Showing papers in "Journal of the American Dental Association in 2002"

Periodontal disease and cardiovascular disease: Epidemiology and possible mechanisms

Abstract: Background Many early epidemiologic studies reported an association between periodontal disease and cardiovascular disease. However, other studies found no association or nonsignificant trends. This report summarizes the evidence from epidemiologic studies and studies that focused on potential contributing mechanisms to provide a more complete picture of the association between periodontal and heart disease. Types of Studies Reviewed The authors summarize the longitudinal studies reported to date, because they represent the highest level of evidence available regarding the connection between periodontal disease and heart disease. The authors also review many of the case-control and cross-sectional studies published, as well as findings from clinical, animal and basic laboratory studies. Results The evidence suggests a moderate association—but not a causal relationship—between periodontal disease and heart disease. Results of some case-control studies indicate that subgingival periodontal pathogenic infection may be associated with myocardial infarction. Basic laboratory studies point to the biological plausibility of this association, since oral bacteria have been found in carotid atheromas and some oral bacteria may be associated with platelet aggregation, an event important for thrombosis. Animal studies have shown that atheroma formation can be enhanced by exposure to periodontal pathogens. Conclusions The accumulation of epidemiologic, in vitro, clinical and animal evidence suggests that periodontal infection may be a contributing risk factor for heart disease. However, legitimate concerns have arisen about the nature of this relationship. These are early investigations. Since even a moderate risk contributed by periodontal disease to heart disease could contribute to significant morbidity and mortality, it is imperative that further studies be conducted to evaluate this relationship. One particularly important study to be carried out is the investigation of a possible clinically meaningful reduction in heart disease resulting from the prevention or treatment of periodontal disease.

A comparison of polymerization by light-emitting diode and halogen-based light-curing units

Abstract: Background Light-emitting diode, or LED, technology provides certain advantages over halogen-based light polymerization of resin-based composites. The authors investigated the adequacy of cure of LED light-curing units, or LCUs. Methods The authors used two halogen-based light-curing units (Optilux 400 and 501, Demetron Research Corp., Danbury, Conn.) and two commercially available LED LCUs (LumaCure, LumaLite, Spring Valley, Calif., and VersaLux, Centrix, Shelton, Conn.) to polymerize top surfaces of hybrid (Filtek Z-250, 3M, St. Paul, Minn.) and microfilled (Renamel, Cosmedent, Chicago) resin-based composite specimens. Specimens were indented on their top and bottom surfaces with a Knoop hardness tester and measured for hardness. Bottom:top hardness ratios determined the percentage of cure. The authors separated the data into eight groups (two composites cured with four different lights) with 15 observations per group, for a total sample size of 120. Results The authors compared composites and curing lights by a two-way analysis of variance, and results indicated significant main effects. The main effect of composite was statistically significant ( P P Conclusions The light output of commercially available diodes for resin-based composite polymerization still requires improvement to rival the adequacy of cure of halogen-based LCUs. Additional studies are necessary. Clinical Implications Commercially available LED LCUs were introduced just in the past year. However, they may not adequately polymerize resin-based composites, which can lead to restoration failures and adverse pulpal responses to unpolymerized monomers.

Platelet-rich plasma: Clinical applications in dentistry

Abstract: Background Platelet-rich plasma, or PRP, has become a valuable adjunct in wound healing in dentistry. Postsurgically, blood clots initiate the healing and regeneration of hard and soft tissues. Clinicians and scientists are investigating the use of PRP in dentistry as a way to enhance the body's natural wound-healing mechanisms. Types of Articles Reviewed The authors reviewed scientific articles that discuss the basic knowledge of wound healing mechanisms and that directly studied the growth factors shown to be concentrated in PRP. They also reviewed articles written by clinicians and researchers in dentistry fields, including oral and maxillofacial surgery and periodontics to determine applications of PRP in the field of dentistry. Results All of the reviewed articles expressed promise in PRP use and in the growth factors expressed by the platelets concentrated in PRP—namely platelet-derived growth factor, or PDGF, and transforming growth factor-β, or TGF-β—as an adjunct to postsurgical wound healing. Both PDGF and TGF-β have been shown in vivo to accelerate wound healing through different mechanisms. The development of an autologous PRP has been shown to be relatively easy, to be effective as a surgical adjunct, to retain high levels of the desired growth factors after preparation and to be clinically effective in accelerating postsurgical healing in both periodontal and oral surgery applications. Clinical Implications PRP has proven to be effective at improving surgical results in a variety of procedures in the field of oral and maxillofacial surgery. PRP also shows promise in periodontal regenerative therapy and should continue to be studied by scientists and clinicians alike.

Curing-light intensity and depth of cure of resin-based composites tested according to international standards.

