Comparison of the intakes of sugars by young children with and without dental caries experience

BACKGROUND: Relationships among sugars and dental caries in contemporary societies are unclear. The authors describe young children's intakes of nonmilk extrinsic (NME) and intrinsic/milk sugars and relate those intakes to dental caries. METHODS: The authors conducted cross-sectional analyses of dietary data collected from the Iowa Fluoride Study using three-day diaries for subjects at ages 1, 2, 3, 4 and 5 years and for subjects aged 1 through 5 years according to dental caries experience at 4.5 to 6.9 years of age. They categorized foods and beverages as containing NME or intrinsic/milk sugars. RESULTS: Subjects' total, NME, food NME and intrinsic/milk sugars intakes at ages studied did not differ between subjects with and without caries experience. Beverage NME sugars intakes at age 3 years predicted caries (P < .05) in logistic regression models adjusted for age at dental examination and for fluoride intake. CONCLUSIONS: Dental caries is a complex, multifactorial disease process dependent on the presence of oral bacteria, a fermentable carbohydrate substrate and host enamel. A simple NME-intrinsic/milk sugars categorization appears insufficient to capture the complex dietary component of the caries process. CLINICAL IMPLICATIONS: Cariogenicity is more likely a function of the food and/or beverage vehicle delivering the sugar and the nature of exposure-that is, frequency and length of eating events-than of the sugar's categorization.     

Hepatitis B virus transmissions associated with a portable dental clinic,West Virginia, 2009

BackgroundAlthough hepatitis B virus (HBV) transmission in dental settings is rare, in 2009 a cluster of acute HBV infections was reported among attendees of a two-day portable dental clinic in West Virginia.MethodsThe authors conducted a retrospective investigation by using treatment records and volunteer logs, interviews of patients and volunteers with acute HBV infection as well as of other clinic volunteers, and molecular sequencing of the virus from those acutely infected.ResultsThe clinic was held under the auspices of a charitable organization in a gymnasium staffed by 750 volunteers, including dental care providers who treated 1,137 adults. Five acute HBV infections—involving three patients and two volunteers—were identified by the local and state health departments. Of four viral isolates available for testing, all were genotype D. Three case patients underwent extractions; one received restorations and one a dental prophylaxis. None shared a treatment provider with any of the others. One case volunteer worked in maintenance; the other directed patients from triage to the treatment waiting area. Case patients reported no behavioral risk factors for HBV infection. The investigation revealed numerous infection control breaches.ConclusionsTransmission of HBV to three patients and two volunteers is likely to have occurred at a portable dental clinic. Specific breaches in infection control could not be linked to these HBV transmissions.Practical ImplicationsAll dental settings should adhere to recommended infection control practices, including oversight; training in prevention of bloodborne pathogens transmission; receipt of HBV vaccination for staff who may come into contact with blood or body fluids; use of appropriate personal protective equipment, sterilization and disinfection procedures; and use of measures, such as high-volume suction, to minimize the spread of blood.     

The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence

BACKGROUND: Concern about inadvertently sealing over caries often prevents dentists from providing dental sealants. The objective of the authors' review was to examine the effects of sealants on bacteria levels within caries lesions under dental sealants. METHODS: The authors searched electronic databases for comparative studies examining bacteria levels in sealed permanent teeth. To measure the effect of sealants on bacteria levels, they used the log(10) reduction in mean total viable bacteria counts (VBC) between sealed and not-sealed caries and the percentage reduction in the proportion of samples with viable bacteria. RESULTS: Six studies--three randomized controlled trials, two controlled trials and one before-and-after study-were included in the analysis. Although studies varied considerably, there were no findings of significant increases in bacteria under sealants. Sealing caries was associated with a 100-fold reduction in mean total VBC (four studies, 138 samples). Sealants reduced the probability of viable bacteria by about 50.0 percent (four studies, 117 samples). CONCLUSIONS: The authors found that sealants reduced bacteria in carious lesions, but that in some studies, low levels of bacteria persisted. These findings do not support reported concerns about poorer outcomes associated with inadvertently sealing caries. CLINICAL IMPLICATIONS: Practitioners should not be reluctant to provide sealants-an intervention proven to be highly effective in preventing caries-because of concerns about inadvertently sealing over caries.     

