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.     

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.     

A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder

BackgroundTemporomandibular pain has multiple etiologies and a range of therapeutic options. In this pilot study, the authors assessed the feasibility of conducting a larger trial to evaluate chiropractic treatment of temporomandibular disorders (TMDs).MethodsThe authors assigned 80 participants randomly into one of the following four groups, all of which included a comprehensive self-care program: reversible interocclusal splint therapy (RIST), Activator Method Chiropractic Technique (AMCT) (Activator Methods International, Phoenix), sham AMCT and self-care only. They made assessments at baseline and at month 2 and month 6, including use of the Research Diagnostic Criteria for Temporomandibular Disorders.ResultsThe authors screened 721 potential participants and enrolled 80 people; 52 participants completed the six-month assessment. The adjusted mean change in current pain over six months, as assessed on the 11-point numerical rating scale, was 2.0 (95 percent confidence interval, 1.1–3.0) for RIST, 1.7 (0.9–2.5) for self-care only, 1.5 (0.7–2.4) for AMCT and 1.6 (0.7–2.5) for sham AMCT. The authors also assessed bothersomeness and functionality.ConclusionsThe authors found the study design and methodology to be manageable. They gained substantial knowledge to aid in conducting a larger study. AMCT, RIST and self-care should be evaluated in a future comparative effectiveness study.Practical ImplicationsThis pilot study was a necessary step to prepare for a larger study that will provide clinicians with information that should be helpful when discussing treatment options for patients with TMD.     

Foreign-trained dentists licensed in the United States: exploring their origins

BACKGROUND: The authors explored the origins of foreign-trained dentists seeking licensure in the United States. METHODS: The authors analyzed data received from the American Dental Association Department of Testing Services for candidates who took the National Board Dental Examinations (NBDE) Part II from 2002 through 2005. They also established proxies for the information they sought in lieu of existing direct data. RESULTS: A total of 4,136 candidates took NBDE Part II from 2002 through 2005. The greatest number of foreign-trained dentists originated from India, the Philippines and Colombia. CONCLUSION: The greatest number of potential U.S. dental licensees are primarily from Asia, the Middle East and South America. However, precise studies need to be conducted to generate more exact data about foreign-trained dentists who practice in the United States. CLINICAL IMPLICATIONS: The source of international dental graduates seeking licensure in the United States has implications for the licensure process and for the potential accreditation of foreign dental schools.     

Pulpalgia contributing to temporomandibular disorder-like pain: a literature review and case report

BACKGROUND: Dentists need to be cognizant that temporomandibular disorder (TMD) -like pain can be caused by a tooth pulpalgia. The author provides suggestive symptom characteristics and definitive diagnostic techniques. CASE DESCRIPTION: A patient had severe bilateral TMD-like pain, which increased when something cold touched a premolar and when the patient lay down, and which awakened her several times every night. The author identified the offending tooth and administered a ligamentary injection along the tooth, which eliminated her bilateral TMD-like pain. Occlusal adjustment of her tooth reduced her pain, and subsequent endodontic therapy eliminated her pain. To the author's knowledge, this is the first report of a pulpalgia in a posterior tooth causing bilateral TMD-like pain. CLINICAL IMPLICATIONS: Pulpalgia may cause symptoms that mimic TMD or may contribute to TMD signs and symptoms. When patients with TMD-like pain report feeling increased pain due to a cold stimulus' coming into contact with a tooth, practitioners should ensure that a pulpalgia is not contributing to their pain.     