Abstract: Background Several factors control the light curing of a resin-based composite: the composition of the composite, the shade of the composite, the wavelength and bandwidth of the curing light, the distance of the light from the composite, the intensity of the curing light and the irradiation time The authors investigated the depth of cure of several shades of five brands of resin-based composites when irradiated via light in the 400- to 515-nanometer wavelength bandwidth at the International Organization for Standardization, or ISO, recommended intensity of 300 milliwatts per square centimeter The resin-based composites were irradiated for the times recommended by the products' manufacturers Methods The authors used a curing light adjusted to emit 300 mW/cm 2 in the 400-nm to 515-nm wavelength bandwidth to polymerize five samples of each composite brand type and shade They measured depth of cure using a scraping method described in the ISO standard for resin-based composites Depth of cure was defined as 50 percent of the length of the composite specimen after uncured material was removed by manual scraping The authors determined a mean from the five samples of each composite brand and shade Results Thirteen (62 percent) of 21 composite materials met the ISO standard depth-of-cure requirement of 15 millimeters Six of the eight remaining materials met the depth-of-cure requirement when the authors doubled the irradiation time recommended by the product manufacturers Conclusions and Clinical Implications Curing lights with an intensity of 300 mW/cm 2 appear to effectively cure most resin-based composite materials when appropriate curing times are used, which, in some cases, are longer than those recommended by the manufacturers Dentists should verify the depth of cure of a composite material as a baseline measure, and then check depth of cure periodically to confirm light and material performance The ISO depth-of-cure measurement method can be used for this purpose

Characteristics of noncarious cervical lesions: A clinical investigation

Abstract: Background The purpose of the authors' in vivo investigation was to analyze the characteristics of noncarious cervical lesions, or NCCLs, in adult patients who had a high incidence of them. Methods The patient pool consisted of a total of 57 patients and 171 teeth (three teeth per patient), with one NCCL per tooth. The characteristics the authors evaluated were shape, dimensions, sensitivity, sclerosis and occlusion. Results In terms of lesion characteristics, 91 percent of the lesions had axial depths of 1 to 2 millimeters, 49 percent had occlusogingival widths of 1 to 2 mm, 74 percent had an angular shape of 45 to 135 degrees, 76 percent had mild or moderate sclerosis, and 73 percent had no or mild sensitivity. In terms of occlusion, 75 percent of teeth had an Angle Class I occlusion on the involved side, 60 percent had group function or mixed excursive guidance, 82 percent had wear facets, and 99 percent had Type 0 or I mobility. In terms of tooth location, 70 percent of NCCLs were on posterior teeth, 65 percent were on maxillary teeth, and 46 percent were on premolars. Conclusions The evaluated NCCLs were found mainly to have small dimensions of depth and width ( Clinical Implications A knowledge of the NCCL characteristics and etiologic covariables aids in proper case selection for treatment, aids in selection of appropriate treatment protocols and improves assessment of prognosis.

Oral health, nutrient intake and dietary quality in the very old

Abstract: Background Limited food choices and inadequate nutrient intake are linked to poor oral health. The authors describe relationships between dietary variety, nutrient intake and oral health measures in community-dwelling, rural Iowans aged 79 years and older. Methods Dental examinations were conducted by trained and calibrated examiners, and trained interviewers completed standardized interviews in subjects' homes. Subjects (n = 220) then completed three-day dietary records. Adequate nutrient intakes were defined using the Dietary Reference Intakes of the Food and Nutrition Board of the National Academy of Sciences. Results Mean daily nutrient intakes were significantly lower in subjects who had fewer natural or functional teeth and ill-fitting mandibular dentures than in subjects who had more teeth or did not have these problems. Adequacy of intakes was lower in subjects who had fewer natural or functional teeth and ill-fitting mandibular dentures. Mean daily nutrient intakes did not differ between subjects with well-fitting dentures (either complete or partial) and subjects with natural teeth. Neither mean daily intake nor adequacy of intake was associated with subjects' perceptions of oral health problems, chewing difficulties or temperature sensitivity. Conclusions The presence of natural teeth and well-fitting dentures were associated with higher and more varied nutrient intakes and greater dietary quality in the oldest old Iowans sampled. Clinical Implications Maintenance of natural dentition or provision and maintenance of adequate mandibular prostheses are important for nutrient intakes to support systemic health.

Oral health status of older rural adults in the United States.

Abstract: Background. Little is known about the oral health care of older rural residents. The authors describe oral health indicators for the older adult population by place of residence in the United States. Methods. The authors analyzed data from the Third National Health and Nutrition Examination Survey and the 1995, 1997 and 1998 National Health Interview Surveys. Oral health indicators included perceived oral health (self-reported dental status and unmet dental needs) and dental status (untreated caries; decayed, missing and filled permanent teeth, or DMFT; and edentulism). Dental care utilization and access were measured by number of dental visits, frequency of dental visits and dental insurance status. Results. Older rural adults were more likely than their urban counterparts to be uninsured for dental care (72.1 percent versus 66.1 percent, respectively) and were less likely to report dental visits in the past year (46.9 percent versus 58.4 percent, respectively). A higher proportion of rural residents than urban residents were edentulous (36.7 percent versus 28.2 percent, respectively) and reported poor dental status (50.7 percent versus 42.2 percent, respectively). There were no differences in unmet dental needs, percentage of people with untreated caries or in mean DMFT by place of residence. Conclusions. Older rural residents inadequately utilize dental care and have less favorable oral health indicators than do older urban residents. Clinical Implications. This article shows the need for more dental practitioners in rural areas. With the low density of dentists per person and the high need for care, rural America offers an excellent opportunity for oral health professionals to provide much needed services.

The physiology, medical management and oral implications of menopause.

