Predicting anxiety during dental treatment using patients'self-reports: less is more

BACKGROUND: Self-reported dental fear measures seldom are used in clinical practice to assess patients' fears. This study examined how well dental fear measures predicted anxious behaviors displayed during dental treatment. METHODS: One hundred eight adult patients (54 percent female) in a periodontology clinic completed several paper-and-pencil demographic, dental fear and general anxiety measures before treatment. Dental practitioners, blinded to their patients' responses, rated their patients' anxiety during treatment on a series of 100-millimeter visual analog scales. RESULTS: Higher Dental Fear Survey scores, younger age, more invasive treatment type and previous avoidance of dental care because of a bad experience all were predictive of greater observed anxiety. Neither self-reported nor observed anxiety was affected by previous experience with a particular practitioner or treatment. CONCLUSIONS: Dentists may assess patients' anxiety quickly and accurately with the Dental Fear Survey or a similar measure, as well as by asking patients about their current dental attendance and previous dental experiences.     

The impact of oral disease and nonsurgical treatment on bacteremia in children

BACKGROUND: The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children. METHODS: The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4-8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia. RESULTS: The authors enrolled 100 children (aged 1-8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 +/- 2.5 standard deviation [SD] versus 1.5 +/- 1.6 SD, P = .04), while they found almost no differences for draw 2. CONCLUSIONS: This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.     

Cost-effectiveness of treatments for temporomandibular disorders: biopsychosocial intervention versus treatment as usual

BACKGROUND: The authors conducted a randomized clinical trial to evaluate the cost-effectiveness of a biopsychosocial intervention with patients who are at high risk (HR) of progressing from acute to chronic TMD-related pain. METHODS: The authors classified 96 patients with acute TMD (less than six months' duration) as HR according to a predictive algorithm and randomized them into an early intervention (EI) or a nonintervention (NI) group. The NI group received a biopsychosocial treatment that included cognitive behavioral skills training and biofeedback. Both groups were followed up for one year. The authors collected TMD cost data throughout the year. RESULTS: The authors found that the EI group spent significantly fewer jaw-related health care dollars, relative to the NI group, from intake to the one-year follow-up. CONCLUSION AND CLINICAL IMPLICATIONS: The reduced jaw-related health care expenditures for patients in the EI group compared with expenditures for patients in the NI group at one year suggest that an early biopsychosocial intervention is a cost-effective measure in dealing with often unnecessarily costly TMD-related pain.     

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.     

Adverse events associated with chlorhexidine use: results from the Department of Veterans Affairs Dental Diabetes Study

BACKGROUND: The authors report adverse events (AEs) related to the use of chlorhexidine gluconate mouthrinse in a clinical trial of the efficacy of periodontal treatment in older adults with diabetes. METHODS: Participants were U.S. veterans with uncontrolled diabetes (hemoglobin A(1c) value > or =8.5 percent) and periodontal disease. Treatment included periodontal scaling, 0.12 percent chlorhexidine lavage during ultrasonic scaling and use of chlorhexidine mouthrinse at home. RESULTS: Forty-four (31 percent) of 140 subjects reported having AEs. Most common were taste changes and tooth staining, sore mouth and/or throat, tongue irritation and wheezing/shortness of breath; the latter was reported more commonly before chlorhexidine use than after. Only body mass index greater than 30 was significantly related to AEs. CONCLUSIONS: AEs are common among subjects using chlorhexidine mouthrinse. Most AEs (taste change and staining) were resolved easily by subjects' discontinuing mouthrinse use and receiving dental prophylaxis. No serious AEs were reported. CLINICAL IMPLICATIONS: Clinicians should advise patients using chlorhexidine mouthrinse of possible side effects. If necessary, patients should discontinue mouthrinse use and obtain medical care. Careful monitoring of AEs in patients using chlorhexidine is warranted.     