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 care access and unmet dental care needs among U.S. workers: the National Health Interview Survey, 1997 to 2003

BACKGROUND: Healthy People 2010 oral health objectives call for an increase in the proportion of adults who use the oral health care system annually. To assess progress toward this goal, the authors evaluated dental care utilization and the extent of unmet dental care needs of U.S. workers and their families. METHODS: The authors conducted sex-specific analyses by occupation of 135,004 U.S. worker participants in the nationally representative National Health Interview Surveys (NHIS) conducted from 1997 to 2003. RESULTS: The reported lack of oral health care within the preceding year ranged from 18.9 to 57.8 percent among male workers and from 17.6 to 50.0 percent among female workers. Sex-specific occupational groups with the highest rates of reported unmet dental care needs included male health service occupations (17.1 percent) and female construction and extractive trade workers (26.8 percent). CONCLUSION: There are significant oral health care underutilization and high rates of unmet dental care needs among many U.S. worker groups. Strategies to increase regular dental visits for U.S. worker groups reporting low dental care access and high dental need are paramount. CLINICAL IMPLICATIONS: Targeting strategic dental care access programs to identified U.S. worker groups reporting dental care access deficits can improve oral health.     

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.     

An assessment of the usefulness of jaw kinesiography in monitoring temporomandibular disorders: Correlation of treatment-related kinesiographic and pain changes in patients receiving temporomandibular joint injections

BackgroundThe authors conducted a study in patients with temporomandibular joint (TMJ) osteoarthritis to assess whether treatment-related changes in pain levels and chewing ability coincide with a change in jaw kinesiographic (KG) parameters.MethodsThe authors selected 34 patients with a diagnosis of TMJ osteoarthritis that met Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to undergo a cycle of five weekly arthrocentesis procedures with injections of 1 milliliter hyaluronic acid. They performed a permutation test to assess the correlation between changes across time (from baseline to end of treatment) in two clinical outcome parameters—pain level and chewing ability—and changes across time in the KG outcome parameters.ResultsThe authors observed improvement across time in both chewing ability (F = 8.328; P = .005) and pain level (F = 10.903; P = .002). The authors observed no significant changes in any KG variables. With minor exceptions, no significant correlations were shown between changes in the clinical and KG parameters during the treatment period.ConclusionsTreatment-related changes in pain levels and chewing ability in patients with TMJ osteoarthritis do not coincide with changes in KG parameters.Practical ImplicationsIf one assumes pain variables to be the primary outcome measures in assessing treatment of TMJ osteoarthritis, KG recordings of the jaw are not useful for monitoring TMJ osteoarthritis in the clinical setting.     

Reduced or painful jaw movement after collision-related injuries: a population-based study

BACKGROUND: The authors report the incidence of and factors associated with reduced and/or painful jaw movement after motor vehicle collisions that resulted in whiplash-associated disorders (WADs). METHODS: All adults filing collision-related personal injury claims during an 18-month period in Saskatchewan, Canada, were evaluated via questionnaire to determine demographic characteristics, precollision health (including jaw pain), collision parameters and collision-related symptoms, including reduced and/or painful jaw movement and injury-related neck pain. The authors excluded patients who were hospitalized for more than two days and those who sustained injuries as a pedestrian, bicyclist or motorcyclist. In determining incidence rates, the authors also excluded those who had had jaw pain before the collision. RESULTS: The incidence of reduced and/or painful jaw movement was 14.9 percent (n = 1,158), and it was higher in subjects with WADs (15.8 percent) than in those without WADs (4.7 percent; relative risk = 3.36, 95 percent confidence interval, 2.36 to 4.78). Within the WAD injuries, multivariable logistic regression revealed that the onset of reduced and/or painful jaw movement was associated with female sex; age < 50 years; having hit one's head in the collision; and postinjury symptoms of difficulty swallowing, ringing in the ears, dizziness or unsteadiness, and more intense neck pain. Collision parameters, such as head position at the time of the crash and headrest use and type, were not associated with onset of jaw symptoms. CONCLUSIONS: Reduced or painful jaw movement was more common in people with WADs than in those with other collision-related injuries. Among those with WADs, reduced or painful jaw movement was more common in women and younger people. CLINICAL IMPLICATIONS: Reduced or painful jaw movement is an important aspect of WADs, and more studies are needed to determine how to best assess and treat this problem.     

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 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.     

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.     

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.     

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.     

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.     

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.