Abstract: Background Approximately 36 million women in the United States are in the postmenopausal phase of life. The vast majority of these women experienced spontaneous cessation of menses between the ages of 47 and 55 years when the production of estrogen decreased because of an inadequate number of functioning follicles within their ovaries. Fewer women entered menopause after surgical removal of both ovaries. This procedure usually is performed prophylactically to prevent ovarian cancer in conjunction with a hysterectomy, which is required to treat abnormal bleeding, endometriosis or pelvic inflammatory disease. The physiological changes associated with spontaneous or surgical menopause cause some women to experience uncomfortable symptoms such as hot flashes, night sweats and vaginal dryness. In addition, estrogen deprivation arising from menopause in association with age-related factors disproportionately increases the risk of developing cardiovascular disease (that is, myocardial infarct, stroke), osteoporosis, Alzheimer's disease and oral disease. Hormone replacement therapy, or HRT (estrogen or estrogen and progestin), often is prescribed on a short-term basis to alleviate the uncomfortable symptoms associated with estrogen deficiency and on a long-term basis to prevent some of the chronic illnesses common to postmenopausal women. Conclusions Dentists who treat women entering menopause need to consider the stressful phase of life their patients are experiencing. Clinical findings of postmenopausal problems on dental examination may include a paucity of saliva, increased dental caries, dysesthesia, taste alterations, atrophic gingivitis, periodontitis and osteoporotic jaws unsuitable for conventional prosthetic devices or dental implants. Panoramic dental radiographs may reveal calcified carotid artery atheromas. Clinical Implications Dentists have an opportunity to refer women who are not under the care of a gynecologist for an evaluation to determine the appropriateness of HRT for its systemic and oral health benefits.

Validity and accuracy of a risk calculator in predicting periodontal disease.

Abstract: Background Research on the pathobiology of periodontal diseases has increased our knowledge of these diseases and is fostering a transition from the repair model to the medical or wellness model of periodontal care. Successful application of the wellness model depends on an accurate and valid assessment of disease risk, as well as institution of risk reduction as an integral part of prevention and treatment. A computer-based risk assessment tool has been developed. Methods The authors reviewed clinical records and radiographs of 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study to evaluate the validity of risk prediction using the computer-based tool. Data from baseline examinations was entered into the risk calculator, and a risk score on a scale from 1 (lowest risk) to 5 (highest risk) was calculated for each subject to predict periodontal deterioration. Actual periodontal status in terms of alveolar bone loss (determined from digitized radiographs) and tooth loss (determined from clinical records) was assessed at years 3, 9 and 15. The authors determined the statistical strength of the association between risk prediction and actual outcome. Results The risk scores were strong predictors of periodontal status, as measured by alveolar bone loss and loss of periodontally affected teeth. Risk scores consistently ranked risk score groups from least to most bone loss and tooth loss. Compared with a risk score of 2, the relative risk of tooth loss was 3.2 for a risk score of 3, 4.5 for a risk score of 4 and 10.6 for a risk score of 5. Conclusions and Practice Implications Use of the risk assessment tool over time may result in more uniform and accurate periodontal clinical decision-making, improved oral health, reduction in the need for complex therapy, reduction in health care costs and a hastening of the transition from a repair model to a wellness model of care.

An alternative method to reduce polymerization shrinkage in direct posterior composite restorations

Abstract: Background Polymerization shrinkage is one of dental clinicians' main concerns when placing direct, posterior, resin-based composite restorations. Evolving improvements associated with resin-based composite materials, dental adhesives, filling techniques and light curing have improved their predictability, but shrinkage problems remain. Methods The authors propose restoring enamel and dentin as two different substrates and describe new techniques for placing direct, posterior, resin-based composite restorations. These techniques use flowable and microhybrid resin-based composites that are polymerized with a progressive curing technique to restore dentin, as well as a microhybrid composite polymerized with a pulse-curing technique to restore enamel. Combined with an oblique, successive cusp buildup method, these techniques can minimize polymerization shrinkage greatly. Conclusions Selection and appropriate use of materials, better placement techniques and control polymerization shrinkage may result in more predictable and esthetic Class II resin-based composite restorations. Clinical Implications By using the techniques discussed by the authors, clinicians can reduce enamel microcracks and substantially improve the adaptation of resin-based composite to deep dentin. As a consequence, marginal discoloration, recurrent caries and postoperative sensitivity can be reduced, and longevity of these restorations potentially can be improved.

Clinical evaluation of fiber-reinforced fixed bridges.

Abstract: Background This study evaluated the clinical performance of 39 light and heat polymerized fixed partial bridges made with a substructure of preimpregnated, unidirectional fiber-reinforced composite, or FRC, veneered with a hybrid particulate composite. Methods The authors evaluated 22 extracoronal, full-coverage retainer prostheses and 17 intracoronal, partial-coverage retainer prostheses placed over a 37-month period. All substructures initially were fabricated with a low-volume FRC. The authors reevaluated this design after early failures occurred, leading to a substructure with a higher volume of FRC. All prostheses were assessed for surface integrity, anatomical contour, marginal integrity and structural integrity at several intervals. Results The data show that survival was associated primarily with substructure design volume. When patients with severe parafunctional habits were excluded, the survival rate was 95 percent for prostheses made with a high-volume substructure (survival range, 2.77 to 4.30 years; mean ± standard deviation survival, 3.75 ± 0.4 years). Retainer configuration did not have a statistically significant influence on clinical survival. For all surviving prostheses, the authors observed few changes in any clinical parameters from baseline to 48 months. A loss of surface luster was observed in the majority of cases. Repairable surface defects were detected on two prostheses at 24 months. Scanning electron microscopic analyses indicated no exposed fibers on the occlusal surface and minimal wear. Conclusions This study shows that a unidirectional, preimpregnated FRC can be used successfully to make bridges of variable retainer designs that last up to four or more years when a high-volume substructure is used. Clinical Implications Short-span polymer prostheses made with particulate composite and unidirectional glass FRC can be used in certain clinical situations in which a metal substructure is not desired.