Implications of medical screenings of patients arriving for dental treatment: The results of a comprehensive laboratory screening

BackgroundThe authors conducted medical laboratory screenings in a dental setting to determine the relationships between the laboratory test results and self-reported medical health findings.MethodsThe authors collected serum, urine and medical histories from 171 patients (116 [68 percent] women; mean age, 43.4 years) who arrived for dental treatment as a component of a clinical trial and performed complete blood cell counts, standard blood chemistry panels and urinalysis on the samples.ResultsThe authors found 414 abnormal laboratory test results (an average of 2.42 per patient). Eighty-three percent of participants had one or more abnormal test results, 83 percent had abnormal test results and did not indicate a relevant disease in their medical history, and 18 percent had laboratory test results outside the 99 percent reference range (that is, > three standard deviations from the mean). Abnormal test results were significantly associated with sex, age, race and medical history (P < .05). Abnormal test results associated with kidney disease were related to patients with cardiovascular disease and diabetes, as well as those who tended to be on average older than 50 years.ConclusionsThe high frequency of significant abnormal laboratory test results detected in this study suggests that many patients may be unaware of their medical statuses.Practical ImplicationsAbnormal laboratory test results are detected frequently in the serum and urine of patients arriving for dental treatment, which could indicate undiagnosed disease and less than optimal medical management.     

Chemomechanical caries removal in children: an operator's and pediatric patients' responses

BACKGROUND: This study investigated an operator's and pediatric patients' responses to chemo-mechanical caries removal (CMCR) versus the traditional method (TM) of caries removal using a handpiece and a round bur when treating dentinal-depth occlusal lesions with minimal enamel access in primary molars. METHODS: Data were collected from 50 children at baseline and before, during and after caries removal using CMCR or TM. The subjects in the CMCR group were on average younger than the subjects in the TM group and had more deep lesions. RESULTS: The operator rated CMCR as needing more clinical and technical effort and more total effort than TM. He was less satisfied with CMCR than with TM. Subjects in the CMCR group perceived the time needed for treatment as significantly longer than did the subjects in the TM group. Fear of the dentist decreased in subjects in the TM group from before to after the operative appointment, while it increased in subjects in the CMCR group. CONCLUSIONS: The authors found no direct advantage in using CMCR over using TM. CLINICAL IMPLICATIONS: CMCR cannot be recommended as an alternative to TM when treating dentinal depth occlusal lesions with minimal access in primary molars.     

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.     

Pain catastrophizing in dental patients: Implications for treatment management

Background”Pain catastrophizing“ refers to an exaggerated negative mental set brought to bear during an actual or anticipated painful experience. A patient's perception of a dental care experience as catastrophic can result not only in poor satisfaction with the therapy but also in avoidance of necessary treatments, resulting in the deterioration of oral health.MethodsThe author reviewed literature regarding pain catastrophizing regarding dental treatment as well as behavioral models related to catastrophizing.ResultsPeople who catastrophize show excessive attention to pain (rumination), exaggerate the threat value of pain (magnification) and feel unable to cope with their suffering (helplessness). During dental treatments, greater pain catastrophizing is associated with increased pain, dental anxiety and negative thoughts regarding pain and dental procedures.ConclusionsIt is important that clinicians identify dental patients who catastrophize so as to plan and provide the best treatment for their needs.Practical ImplicationsTo manage the care of patients who catastrophize, the clinician can actively probe patients' pain experience, help them reappraise threat, manipulate their attention to pain and improve dentist-patient communication.     

Dental treatment intensity in frail older adults in the last year of life

BackgroundPalliative care focusing on pain and infection is recommended for patients who are terminally ill. It is difficult to implement this strategy in practice because of the lack of clear guidelines. The authors conducted a study to examine dental treatment provided to a group of long-term care (LTC) residents in the last year of life.MethodsThe authors retrospectively followed 197 LTC residents (60 years or older) in the last year of life to death. On the basis of the dental services patients received between the new patient examination and death, the authors categorized the patients into three groups: no care (NC), limited care (LC) and usual care (UC). The authors developed a multivariable continuation ratio logit model with shared regression coefficients across two logits to identify the factors associated with the end-of-life dental care pattern.ResultsThe authors found that 50.8 percent of the patients received NC before death. Among those who received treatment, 62.9 percent received UC, and 60.7 percent of the patients in the UC group had completed their treatment in the last three months of life. A three-month increment in survival and having dental insurance resulted in 1.74 (95 percent confidence interval [CI], 1.32–2.30) and 2.59 (95 percent CI, 1.03–6.52) times greater odds, respectively, of receiving some dental treatment before death. Neither survival nor dental insurance, however, was associated with dental care intensity in the last year of life (that is, UC versus LC).ConclusionsWhile most of the patients who were in the last year of life received insufficient dental care, comprehensive treatment was provided commonly to frail patients at the end of life, raising questions about quality of care.Practical ImplicationsPalliative oral health management needs to be revisited to improve quality of care for frail older adults at the end of life.     