Preventing percutaneous injuries among dental health care personnel

BACKGROUND: The Occupational Safety and Health Administration and the Centers for Disease Control and Prevention (CDC) recommend that health care personnel (HCP) adopt safer work practices and consider using medical devices with safety features. This article describes the circumstances of percutaneous injuries among a sample of hospital-based dental HCP and estimates the preventability of a subset of these injuries: needlesticks. METHODS: The authors analyzed percutaneous injuries reported by dental HCP in the CDC's National Surveillance System for Health Care Workers (NaSH) from December 1995 through August 2004 to describe the circumstances. RESULTS: Of 360 percutaneous injuries, 36 percent were reported by dentists, 34 percent by oral surgeons, 22 percent by dental assistants, and 4 percent each by hygienists and students. Almost 25 percent involved anesthetic syringe needles. Of 87 needlestick injuries, 53 percent occurred after needle use and during activities in which a safety feature could have been activated (such as during passing and handling) or a safer work practice used. CONCLUSIONS: NaSH data show that needlestick injuries still occur and that a majority occur at a point in the workflow at which safety syringes--in addition to safe work practices and recapping systems--could contribute to injury prevention. CLINICAL IMPLICATIONS: All dental practices should have a comprehensive written program for preventing needlestick injuries that describes procedures for identifying, screening and, when appropriate, adopting safety devices; mechanisms for reporting and providing medical follow-up for percutaneous injuries; and a system for training staff members in safe work practices and the proper use of safety devices.     

A usability evaluation of four commercial dental computer-based patient record systems

BackgroundThe usability of dental computer-based patient record (CPR) systems has not been studied, despite early evidence that poor usability is a problem for dental CPR system users at multiple levels.MethodsThe authors conducted formal usability tests of four dental CPR systems by using a purposive sample of four groups of five novice users. The authors measured task outcomes (correctly completed, incorrectly completed and incomplete) in each CPR system while the participants performed nine clinical documentation tasks, as well as the number of usability problems identified in each CPR system and their potential relationship to task outcomes. The authors reviewed the software application design aspects responsible for these usability problems.ResultsThe range for correctly completed tasks was 16 to 64 percent, for incorrectly completed tasks 18 to 38 percent and for incomplete tasks 9 to 47 percent. The authors identified 286 usability problems. The main types were three unsuccessful attempts, negative affect and task incorrectly completed. They also identified six problematic interface and interaction designs that led to usability problems.ConclusionThe four dental CPR systems studied have significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption.Clinical ImplicationsThe significant number of data entry errors raises concerns about the quality of documentation in clinical practice.     

Risk of adrenal crisis in dental patients: Results of a systematic search of the literature

BackgroundThe authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.MethodsThe authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.ResultsOf 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as “suggestive of adrenal crisis” and two cases as “consistent with adrenal crisis.” Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.ConclusionsAdrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.Clinical ImplicationsRisk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.     

The impact of the Great Recession on untreated dental caries among kindergarten students in North Carolina

BackgroundThe authors conducted a study to determine the impact of the Great Recession on untreated dental caries in kindergarten-aged children in North Carolina (NC).MethodsDuring the seven school years from 2003–2004 through 2009–2010, the state dental public health program assessed 608,339 kindergarten students for untreated decayed primary teeth (dt) as part of the statewide public health surveillance system. The authors aggregated observations to the school level and matched 7,660 school-year observations for 1,215 schools to National School Lunch Program (NSLP) participation rates, their primary economic indicator of the Great Recession. The authors included additional county-level economic indicators and measures of dentist supply and Medicaid enrollment. They used ordinary least squares regression with school-and year-fixed effects to examine the association of variables with the proportion of children with more than one dt for all schools and for schools with a greater than 10 percent increase in NSLP participation after 2006.ResultsThe authors found a small but statistically significant association between the proportion of children in the schools participating in the NSLP and the proportion of kindergarten students who had more than one dt (β, 0.031; 95 percent confidence interval [CI], 0.001 to 0.0604). This association was greater in schools that had a greater than 10 percent increase in NSLP participation (β, 0.068; 95 percent CI, ?0.007 to 0.143). Regression estimates indicate a 1.3– and 3.1–percentage point cumulative increase in the proportion of children with more than one dt during the period from 2008 through 2009 for all schools and high-risk schools, respectively.ConclusionIncreased NSLP enrollment was associated with less treatment for dental caries in 5-year-old children.Practical ImplicationsFewer children are receiving needed dental treatment because of the Great Recession. Recent gains made in the treatment of dental caries in children in NC have slowed as a result.     