The efficacy of combination analgesic therapy in relieving dental pain

Abstract: Background An experience of poorly managed pain related to dental treatment can lead patients to avoid or postpone treatment. The development of new pain management strategies equips dental clinicians with additional treatment options that can provide more effective pain relief. Literature Reviewed The author reviewed dental and medical literature dealing with the safety, efficacy and mechanisms of action of common analgesic treatments. Conclusions For the treatment of mild to moderate pain, acetaminophen and non-steroidal anti-inflammatory drugs, or NSAIDs, continue to be the most appropriate options. The use of cyclo-oxygenase-2–inhibitor NSAIDs should be strongly considered for use with patients at risk of experiencing gastrointestinal toxicity. The pathophysiology of pain is a complex central and peripheral nervous system process, and the use of combination analgesics that act at multiple pain sites can improve pain relief after a dental procedure. For moderate to moderately severe pain, tramadol or combination medications such as tramadol with acetaminophen or codeine with acetaminophen are appropriate. For severe pain, use of opioids or opioid combinations is advised. Clinical Implications Providing appropriate treatment after dental surgery requires a careful medical history and an educated anticipation of the level of pain the patient may encounter. New analgesic options are available and should be considered, particularly combination analgesics, which can provide faster onset and prolonged duration of action and can combat pain at multiple sites of action.

The dental home: A primary care oral health concept

Abstract: Background The pediatrics community has promoted the concept of a medical home to improve families' care utilization. The authors describe the medical home and propose a dental home concept to improve families' access to dental care. Description The dental home is a locus for preventive oral health supervision and emergency care. It can be a repository for records and the focus for making specialty referrals. When culture and ethnicity are barriers to care, the dental home offers a site adapted to care delivery and is sensitive to family values. Clinical Implications The dental home can provide access to preventive and emergency services for children. Establishment of the home early in the child's life can expose a child to prevention and early intervention before problems occur, reduce anxiety and facilitate referral.

Incidence of tooth sensitivity after home whitening treatment

Abstract: Background A potential side effect of dentist-dispensed home tooth-whitening systems is tooth sensitivity. The authors conducted a randomized prospective double-blind study to determine the incidence of tooth sensitivity after home whitening treatment. Methods Fifty adult subjects used a gel containing 15 percent carbamide peroxide and 0.11 percent fluoride ion; an additional 50 adult subjects used a placebo gel daily for four weeks. Each subject's plaque index score, gingival recession status, caries status, current dentifrice and smoking history were recorded at baseline. The researchers evaluated sensitivity weekly by interview for four weeks. Results Fifty-four percent of subjects in both test and control groups reported mild sensitivity; 10 percent of test subjects and 2 percent of control subjects reported moderate sensitivity; 4 percent of test subjects and no control subjects reported severe sensitivity. Sensitivity decreased with time; by the second week, no severe sensitivity was reported, and by the fourth week, no moderate sensitivity was reported. The authors found a statistically significant positive correlation between reported sensitivity and gingival recession. They found no statistically significant correlations between sensitivity and any of the other recorded parameters. Conclusions Mild tooth sensitivity can be expected in approximately one-half of patients who undergo home whitening treatment using the gel studied. Approximately 10 percent of patients may experience moderate sensitivity, and 4 percent of patients may experience severe sensitivity for one to two weeks. Patients with gingival recession appear more likely to experience tooth sensitivity during home whitening treatment. Clinical Implications Patients considering home whitening treatment should be advised that mild tooth sensitivity is a common side effect and that severe tooth sensitivity occasionally occurs. If gingival recession is present, the probability of tooth sensitivity increases, and tooth sensitivity tends to decrease as treatment progresses.

The analgesic efficacy of valdecoxib vs. oxycodone/acetaminophen after oral surgery.

Abstract: Background The authors conducted two studies to compare the analgesic efficacy and safety of the cyclooxygenase, or COX, -2–specific inhibitor, valdecoxib, with oxycodone/acetaminophen in patients who have undergone oral surgery. Methods In total, 205 eligible subjects in Study A and 201 in Study B were randomized to receive a single oral dose of valdecoxib (20 or 40 milligrams), a combination of oxycodone 10 mg/acetaminophen 1,000 mg or placebo. Eligible subjects experienced moderate-to-severe pain within six hours of surgery during which two or more impacted third molars were extracted. Analgesic efficacy was assessed over 24 hours or until the patient required rescue analgesia. Results In both studies, subjects receiving either dose of valdecoxib experienced a rapid onset of analgesia and (among those who received valdecoxib 40 mg) a level of pain relief comparable with that of those who received oxycodone/acetaminophen. Both valdecoxib doses had a significantly longer duration of analgesic effect than did oxycodone/acetaminophen. Pooled safety data demonstrated that each valdecoxib dose had a tolerability profile superior to that of oxycodone/acetaminophen and similar to that of placebo. Conclusions Orally administered valdecoxib is as rapidly acting and effective as oxycodone/acetaminophen, and it has a superior duration of analgesic effect in patients after oral surgery. Valdecoxib has a tolerability profile superior to that of oxycodone/acetaminophen. Clinical Implications The current standard of care for alleviating acute pain after oral surgery has rested largely on conventional nonsteroidal anti-inflammatory drugs or opioid/analgesic combination products. The studies reported here suggest that the COX-2–specific inhibitor valdecoxib offers an efficacious and safe alternative to other analgesics used to treat pain after oral surgery.

