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.     

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.     

An adverse event trigger tool in dentistry: A new methodology for measuring harm in the dental office

BackgroundThere is a dearth of knowledge about the type and frequency of adverse events (AEs) in dentistry. Current approaches to obtaining information rely on reviews of randomly selected records, which may not be the most efficient or effective methodology.MethodsInspired by the Institute for Healthcare Improvement's (IHI) global and outpatient trigger tools, which identifies records with characteristics (”triggers“) that are associated with AEs, the authors created the dental clinic trigger tool. The triggers included procedures for incision and drainage, failed implants and selected treatment patterns. The authors ran the trigger tool against six months of electronic health records data and compared its performance with that of a review of 50 randomly selected patient records.ResultsIn total, 315 records were triggered, 158 (50 percent) of which were positive for one or more AEs; 17 (34 percent) of the 50 randomly selected records were positive for at least one AE. The authors assigned each AE an IHI severity ranking. Most AEs caused temporary harm, but nine were considered to have caused permanent harm according to a modified IHI severity ranking.ConclusionsThe study results demonstrate the promise of a directed records review approach, as the dental clinic trigger tool was more effective in identifying AEs than was a review of randomly selected records.Practical ImplicationsAll dental practices should proactively monitor the safety of the care they provide. Use of the trigger tool will help make this process more efficient and effective.     

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.     

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.     

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.     

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.     

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.     

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.     

Controlling bacterial contamination of dental impression guns

BackgroundDental impression material handgun cartridge dispensers are contaminated easily during clinical use. The authors attempted to quantify contamination by bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), of impression guns used in an academic dental clinic after five infection-prevention protocols were followed.MethodsThe authors obtained samples from four commercially available impression guns at four specific sites (button, handle, latch, trigger) after routine clinical use, disinfection, steam sterilization (also known as autoclaving), steam sterilization followed by use of plastic impression gun covers and steam sterilization followed by use of plastic impression gun covers and disinfection.ResultsThe authors found that after routine clinical use, bacteria—including MRSA—heavily contaminated the impression guns. After the impression guns underwent disinfection, there was a 6 percent decrease in bacterial counts. The use of steam sterilization achieved sterility without harming the impression guns. Use of steam-sterilized impression guns with plastic impression gun covers decreased bacterial isolates by approximately 60 percent. Use of steam-sterilized impression guns plus covers and disinfection resulted in an approximately 95 percent reduction in contamination.ConclusionsThe use of common infection-prevention methods appears to reduce the bacterial counts, including those of MRSA. Bacterial contamination was lowest after steam sterilization, followed by the use of plastic impression gun covers and disinfection.Clinical ImplicationsUse of contaminated impression guns on successive patients could increase the risk of causing cross-transmission of disease. The use of sterilization, plus plastic impression gun covers and disinfection, for impression guns after each use could be an effective and practical infection-control method for dental practices.     

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.     

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.     

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.     

Heuristic evaluation of clinical functions in four practice management systems: a pilot study

BACKGROUND: Dentists report that the complexity and poor usability of practice management systems (PMSs) are factors in the slow adoption of computers at chairside. METHODS: Three dental informatics researchers performed heuristic evaluations of four PMSs to identify potential usability problems that may be encountered during the clinical care process. Each researcher performed three common clinical documentation tasks on each PMS and examined the clinical user interface of each system using a published list of 10 software heuristics. An observer recorded all findings, summarized the results and totaled the heuristic violations across all programs. RESULTS: The authors found 229 heuristic violations. Consistency and Standards, Match Between System and the Real World, and Error Prevention were the heuristics that were violated most commonly. The patterns of heuristic violations across software packages were relatively similar. CONCLUSIONS: The findings provide an initial assessment of potential usability problems in four PMSs. The identified violations highlight aspects of dental software that may present the most significant problems to users. CLINICAL IMPLICATIONS: Heuristic violations in PMSs may result in usability problems for dentists and other office personnel, reducing efficiency and effectiveness of a software implementation. Vendors should consider applying user-centered design methodologies to reduce the number of potential usability problems.