/139/3/271
Caries Risk in Formerly Sealed Teeth
M. Malvitz and Barbara F. Gooch, Susan O. Griffin, Shellie Kolavic Gray, Dolores
This article reviewed five published studies that compare the risk of caries development in teeth with partially or fully lost sealants relative to the risk of caries development in teeth that never had received sealants. The authors found that individual teeth with partial or complete loss of sealant are not at a higher risk of developing caries than teeth that never had received sealants. Significance to Health Center dental program: This article addresses one barrier to sealant placement, the concern about the ability to provide a follow up sealant retention examination. This concern has become an obstacle to implementation of school-based sealant programs as well as transient patient populations. Sealant prevalence among high caries risk lower income children is around 30% well below the Healthy People 2010 objective of 50%. The reported findings suggest that a child should not be deprived of the benefits of a sealant even when follow-up care cannot be ensured.
The entire article can accessed at: http://jada.ada.org/cgi/content/full/140/4/415
Effects of Fluoride Dentifrices on Enamel Lesion Formation
S. Toda and J. D. Featherstone
This article uses an in vitro study design to compare three different fluoride dentifrice systems on caries remineralization. The study design is specific to the free fluoride ion concentration. The three fluoride compounds compared are (a) amine fluoride; (b) sodium monofluorophosphate; (c) sodium fluoride. The study confirms the free fluoride ion is the key to remineralization and sites NaMFP as effective in caries control. Significance to Health Center dental programs: It is obvious caries control is important in what we do. The problem is there is nothing new in this article. In the conclusion of the article it confirms articles published in 1991, 1993 and 2003. The only difference from previous published results is methodology, but the information is not new.
Follow the link to read the entire article: Journal of Dental Research 2008; 87(3) 228- 232
Preparing Practicing Dentists to Engage in Practice Based Research.
Timothy A. Derouen, PhD; Phelippe Hujoel, LTH, MSD, PhD; Brian Leroux, PhD, et al., for the Northwest Practice-based Research Collaborative in Evidenced-based DENTistry (PRECEDENT)
This article describes an educational program designed to prepare practicing dentists to engage in practice based research. A one educational program developed by PRECEDENT to educate practitioners in principles of good clinical research is described. The course or program has four components is built around the following questions: What is the question?; What are the options?; How do you evaluate the evidence?; and How do you conduct a study? Significance to Health Center dental programs: This article encourages practice based research. The Health Center with on site medical has the opportunity to ask and potentially answer questions that would be useful to the profession. Many practicing dentists are hesitant to begin research projects due to not knowing how to take on such a project. This article provides a method for the HC dentist to become comfortable with basic research methodologies and protocols. It is a model for practice based research that might be applicable to the HC model. Journal of the American Dental Association 2008; 14(2): 99 – 108: 339- 345 Abstract.
Improving the Public Health Workforce: Evaluation of a Training Course to Enhance Evidence-Based Decision Making
Mariah Dreisenger, Terry L. Leet, Elizabeth A. Baker, Kathleen N. Gillepsie, Beth Haas, and Ross C. Browson
An evidenced based public health (EBPH) was developed in 1997. The intention of the course was to train and enhance dissemination of EBPH into public health practice. An on-line evaluation was used to determine the impact of the course on course participants. The survey generated 107 respondents. The majority of these individuals were program directors, managers, or coordinators working in state health departments. The survey results showed barriers are still prevalent in dissemination of EBPH. Significance to Health Center dental programs: the application into oral health of this article is minimal. The article focuses on the evaluation of one course developed and given in the mid-west. It is geared toward state and local health departments not the clinical practice of oral health care. The focus is on the management of public health, not provision of care.
Follow the link to read the entire article: Journal of Public Health Management and Practice 2008; 14(2) ; 138 – 143. Abstract.