Maxillomandibular advancement surgery for obstructive sleep apnea syndrome.

Abstract: Background Although maxillomandibular advancement, or MMA, surgery is highly successful, the indications for and staging of MMA in the treatment of obstructive sleep apnea syndrome, or OSAS, have not been settled upon. Types of Studies Reviewed The author presents a retrospective review of several published case series with inclusion criteria of 20 or more patients who underwent MMA and received documented preoperative and postoperative diagnostic polysomnography. Protocols of MMA as a primary vs. secondary operation, with and without adjunctive procedures in a site-specific approach, are compared and discussed. Results As an extrapharyngeal operation that enlarges and stabilizes the entire velo-orohypopharyngeal airway, MMA, which can be safely combined with adjunctive non-pharyngeal procedures, may circumvent the staging dilemmas associated with multiple, less successful, segmental, invasive, pharyngeal procedures. In accordance with current goals and guidelines governing OSAS surgery, MMA does not need to be limited to severe OSAS cases as a last resort after other procedures have failed but, rather, is also indicated as an initial operation for (velo-oro)hypopharyngeal narrowing. Conclusions MMA is a highly successful and potentially definitive primary single-staged surgery that may result in a significant reduction in OSAS-related health risks, as well as financial savings for the health care system. Clinical Implications The diagnosis and management of OSAS requires a multi-disciplinary team approach, including a working relationship between the dentist and sleep physician. General dentists and dental specialists who participate in the management of snoring and OSAS cases should have some knowledge of basic sleep medicine.

The psychopathology, medical management and dental implications of schizophrenia

Abstract: Background Schizophrenia is a psychiatric illness characterized by thought disturbances, bizarre behaviors and cognitive impairments that may diminish a person's abilities in the areas of social relations, school or work and self-care. The onset of the disorder typically occurs between the late teens and mid-30s. Advanced dental disease is seen frequently in patients with schizophrenia for several reasons: the disease impairs these patients' ability to plan and perform oral hygiene procedures; some of the antipsychotic medications they take have adverse orofacial effects such as xerostomia; and these patients sometimes have limited access to treatment because of a paucity of financial resources and adequate number of dentists comfortable in providing care. The recent introduction of more effective medications has permitted the majority of patients to receive their psychiatric care from community-based providers rather than in the hospital. Consequently, dentists in the private sector also are being called on more frequently to care for these people. Conclusions Dentists cognizant of the signs and symptoms of schizophrenia are likely to feel more secure in treating patients with schizophrenia and more confident when obtaining consultative advice from the patients' psychiatrists. Dentists usually can provide a full range of services to such patients, can enhance these patients' self-esteem and can contribute to the psychotherapeutic aspect of management. Clinical Implications To effectively provide treatment to patients with schizophrenia, dentists must be familiar with the disease process so that they can communicate effectively with the patient, the treating psychiatrist and family members who serve as caregivers. In addition, dental treatment may need to be modified because of the patient's impaired ability to think logically, the local and systemic effects of psychiatric medications, and adverse interactions between these drugs and medications used in dentistry.

Management of patients with trigeminal nerve injuries after mandibular implant placement

Abstract: Background Placement of mandibular endosseous implants can result in damage to the lingual nerve, the inferior alveolar nerve or both nerves. All dentists who place mandibular implants should be aware of the appropriate early management of these injuries, as well as the appropriate time to refer patients with these injuries to a microneurosurgeon. Overview The lingual nerve is less likely to undergo spontaneous regeneration than is the inferior alveolar nerve, which is protected within the inferior alveolar canal. Since the inferior alveolar canal can be seen on most panoramic radiographs and on all high-quality computed tomographic scans, it is easier to avoid damage to the inferior nerve than to the lingual nerve, which is not visualized on radiographs and whose relationship to the posterior portion of the mandible varies from person to person. Results The authors reviewed one study that showed that lingual nerve repair helped 90 percent of patients. A second study found that patients who underwent lingual nerve repair reported a mean score of 7 on a scale from 0 to 10 in regard to the postoperative return of nerve function. Several other studies reported favorable patient responses to inferior alveolar nerve repair. Conclusions and Clinical Implications These results reinforce the need for early referral and intervention when inferior alveolar nerve injuries occur. Failure to refer patients with trigeminal nerve injury before distal nerve degeneration develops prevents minimization of the injury through microneurosurgical repair.

Oral cancer knowledge, risk factors and characteristics of subjects in a large oral cancer screening program.