Advancing infection control in dental care settings: Factors associated with dentists' implementation of guidelines from the Centers for Disease Control and Prevention

Background and OverviewThe authors set out to identify factors associated with implementation by U.S. dentists of four practices first recommended in the Centers for Disease Control and Prevention's Guidelines for Infection Control in Dental Health-Care Settings—2003.MethodsIn 2008, the authors surveyed a stratified random sample of 6,825 U.S. dentists. The response rate was 49 percent. The authors gathered data regarding dentists' demographic and practice characteristics, attitudes toward infection control, sources of instruction regarding the guidelines and knowledge about the need to use sterile water for surgical procedures. Then they assessed the impact of those factors on the implementation of four recommendations: having an infection control coordinator, maintaining dental unit water quality, documenting percutaneous injuries and using safer medical devices, such as safer syringes and scalpels. The authors conducted bivariate analyses and proportional odds modeling.ResultsResponding dentists in 34 percent of practices had implemented none or one of the four recommendations, 40 percent had implemented two of the recommendations and 26 percent had implemented three or four of the recommendations. The likelihood of implementation was higher among dentists who acknowledged the importance of infection control, had practiced dentistry for less than 30 years, had received more continuing dental education credits in infection control, correctly identified more surgical procedures that require the use of sterile water, worked in larger practices and had at least three sources of instruction regarding the guidelines. Dentists with practices in the South Atlantic, Middle Atlantic or East South Central U.S. Census divisions were less likely to have complied.ConclusionsImplementation of the four recommendations varied among U.S. dentists. Strategies targeted at raising awareness of the importance of infection control, increasing continuing education requirements and developing multiple modes of instruction may increase implementation of current and future Centers for Disease Control and Prevention guidelines.The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, Atlanta.The authors thank Jon Ruesch, who when this study was conducted was the director, Survey Center, American Dental Association, Chicago, for his effort in the collection of the data for this research project. Mr. Ruesch is now retired.     

Using a caries activity test to predict caries risk in early childhood

BACKGROUND: The authors conducted a two-year longitudinal study to show the predictive abilities of a caries activity test (Cariostat, Dentsply-Sankin, Tokyo), and to include the predicted screening indexes that were based on previous caries activity test results and lifestyle factors that influence caries activity. METHODS: The subjects were 1,206 children born in 2000. These children participated in health examinations at 18 months, 2 years and 3 1/2 years of age at Kurashiki-City Public Health Center in Kurashiki-City, Japan. Two of the authors performed caries activity tests at 18-month and 2-year examinations. Questionnaires regarding the patient's lifestyle were mailed to each participant's parents or guardians. The authors analyzed these questionnaires to evaluate lifestyle factors that made participants susceptible to caries. RESULTS: A caries activity test score at 18 months of age not only reflected caries incidence but also predicted caries incidence and screening results in 2- and 3 1/2-year-old children. A caries activity test score at 2 years of age both reflected and predicted children's caries incidence and screening results at 3 1/2 years of age. Breast-feeding and use of the bottle to intake liquids other than water produced significant caries susceptibility in 18-month-old children. Additionally, increased frequency and total time of sucrose intake put 2-year-old children at high risk of developing caries and failure of parental brushing produced a high risk in 3 1/2-year-old children. CONCLUSIONS: A caries activity test could predict 3 1/2-year-old children's caries risk based on 18-month and 2-year-old test results. Early weaning, less sucrose intake and toothbrushing by parents were effective in reducing a child's caries risk. CLINICAL IMPLICATIONS: The caries activity test is more useful than oral examination because it can indicate the need for caries-preventive treatment before a carious lesion actually is manifest.     