The creation and development of the dental practice-based research network

BACKGROUND: Practice-based research networks (PBRNs) are consortia of practices committed to improving clinical practice. They have become more common and include dental PBRNs. Few reports in the literature, however, have addressed the structure and function of dental PBRNs. METHODS: After initial development in Alabama, the Dental Practice-Based Research Network (DPBRN) now includes practitioner-investigators in seven U.S. states and three Scandinavian countries. Although most of the function and structure was developed at the inception of DPBRN, valuable input from practitioner-investigators has led to significant ongoing refinements. RESULTS: DPBRN practitioner-investigators have contributed to research at each stage of its development, leading to substantial improvements in study designs and customization of study protocols to their daily clinical practices. Practitioner-investigators also have helped refine the structure and function of DPBRN to foster the potential impact of research. CONCLUSIONS: Practitioners from diverse settings are partnering with fellow practitioners and academics to improve daily clinical practice and meet the needs of clinicians and their patients in DPBRN. Practice Implications. Dental PBRNs can improve clinical practice by engaging dentists in the development and implementation of studies that are of direct interest to them and their patients, and by incorporating findings from these studies into their daily clinical practice.     

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.     

Concordance between clinical practice and published evidence: Findings from The National Dental Practice-Based Research Network

BackgroundDocumenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network (“the network”).MethodsNetwork dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent (“1”) or inconsistent (“0”) with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.ResultsThe authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).ConclusionDentists reported a medium-range concordance between practice and published evidence.Practical ImplicationsEfforts to bring research findings into routine practice are needed.     

Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice

BackgroundEffective and safe drug therapy for the management of acute postoperative pain has relied on orally administered analgesics such as ibuprofen, naproxen and acetaminophen, or N-acetyl-p-aminophenol (APAP), as well as combination formulations containing opioids such as hydrocodone with APAP. The combination of ibuprofen and APAP has been advocated in the last few years as an alternative therapy for postoperative pain management. The authors conducted a critical analysis to evaluate the scientific evidence for using the ibuprofen-APAP combination and propose clinical treatment recommendations for its use in managing acute postoperative pain in dentistry.Types of Studies ReviewedThe authors used quantitative evidence-based reviews published by the Cochrane Collaboration to determine the relative analgesic efficacy and safety of combining ibuprofen and APAP. They found additional articles by searching the Ovid MEDLINE, PubMed and http://ClinicalTrials.gov databases.ConclusionsThe results of the quantitative systematic reviews indicated that the ibuprofen-APAP combination may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations. In addition, the authors found several randomized controlled trials that also indicated that the ibuprofen-APAP combination provided greater pain relief than did ibuprofen or APAP alone after third-molar extractions. The adverse effects associated with the combination were similar to those of the individual component drugs.Practical ImplicationsCombining ibuprofen with APAP provides dentists with an additional therapeutic strategy for managing acute postoperative dental pain. This combination has been reported to provide greater analgesia without significantly increasing the adverse effects that often are associated with opioid-containing analgesic combinations. When making stepwise recommendations for the management of acute postoperative dental pain, dentists should consider including ibuprofen-APAP combination therapy.     

Predoctoral teaching of temporomandibular disorders: a survey of U.S. and Canadian dental schools

BACKGROUND: In the United States and Canada, there are no specific curriculum guidelines for predoctoral dental education in the field of temporomandibular disorders (TMDs). This situation has the potential to cause confusion for new graduates. METHODS: The authors sent an 11-question survey regarding predoctoral teaching of TMDs to the appropriate faculty members in all U.S. and Canadian dental schools either electronically or via the postal service between June and December 2005. RESULTS: Predoctoral teaching of TMD--both didactic and clinical aspects--has progressed. Some schools, however, do not address these topics adequately, while others teach outdated concepts. CONCLUSIONS: Both qualitative and quantitative standards are needed to ensure that all predoctoral dental students learn about the diagnosis and treatment of nondental orofacial pain problems. Practice Implications. Owing to the lack of standardized predoctoral teaching of TMD, U.S. or Canadian patients with TMD or facial pain are at risk when seeking appropriate primary care for their problems.     