Abstract: Background Screening people who are at high risk of developing oral cancers is a promising tool for decreasing morbidity and mortality attributable to this cancer Methods A consortium led by the New York University College of Dentistry conducted a three-day oral cancer screening during June 1999 As part of the screening intake, the authors conducted a survey to assess the sociodemographic characteristics, level of knowledge of risk factors and predictors of oral cancer awareness among the subjects The authors performed bivariate and multivariate analyses using two indicators of oral cancer awareness as dependent variables Results The 803 subjects were racially and ethnically diverse, 66 percent were 40 years of age or older, 43 percent had a history of smoking, and 9 percent were likely to have had a history of alcohol abuse Race/ethnicity, education level and knowledge of risk factors for oral cancer were predictors of awareness of an oral cancer examination, whereas only knowledge and possible history of alcohol abuse were predictors of having a history of examinations Conclusions This screening program attracted a diverse sample of people at high risk of developing oral cancer due to smoking and likely history of alcohol abuse Consistent with other national and international studies, the authors found a lack of knowledge of the risk factors associated with oral cancer and a low rate of histories of oral cancer examinations among the subjects Clinical Implications Oral cancer screening programs represent potential opportunities not only for early detection of oral cancer but to raise awareness and educate the public about the disease

Dental visits to hospital emergency departments by adults receiving Medicaid: Assessing their use

Abstract: Background Pain from toothaches represents a significant problem. People lacking access to private dental services may use hospital emergency departments, or EDs. In 1993, Maryland eliminated Medicaid reimbursement to dentists for adult emergency services. Methods The authors used the change in Medicaid policy that eliminated dentist reimbursement to establish two study periods. Data tapes describing patients' use of EDs were obtained from the Maryland Medicaid Management Information System. A total of 3,639 people visited EDs for dental problems sometime during the four-year study period. Results After controlling for age, race and sex, the authors found that the rate of ED claims was 12 percent higher in the postchange period than in the prechange period. Comparisons between periods show significant rate increases during the postchange period for men, whites, African-Americans and patients aged 21 through 44 years and 45 through 64 years. Conclusions The change in Medicaid policy that eliminated dentist reimbursement and participation in the program appears to have increased the use of EDs for the treatment of dental problems. Practice Implications Many EDs lack dental services and are not capable of providing definitive treatment. When definitive treatment is not provided, this pattern of care may be repeated if patients are forced to return for treatment.

Private dental coverage: who has it and how does it influence dental visits and expenditures?

Abstract: Background Dental insurance has had a significant impact on dentistry and dental care use. Dental insurance coverage may influence people's decisions to use dental care. During 1996, 42.9 percent of all dental expenditures were paid by private dental insurance. Methods The focus of this analysis is on private dental coverage, use and expenditures for the U.S. civilian community-based population during 1996. The authors provide national estimates for the population with private dental coverage, the population with a dental visit, mean number of dental visits per year and mean total expenditures for several socioeconomic and demographic categories during 1996, using Medical Expenditure Panel Survey, or MEPS, data. Results Poor and low-income people were less likely to have private dental coverage than were people with higher incomes. People without coverage at all income levels were less likely to report a dental visit than were people with coverage. When they controlled for coverage, the authors found that education at any income level did not appear to affect the likelihood of people's having multiple visits or higher expenditures. Conclusion People with private coverage are more likely to visit a dentist, have a greater number of visits and have higher expenditures than are those without coverage. Private dental insurance coverage, however, is not the only determinant of dental care use. MEPS data also show that other factors play key roles. Comprehensive strategies designed to improve dental care use should keep each of these determinants in mind. Practice Implications While dentists may have a limited ability to influence people to seek care initially, they may be in a better position to influence the amount of care patients obtain, thereby helping make sure that patients receive the care that they need and want.

Women's health issues and their relationship to periodontitis

Abstract: Background The emergence of sex-specific associations between periodontitis and certain systemic disorders has prompted researchers to investigate the possibility of associations between periodontitis and specific women's health issues. The authors review the potential relationships between periodontitis and hormonal changes and their ramifications in regard to pregnancy outcomes, cardiovascular disease, or CVD, and osteoporosis. Methods Changes in hormone levels, such as those that occur during puberty, pregnancy, menstruation and menopause, as well as those that occur with the use of hormonal supplements, have long been associated with the development of gingivitis. Furthermore, bacterial anaerobes have been found to change during the normal hormonal cycle. In periodontitis, the inflammatory response results in ulceration of the gingivae and the subsequent entry of bacterial cells, bacterial products, peptidoglycan fragments and hydrolytic enzymes into the systemic circulation. The result is a systemic response of increased cytokines and biological mediators, as well as increased levels of serum antibodies. Results Some researchers have found that pregnant women with periodontitis were 7.5 times more likely to have a preterm low-birth-weight infant than were control subjects. Other researchers reported that the risk of preterm birth was directly related to the severity of periodontitis. Similarly, researchers have linked periodontitis to CVD. Many studies have indicated that estrogen exerts a protective effect against CVD development, and much evidence suggests that when hormone replacement therapy is administered to postmenopausal women, this effect continues. A relationship between periodontitis and osteoporosis has been established, such that more clinical attachment loss has been noted in osteoporotic people. Conclusions The literature suggests that more sex-specific research is essential to determine the strategies needed to prevent and treat adverse pregnancy outcomes, CVD and osteoporosis through hormone modification and periodontitis control. Clinical Implications Dentists must assume greater responsibility for the overall health of their patients, and acquire knowledge of relevant systemic conditions to interact meaningfully with medical colleagues.