Minimally invasive management of dental caries: contemporary teaching of posterior resin-based composite placement in U.S. and Canadian dental schools

BackgroundResin-based composites are an increasingly popular material for restoring posterior teeth, permitting minimally invasive cavity preparations and esthetic restorations. The authors investigated current teaching of the placement of posterior resin-based composites in U.S. and Canadian dental schools.MethodsIn late 2009 and early 2010, the authors, with the assistance of the Consortium of Operative Dentistry Educators (CODE), invited 67 dental schools to participate in an Internet-based survey.ResultsThe response rate was 73 percent. Although all schools taught the placement of resin-based composites in occlusal and most occlusoproximal cavities, eight schools (16 percent) did not teach placement of three-surface occlusoproximal resin-based composite restorations in permanent molars. Resin-based composites accounted for 49 percent of direct posterior restorations placed by dental students in 2009 and 2010, a 30 percent increase from 2005.ConclusionsTeaching placement of posterior resin-based composites continues to increase in dental schools in the United States and Canada, with predoctoral students gaining, on average, an equal amount of experience placing posterior resin-based composites and amalgams in terms of numbers of restorations.Clinical ImplicationsEvidence-based, up-to-date teaching programs, including those in operative dentistry, are needed to best prepare students for careers in dentistry.     

Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists

BackgroundThe authors investigated the prevention and treatment of white-spot lesions (WSLs) during and after orthodontic therapy from the perspective of general dentists and orthodontists.MethodsThe authors administered a cross-sectional survey to general dentists (n = 191) and orthodontists (n = 305) in Virginia, Maryland and North Carolina.ResultsSixty-nine percent of general dentists and 76 percent of orthodontists recommended in-office fluoride treatment for patients with severe WSLs immediately after orthodontic treatment. Sixty-nine percent of general dentists reported that they had treated WSLs during the previous year, and 37 percent of orthodontists reported that they had removed braces because of patients' poor oral hygiene. Sixty percent of orthodontists referred patients with WSLs to general dentists for treatment. Eighty-five percent of orthodontists responded that they encouraged patients to use a fluoride rinse as a preventive measure. More than one-third of general dentists indicated that severe WSLs after orthodontic treatment could have a negative effect on their perception of the treating orthodontist.ConclusionsWSLs are a common complication of orthodontic treatment and their presence can result in a negative perception of the treating orthodontist by the patient's general dentist.Clinical implicationsGeneral dentists and orthodontists should work together to prevent the development of WSLs in their patients. Treatment with fluoride supplements and motivating and training patients to practice good oral hygiene will help achieve this goal. Treatment after debonding should include the topical application of low concentrations of fluoride.     

Metabolic syndrome: pathogenesis, medical care and dental implications

BACKGROUND: The dental literature contains little information about metabolic syndrome (MetS) and its dental implications. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 2000 through 2005, using the term "metabolic syndrome" to define its pathophysiology, medical treatment and dental implications. RESULTS: MetS is the co-occurrence of abdominal obesity, hyper-triglyceridemia, reduced high-density lipoprotein cholesterol levels, hypertension and impaired fasting glucose, which results from consumption of a high-calorie diet and decreased levels of physical activity superimposed on the appropriate genetic setting. Components of MetS synergistically promote the development of atherosclerosis, resulting in myocardial infarction and stroke. CLINICAL IMPLICATIONS: Deteriorating oral health status is associated with worsening of the atherogenic profile. Tooth loss often results in chewing difficulties because of inadequate occlusive surfaces and may lead to alterations in food selection and dietary quality. This, in turn, adversely affects body composition and nutritional status, both of which are related to vascular health. Dentists should develop treatment plans that preserve and restore the dentition, thus ensuring maximum masticatory efficiency and affording patients the optimum opportunity to consume food that will not foster atherogenesis.     

