Pediatric oral health performance measurement: current capabilities and future directions

This paper offers an overview of performance measurement in health care, provides a synopsis of the findings and recommendations of an Oral Health Expert Panel organized by the National Committee for Quality Assurance (NCQA) under contract with the Health Care Financing Administration (HCFA), and discusses challenges and possible future directions for pediatric oral health care performance measures development. Existing performance measures for pediatric oral health care are extremely limited; however, several new measures have been proposed and are in various stages of development and testing. Measures capable of being implemented in the short-term focus on access and use of services, rely on administrative data sources, and represent refinements and enhancements of current measures. Measures proposed for future implementation focus more on the effectiveness of care, consumer assessments of care and plan performance, and the value of services provided to enrolled children. Recommendations are targeted toward high-risk children who, for the most part, are covered by public programs (e.g., Medicaid and the Children's Health Insurance Program). Nevertheless, the entire set of recommended measures is considered to be relevant to all pediatric populations and applicable to all forms of dental care coverage, including state-administered programs and commercial third party arrangements.     

Genetics/epigenetics of oral premalignancy: current status and future research

Squamous cell carcinoma (SCC) of the oral and oropharyngeal region is the sixth most common malignancy in the world today. Despite numerous advances in treatment, long-term survival from this disease remains poor. Early detection can decrease both morbidity and mortality associated with this neoplasm. However, screening for potentially malignant disease is typically confounded by difficulty in discriminating between reactive/inflammatory lesions vs those lesions that are premalignant in nature. Furthermore, the histologic diagnosis of dysplasia can be subjective and is thus prone to a considerable range of interpretation. Similarly, no definitive, validated criteria exist for predicting which dysplastic lesions are most likely to progress to cancer over time. Given this state of science, the presence of dysplasia can only be used to indicate that an oral lesion may have an increased risk of malignant transformation. Molecular biomarkers capable of identifying the subset of lesions likely to progress to cancer are required to eliminate this clinical diagnostic dilemma. The purpose of this review is to assess the current state of knowledge regarding genetic/epigenetic alterations observed in oral mucosal premalignancy. In addition, recommendations for future research studies directed at defining the predictive capacity of specific biomarkers in this modeling are presented.     

Biomechanics of oral implants: future research directions

Biomechanical principles are relevant in dental implant design because all implants share a common biomechanical purpose: the restoration of masticatory function. Key problems confronting implant designers are: What are the in vivo loadings that dental implants must support? What factors govern interfacial stress transfer? How do biomechanical factors influence tissue reactions at the interface? Dental implant designers are currently in the position of trying to design implants without complete or accurate data to answer these biomechanical questions. These three questions and suggestions for future research are answered in this paper.     

Biomaterials and biomechanics of oral and maxillofacial implants: current status and future developments

Research in biomaterials and biomechanics has fueled a large part of the significant revolution associated with osseointegrated implants. Additional key areas that may become even more important--such as guided tissue regeneration, growth factors, and tissue engineering--could not be included in this review because of space limitations. All of this work will no doubt continue unabated; indeed, it is probably even accelerating as more clinical applications are found for implant technology and related therapies. An excellent overall summary of oral biology and dental implants recently appeared in a dedicated issue of Advances in Dental Research. Many advances have been made in the understanding of events at the interface between bone and implants and in developing methods for controlling these events. However, several important questions still remain. What is the relationship between tissue structure, matrix composition, and biomechanical properties of the interface? Do surface modifications alter the interfacial tissue structure and composition and the rate at which it forms? If surface modifications change the initial interface structure and composition, are these changes retained? Do surface modifications enhance biomechanical properties of the interface? As current understanding of the bone-implant interface progresses, so will development of proactive implants that can help promote desired outcomes. However, in the midst of the excitement born out of this activity, it is necessary to remember that the needs of the patient must remain paramount. It is also worth noting another as-yet unsatisfied need. With all of the new developments, continuing education of clinicians in the expert use of all of these research advances is needed. For example, in the area of biomechanical treatment planning, there are still no well-accepted biomaterials/biomechanics "building codes" that can be passed on to clinicians. Also, there are no readily available treatment-planning tools that clinicians can use to explore "what-if" scenarios and other design calculations of the sort done in modern engineering. No doubt such approaches could be developed based on materials already in the literature, but unfortunately much of what is done now by clinicians remains empirical. A worthwhile task for the future is to find ways to more effectively deliver products of research into the hands of clinicians.     

HIV disease: present status and future directions.