Anticipated and experienced pain associated with endodontic therapy.

Abstract: Background The authors compared the levels of anticipated and experienced pain of patients who received endodontic therapy, or ET, with selected patient and dental characteristics. Methods Sensory and affective pain outcome measures (pain and unpleasantness) were evaluated by 333 adult patients immediately before and after dental school faculty or residents performed ET. Dentists provided clinical evaluations and a pulpal diagnosis for each tooth and then rated the level of their patients' pain during treatment. Results Before ET, 43 percent of all patients anticipated high outcome levels, yet only 22 percent experienced high pain levels, and only 18 percent experienced high unpleasantness levels. Outcome levels did not differ by tooth type, pulpal diagnosis, ET history or dental care attendance. Women were significantly more likely to anticipate higher pain and unpleasantness levels than were men. Experienced outcome levels, however, did not differ by sex. Anticipated and experienced outcome levels significantly decreased with increasing age. Dentists' evaluation of their patients' pain levels correlated more highly for female than for male patients. Conclusions Pain experienced during ET often is less than anticipated. Younger people anticipate and experience higher pain levels. Women are more likely than men to anticipate, but not necessarily experience, higher pain levels. Dentists are more closely attuned to the pain experiences of their female patients. Clinical Implications Practitioners could better prepare younger patients and female patients for ET and improve pain communication with male patients. Findings suggest that patients perceive each ET experience as new, implying that dentists should manage patients who have had ET in the past as carefully as those receiving ET for the first time.

Tooth Whitening Today

Abstract: Background Methods to improve the esthetics of the dentition by tooth whitening are of interest to dentists, their patients and the public. In the past 20 years, research on bleaching and other methods of removing tooth discolorations has dramatically increased. Dentist-supervised and over-the-counter products now are available to solve a variety of tooth discoloration problems without restorative intervention. The indications for appropriate use of tooth-whitening methods and products are dependent on correct diagnosis of the discoloration. Overview Tooth-whitening methods include the use of peroxide bleaching agents to remove internal discolorations or abrasive products to remove external stains. Peroxide bleaching procedures are completed by the dentist in single or multiple appointments, or by the patient over a period of weeks to months using custom trays loaded with a bleaching agent. Both methods are safe and effective when supervised by the dentist. Microabrasion is indicated for the removal of isolated discolorations that often are associated with fluorosis. Whitening toothpastes remove surface stains only through the polishing effect of the abrasives they contain. Conclusions and Practice Implications Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive treatment plan developed by a dentist after an oral examination. When used appropriately, tooth-whitening methods are safe and effective.

Failure of inferior alveolar nerve block: Exploring the alternatives

Abstract: Background Achieving proper anesthesia is imperative to performing most dental procedures. The conventional inferior alveolar nerve block is the most commonly used nerve block technique. In certain cases, however, this nerve block fails, even when performed by the most experienced clinician. Overall The authors explore the reasons why the conventional inferior alveolar nerve block fails and describe several alternate techniques. They also present the protocol used in their office to achieve mandibular anesthesia. Conclusions Several alternatives to the inferior alveolar nerve block are available. Clinicians should investigate them, rather than repeat the inferior alveolar nerve block after it has failed. Practice Implications Mastering anesthetic techniques maximizes success in the dental office. It enables clinicians to provide better and more comfortable treatment to patients.

Computer-assisted analysis of oral brush biopsies at an oral cancer screening program.

Abstract: Background Dentists and dental hygienists attending a health screening program were screened for oral cancer. Select oral epithelial lesions were evaluated by oral brush biopsy with a computer-assisted method of analysis (OralCDx, OralScan Laboratories Inc., Suffern, N.Y.). Methods After those who had oral epithelial lesions were identified, the clinical characteristics of each lesion were recorded. Participants with abnormal oral brush biopsy results (“positive” and “atypical”) subsequently underwent incisional biopsy of their lesions by an oral surgeon. Results A total of 930 dentists and dental hygienists were screened over a four-day period at each of the American Dental Association's 1999 and 2000 annual sessions. Eighty-nine people (9.7 percent) with 93 oral epithelial lesions were identified and evaluated by brush biopsy. Seven of the 93 oral lesions—all benign appearing in their clinical appearance—were determined to be “atypical” or “positive.” Of these, three were diagnosed as precancerous by scalpel biopsy and histologic evaluation. Conclusions Computer-assisted brush biopsy analysis is a valuable adjunct to the oral screening examination. The identification of three innocuous-looking precancerous lesions in this low-risk group of dentists and dental hygienists underscores the necessity of evaluating all oral lesions of unknown etiology. Clinical Implications As 9.7 percent of the screened dentists and dental hygienists had epithelial oral lesions, general dentists most likely routinely encounter an even higher percentage of oral lesions in their patients. The minimally invasive brush biopsy lets general dentists evaluate these lesions. Like Pap smears and mammograms, this tool can help identify precancers and potentially curable cancers.