Neurological outcomes in children with and without amalgam-related mercury exposure: seven years of longitudinal observations in a randomized trial

BACKGROUND: Although large-scale, randomized trials involving children have been completed and their results demonstrate an absence of neurobehavioral effects from clinical exposure to mercury amalgam, neurological findings from such studies have not been reported. METHODS: The authors conducted a randomized, prospective trial examining the safety of dental amalgam in which 507 children aged 8 through 12 years were assigned to treatment with either amalgam or resin-based composite. During seven years of follow-up, the authors performed annual clinical neurological examinations, including an evaluation of neurological hard signs (NHSs), presence of tremor and neurological soft signs (NSSs). RESULTS: The authors found no significant differences between treatment groups in any of the neurological measures. Groups did not differ with respect to the presence or absence of NHSs or tremor, nor the presence or absence or severity of NSSs at any point. As expected, NSS severity scores diminished with increasing age. CONCLUSIONS: Even at the levels of amalgam exposure in this study (a mean of 7.7-10.7 amalgam surfaces per subject across the seven years of follow-up), the authors conclude that exposure to mercury from dental amalgam does not adversely affect neurological status. CLINICAL IMPLICATIONS: The current evidence is that potential neurobehavioral or neurological effects from dental amalgam mercury exposure in children are inconsequential.     

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.     

A retrospective review of clinical international normalized ratio results and their implications

BackgroundWarfarin is a key element in therapy for atrial fibrillation, deep venous thrombosis (DVT), stroke (cerebrovascular accident) and cardiac valve replacement. Often, patients’ warfarin blood levels are not tightly controlled with regard to accepted therapeutic ranges, by virtue of the drug’s unpredictable nature.MethodsThe authors searched 16,017 active clinical charts for active patients of record from the three campuses of the School of Dentistry, Marquette University (MU), Milwaukee, for the years 2009 and 2010. Dental records of 315 patients contained entries including “INR,” the abbreviation for the term “international normalized ratio.” Only 247 of those records contained an indication of whether the patient’s INR values were within therapeutic range. The authors found that 1.96 percent of the total MU dental clinic patient population had a history of warfarin use.ResultsWhen the authors compared the INR values for patients with diagnoses of atrial fibrillation, DVT, stroke and cardiac valve replacement, they found that INR values for 107 of the 247 patients (43.3 percent) were not within therapeutic range for the respective diagnoses. For example, only 50 percent of the patients being treated for atrial fibrillation presented themselves for surgical dental treatment while their INR values were in tight control.ConclusionThe INR values for a significant number of dental patients are not within the therapeutic range for their medical conditions. These patients need to seek follow-up care from their medical care providers.Clinical ImplicationsScreening for INR in the dental office—especially before invasive dental treatment such as periodontal surgery, tooth extraction and dental implant placement—can help prevent postoperative complications. It also can aid the clinician in evaluating whether a patient’s INR is within therapeutic range and, subsequently, whether the patient’s physician needs to adjust the warfarin dosage.     

Treating dental patients who use oral antithrombotic medication: a survey of dentists in the Netherlands

BackgroundFor many years, international guidelines have advised health care professionals not to adjust oral antithrombotic medication (OAM) regimens before invasive dental procedures. The authors conducted a study to examine the opinions of Dutch general dentists regarding the dental care of patients receiving treatment with these medications.MethodsThe authors invited via e-mail 1,442 general dentists in the Netherlands to answer a 20-item Internet-based questionnaire that they developed. Survey items consisted of questions about medical history taking, number of patients in the dental practice receiving OAM therapy, frequency of consulting with medical and dental colleagues and suggested dental treatment of patients during various invasive dental procedures.ResultsA total of 487 questionnaires were returned (response rate of 34 percent). The mean age of respondents was 47 years, and 77 percent were male. The majority of dentists responded that they obtain medical histories, but that they did not know how many of their patients were receiving OAM treatment. Dentists reported that they consult with medical colleagues frequently about antithrombotic medication. Ninety-one percent of respondents stated that they obtained their medical knowledge primarily in dental school. More than 50 percent of the dentists reported that they were not familiar with the international normalized ratio. The majority of dentists responded that they felt a need for clinical practice guidelines.ConclusionsAccording to the results of our survey, most dentists remain cautious when performing invasive dental procedures in patients who are treated with OAMs. Moreover, survey respondents tended to estimate that the risk of bleeding during dental procedures when OAM therapy is continued is higher than the risk of rethrombosis when use of antithrombotic medication is interrupted.Clinical ImplicationsA growing proportion of elderly patients and those with medically complex conditions are being treated in dental practices in the Netherlands. Consequently, more needs to be done to ensure that dentists are offered evidence-based guidance when treating patients who receive OAMs.