Early childhood caries screening tools: a comparison of four approaches

BackgroundEarly childhood caries (ECC) is prevalent and consequential. Risk assessment tools have been proposed that can be used to identify children who require intensive interventions. In this study, the authors compare four approaches for identifying children needing early and intensive intervention to prevent or minimize caries experience for their accuracy and clinical usefulness.MethodsThe authors screened 229 predominantly low-income Hispanic children younger than 3 years with ECC and 242 without ECC by using the American Academy of Pediatric Dentistry's Caries-risk Assessment Tool (CAT) and the optional screening measure of culturing Streptococcus mutans. The authors compared four approaches (CAT, CAT minus socioeconomic status, CAT minus socioeconomic status plus mutans streptococci [MS] and MS alone) for accuracy and clinical usefulness.ResultsThe results of the CAT demonstrated high sensitivity (100.0 percent) and negative predictive value (NPV) (100.0 percent) but low specificity (2.9 percent) and positive predictive value (PPV) (49.4 percent). The MS culture alone had the highest combination of accuracy and clinical usefulness (sensitivity, 86.5 percent; specificity, 93.4 percent; PPV, 92.5 percent; NPV, 87.9 percent). When we removed the socioeconomic status element, the CAT's performance improved.ConclusionsSalivary culture of MS alone in a population of young, low-income Hispanic childrenoutperformed the CAT and variations on the CAT for test accuracy (sensitivity and specificity) and clinical usefulness (predictive values).Clinical ImplicationsScreening for ECC by using salivary MS cultures and variations on the CAT are promising approaches for identifying children who need early and intensive intervention to prevent or minimize caries experience.     

Prenatal exposure to dental amalgam: evidence from the Seychelles Child Development Study main cohort

BackgroundDental amalgams contain approximately 50 percent metallic mercury and emit mercury vapor during the life of the restoration. Controversy surrounds whether fetal exposure to mercury vapor resulting from maternal dental amalgam restorations has neurodevelopmental consequences.MethodsThe authors determined maternal amalgam restoration status during gestation (prenatal exposure to mercury vapor [Hg⁰]) retrospectively in 587 mother-child pairs enrolled in the Seychelles Child Development Study, a prospective longitudinal cohort study of the effects of prenatal and recent postnatal methylmercury (MeHg) exposure on neurodevelopment. They examined covariate-adjusted associations between prenatal maternal amalgam restoration status and the results of six age-appropriate neurodevelopmental tests administered at age 66 months. The authors fit the models without and with adjustment for prenatal and recent postnatal MeHg exposure metrics.ResultsThe mean number of maternal amalgam restorations present during gestation was 5.1 surfaces (range, 1–22) in the 42.4 percent of mothers who had amalgam restorations. The authors found no significant adverse associations between the number of amalgam surfaces present during gestation and any of the six outcomes, with or without adjustment for prenatal and postnatal MeHg exposure. Results of analyses with the secondary metric, prenatal amalgam occlusal point scores, showed an adverse association in boys only on a letter- and word-identification subtest of a frequently used test of scholastic achievement, whereas girls scored better on several other tests with increasing exposure.ConclusionsThis study’s results provide no support for the hypothesis that prenatal Hg⁰ exposure arising from maternal dental amalgam restorations results in neurobehavioral consequences in the child. These findings require confirmation from a prospective study of coexposure to MeHg and Hg⁰.     

Assessment of treatment provided by dental health aide therapists in Alaska: a pilot study

BackgroundDental health aide therapists (DHATs) in Alaska are authorized under federal law to provide certain dental services, including irreversible dental procedures. The author conducted this pilot study to determine if treatments provided by DHATs differ significantly from those provided by dentists, to determine if DHATs in Alaska are delivering dental care within their scope of training in an acceptable manner and to assess the quality of care and incidence of reportable events during or after dental treatment.MethodsThe author audited the dental records of patients treated by dentists and DHATs who perform similar procedures for selected variables. He reviewed the records of 640 dental procedures performed in 406 patients in three health corporations.ResultsThe author found no significant differences among the provider groups in the consistency of diagnosis and treatment or postoperative complications as a result of primary treatment. The patients treated by DHATs had a mean age 7.1 years younger than that of patients treated by dentists, and the presence or adequacy of radiographs was higher among patients treated by dentists than among those treated by DHATs, with the difference being concentrated in the zero- to 6-year age group.ConclusionsNo significant evidence was found to indicate that irreversible dental treatment provided by DHATs differs from similar treatment provided by dentists. Further studies need to be conducted to determine possible long-term effects of irreversible procedures performed by nondentists.Clinical ImplicationsA need to improve oral health care for American Indian/Alaska Native populations has led to an approach for providing care to these groups in Alaska. The use of adequately trained DHATs as part of the dental team could be a viable long-term solution.