This review of the human immunodeficiency virus (HIV) epidemic shows that HIV has had and will have a major impact on dentistry, just as it has had on so many other aspects of medical practice and society. These areas include the prevention of HIV transmission in the dental care workplace, the early and safe care and treatment of those who are infected, and the protection of those who are vulnerable or made more vulnerable because of HIV infection. To do this, the dental professional must be educated about HIV and its diseases, their treatment, and what must be done to prevent HIV transmission. Early recognition and treatment of HIV-related oral diseases have become the norms of practice today. Although more and more dentists face potential exposure to HIV, excellent dental care can be provided while minimizing this risk.     

Present status and future directions in endodontic microbiology

Apical periodontitis and its different manifestations are caused primarily by bacterial infection of the root canal system. Bacteria are usually organized in biofilm communities and can colonize not only the main canal but also spread to other areas in the root canal system. In these regions, bacteria are more difficult to reach and eliminate during treatment. The knowledge of endodontic infections has substantially increased over the past 4 decades, including the main species involved in the different forms of disease, their virulence factors, interactions, ecology, organization and spatial distribution in the root canal system, patterns of antimicrobial resistance, and so on. However, there is a need for all of this information to be translated into improvements in clinical practice and treatment outcomes. This article reviews the present status of endodontic microbiology, discusses perspectives for future research and directions, and emphasizes the need for a call to action in the field of applied endodontic microbiology.     

Oral chronic graft‐versus‐host disease: current pathogenesis,therapy, and research

Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. In this review, we discuss the presentation, prevalence, diagnosis, and treatment of oral manifestations in chronic graft‐versus‐host disease (cGVHD), which is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. We assess current general knowledge of systemic and oral cGVHD and present general treatment recommendations based on literature review and our clinical experience. Additionally, we review areas where the understanding of oral cGVHD could be improved by further research and address tools with which to accomplish the long‐term goal of providing better health and quality of life to patients with cGVHD.     

Dental hygiene education in Japan: present status and future directions

The aim of this report is to provide basic information about the historical development, current status and future needs of education and training of dental hygienists in Japan. The first formal training of dental hygienists in Japan started at Tokyo in 1949. Restructure and modification of the dental hygiene education system has been reiterated over the years in order to satisfy the needs of the constantly changing society. Although previously only vocational training was provided for dental hygienists, higher-level education has been conducted. The present legislation of dental hygiene has gone through a complicated process. The student should take the dental hygienist licensing examination which is held once a year by the National Board organized by the Ministry of Health, Labour and Welfare. Currently there are 136 dental hygiene schools and the total enrolment is about 7000. The duration of dental hygiene education course has been prolonged from 2 to 3 years since 2001. In 2004, the 4-year course started. The 2-year dental hygiene education program is expected to be replaced with the 3- and 4-year courses by 2010. The dental hygiene education system in Japan will be improved in many ways as dental hygienists are expected to participate in health promotion and preventive care, and to gain knowledge of the economics and organization of health care in relation to oral hygiene.     

Salivary enhancement: current status and future therapies.

Saliva provides the principal protective milieu for teeth by modulating oral microbial ecosystems and reversing the initial phases of caries development. Patients with inadequate salivary function are at increased risk for dental decay. Therefore, it is likely that therapies that increase overall fluid output of these individuals will reverse early carious lesions. The most common causes of salivary dysfunction are medication usage, Sj?gren's syndrome, and damage of salivary parenchyma during therapeutic irradiation. For patients with remaining functional acinar tissue, treatment with the parasypathomimetic secretogogues pilocarpine and Cevimeline may provide relief. However, these medications do not benefit all patients. The possibilities of using gene therapy and tissue engineering to develop treatments for those with severe salivary dysfunction are discussed.     

Oral cancer prevention: current status and future promise

Head and neck carcinogenesis is a multistep process requiring the accumulation of multiple genetic alterations in epithelial cells. These alterations allow growth advantages over other cells and the development of malignant phenotypes.     

The impact of smoking on oral and nasopharyngeal bacterial flora

Exposure to direct and passive tobacco smoking has significant impact on the gingival and oropharyngeal flora. The effects of exposure to smoking are evident in both children as well as adults. It increases the acquisition of periodontal pathogens and periodontal disease, colonization by respiratory pathogens, and the occurrence of upper respiratory tract infections, including otitis media. The flora of smokers contains fewer aerobic and anaerobic organisms with interfering activity against bacterial pathogens and harbors more potential pathogens as compared with the flora of non-smokers. The high number of pathogens and the low number of interfering organisms found in the nasopharynx of smokers revert to normal levels after complete cessation of smoking. Since parents who smoke harbor more potential pathogens and fewer interfering organisms, they may serve as a source of pathogens that can colonize and/or infect their children. The reduction in the number of members of the normal flora that interfere with the growth of pathogens and the greater adherence of bacterial pathogens to the oral mucosa are associated with the greater frequency of respiratory infections. Analysis of the data presented illustrates the adverse effects of direct and indirect exposure to smoking on colonization with potential pathogens.