Assessing fluoride concentration uniformity and fluoride release from three varnishes

Abstract: Background The authors investigated the fluoride content uniformity of three commercial fluoride varnishes, as well as their fluoride-release behaviors. Methods The authors examined 20 doses from each of two tubes of Duraphat (Colgate-Palmolive Co., New York) and Duraflor (Pharmascience Inc., Montreal), and 20 doses of individually packaged 0.25-milliliter and 0.40-mL units of CavityShield (OMNII Oral Pharmaceuticals, West Palm Beach, Fla.). Part of the dose was dissolved in chloroform, followed by fluoride extraction with distilled water. The authors painted the remaining varnish from five predetermined doses from each group onto plastic substrates for examination of fluoride release. Fluoride concentrations in the solutions were measured with a fluoride-selective ion electrode. Results One-way analysis of variance showed statistically significant differences between varnish groups. The fluoride content was more uniform in Duraphat and CavityShield than it was in Duraflor. The fluoride release profiles in terms of percentage of total fluoride released over time were different among different groups of varnishes and were similar among samples from the same test group. The authors found that Duraflor released consistently more fluoride in artificial saliva than did the other two varnishes. Conclusions Fluoride content can vary between doses dispensed from the same tube. Uniformity also varies between different varnishes and affects the retention of fluoride in the varnish. Clinical Implications Clinicians should be aware that the nonuniform appearance of fluoride varnish as squeezed out of the tube could indicate separation of ingredients, resulting in variation of fluoride content.

The relationship between oral conditions and ischemic stroke and peripheral vascular disease.

Abstract: Background This article is a critical review of the epidemiologic studies linking or disassociating oral conditions with stroke and peripheral vascular disease, or PVD. It also describes possible causal and non-causal pathways for these associations. Types of Studies Reviewed The author reviewed studies that evaluated the oral conditions of periodontal disease or tooth loss as risk factors for arterial disease and stroke. Results Seven of nine studies evaluating tooth loss and periodontal disease as risk factors for stroke or PVD showed some significant associations. The studies varied in the exposures and outcomes evaluated; therefore, the associations were not consistently replicated. It is unclear whether the associations found between these oral conditions and cardiovascular disease had any causal component. In the absence of any causal relationship, the associations may be explained by common risk factors. Alternatively, there may be a causal relationship that may be explained by one or more potential causal pathways. Further epidemiologic studies are needed, and the role of nutrition and other inflammatory mediators needs to be explored further in this context. Clinical Implications It is recommended that clinicians continue to provide standard professional care, as well as nutritional counseling to help patients maintain a healthy diet after extractions. Clinicians are cautioned against suggesting extractions as a means of preventing cardiovascular disease.

Does chronic periodontitis cause coronary heart disease?: A review of the literature

Abstract: Background Chronic periodontitis, or CP, has been associated with coronary heart disease, or CHD. This article reviews the available prospective CP-CHD evidence. Literature Reviewed In nine cohort studies, CP was associated with a 15 percent greater risk of developing CHD. Conclusions from individual studies depended on study characteristics. Summary risk estimates for studies controlling for smoking intensity (five of nine studies) or health awareness (two of nine studies) or studies with more than 600 CHD events (three of nine studies) suggest that CP is either not at all or weakly associated with CHD. Summary risk estimates for the studies that did not control for these factors or that examined an insufficient number of CHD events reported a weak increase in CHD risk associated with CP (20 percent greater). These data suggest that the CP-CHD associations observed in smaller studies are due to insufficient control for lifestyle differences. In addition, one cohort study reported that edentulous people had a CHD risk similar to that of people with CP. Therefore, the plausibility of dental infection elimination affecting CHD risk appears limited. Summary Current evidence supporting a causal CP-CHD link is weak. Rigorous methodological and analytical control of lifestyle factors such as smoking will be required to elucidate whether the CP-CHD disease association is either small or nonexistent. Clinical Implications Cigarette smoking destroys both oral and systemic health. Because of this strong common causal factor, oral and systemic health are linked. Dentistry should continue to play an important role in implementing smoking prevention and cessation programs.

Use of dental services: an analysis of visits, procedures and providers, 1996.

Abstract: Background While many studies have provided data on Americans' access to dental care, few have provided a detailed understanding of what specific treatments patients receive. This article provides detailed information about the types of dental services that Americans receive and the types of providers who render them. Methods The authors provide national estimates for the U.S. civilian noninstitutionalized population in several socioeconomic and demographic categories regarding dental visits, procedures performed and the types of providers who performed them, using household data from the 1996 Medical Expenditure Panel Survey, or MEPS. Results Data show that while the combination of diagnostic and preventive services adds up to 65 percent of all dental procedures, the combination of periodontal and endodontic procedures represents only 3 percent. Additionally, while 81 percent of all dental visits were reported as visits to general dentists, approximately 7 percent and 5 percent of respondents who had had a dental visit reported having visited orthodontists or oral surgeons, respectively. Conclusion MEPS data show the magnitude and nature of dental visits in aggregate and for each of several demographic and socioeconomic categories. This information establishes a nationally representative baseline for the U.S. population in terms of rates of utilization, number and types of procedures and variations in types of providers performing the procedures. These nationally representative estimates include data elements that describe specific dental visits, dental procedures and type of provider, and they offer details that are useful, important and not found elsewhere. Practice Implications By understanding these analyses, U.S. dentists will be better positioned to provide care and better meet the dental care needs of all Americans.