Implementation of a 4Ms approach in age-friendly oral health care at an Academic Specialty Care Dental Clinic.

BACKGROUND: Implementing the Age-Friendly Health System (AFHS) framework into dental care provides a significant opportunity to link oral health to healthy aging. This project aimed to implement the AFHS 4Ms (what matters, medications, mentation, and mobility) in the provision of oral health care. This article describes the planning, integration, training development, and outcome measurements supporting a 4Ms approach at an academic dental clinic. METHODS: The Eastman Institute for Oral Health (EIOH) implemented screening instruments based on the 4Ms framework recommended for ambulatory care clinics by the Institute for Health Care Improvement (IHI). These ambulatory instruments were integrated into the workflows of a Specialty Care Clinic through the development of a plan-do-study-act cycle, utilization of available clinic resources, and creation of interdisciplinary collaborations. RESULTS: This project demonstrated the feasibility of implementing an AFHS checklist and tracking forms in dental practice by integrating available resources and prioritizing the 4Ms elements. This effort necessitated interdisciplinary collaborations between dental, medical, and social service professionals. It also created a new age-friendly focused education and training curriculum for dental residents and faculty. CONCLUSIONS: This pilot project is the first to establish dental standards for AFHS implementation, adapting the 4Ms assessment and metrics to oral health. This AFHS underscores key oral health processes, including assessment, planning, and personalized oral health care, adapted to the unique needs of the older adult population, especially those with cognitive impairment.

Potential association of anticholinergic medication intake and caries experience in young adults with xerostomia.

Background/purpose: Growing prescription of anticholinergic medications has a critical effect on oral health. A link between anticholinergic medication-induced xerostomia (subjective feeling of oral dryness) and a high Decayed, Missing, and Filled teeth (DMFT) index has been reported in the older population. The purpose of this retrospective study is to determine anticholinergic exposure and prevalence of the most frequently used anticholinergic medications in adults 18-44 years of age, as well as to explore xerostomia and its association with caries status. Materials and methods: We performed a retrospective study of adults between the age of 18 and 44 years who received a dental examination between January 2019 and April 2010, at Eastman Institute for Oral Health (EIOH), Rochester, NY. We reviewed the electronic dental charts and medical records of 236 adults with xerostomia. Results: 71% of young adults with xerostomia were prescribed at least five or more medications (polypharmacy), and 85% took at least one anticholinergic drug. The average anticholinergic drug scale (ADS) was 2.93. We found systemic conditions such as cardiac, neurological, and sleep apnea affecting the DMFT index by predicting the caries status (P < 0.001). Conclusion: Anticholinergic exposure and medication-induced xerostomia in younger adults are associated with dental caries and require complex interdisciplinary therapy.

Anticholinergic burden of medications is associated with dry mouth and reflected in minor labial gland secretion.

OBJECTIVE: Medications with anticholinergic potential inhibit saliva secretion. Polypharmacy potentiates anticholinergic burden, causing dry mouth symptoms and chronic deterioration of oral health. Patients of any age can be affected by anticholinergic medication-triggered hyposalivation (the objective measure of dry mouth); therefore, seeking predictions of hyposalivation to screen dry mouth is needed. DESIGN: In our prospective, cross-sectional clinical study, 55 middle-aged adult patients participated. We examined whether the anticholinergic burden calculated from anticholinergic medications (anticholinergic drug score; ADS) and blood serum anticholinergic activity (SAA; the gold standard measure of anticholinergic burden) is associated with hyposalivation. As no prior studies measured minor salivary glands regarding the quantifiable anticholinergic burden, we assessed hyposalivation by the minor saliva flow (MSF) and unstimulated whole saliva (UWS) secretion. RESULTS: Our data showed a negative linear relationship between SAA and UWS (p < 0.05); when SAA increases by one pmol/ml unit, the saliva flow decreases by 0.058 ml/min. MSF showed a linear correlation (p < 0.005) with UWS. In a multivariate logistic regression model (including age, gender, race, smoking status, xerostomia severity, ADS, and BMI), we identified SAA and age as predictors of hyposalivation (p < 0.05). CONCLUSIONS: We provide evidence for the significant relationship between measurable anticholinergic burden and saliva flow. The correlation between UWS and MSF suggests that both saliva flow rate measurement methods could reflect anticholinergics-induced changes in salivary health.

Editorial: Chronic Orofacial Pain in Older Adults.

No summary.

Association between medication-induced xerostomia and orofacial pain: a systematic review.

OBJECTIVE: Xerostomia (or oral dryness) is most commonly caused by medications that affect saliva secretion, and is often accompanied by symptoms of orofacial pain. Medication-induced xerostomia may or may not be associated with objectively demonstrable hyposalivation. The present study attempted to systematically identify an association between medication-induced xerostomia and orofacial pain. METHOD AND MATERIALS: A systematic search was conducted using the following databases: WoS, PubMed, SCOPUS, and MEDLINE. The search terms used were: xerostomia OR "dry mouth" AND medication AND ("oral pain" OR "orofacial pain" OR "craniofacial pain" OR "burning mouth" OR "glossodynia") NOT Sjögren's NOT cancer. Inclusion criteria were medication-induced xerostomia and reported symptoms of orofacial pain. Four researchers performed the selection process and quality assessment and two researchers conducted data extraction. RESULTS: Seven studies with a total of 1,029 patients were included. These studies were conducted between 2009 and 2022 and consisted of cross-sectional studies, case-control studies, and one randomized crossover trial. The studies consisted of a total of 1,029 participants. All studies included male and female participants whose mean ages ranged from 43 to 100 years. CONCLUSIONS: A positive association was found between medication-induced xerostomia and orofacial pain. No associations were found between salivary flow measurements (hyposalivation) and medication use. Future research should focus on saliva flow measurements, standardized assessment of medication-induced xerostomia, as well as the inclusion of accompanying orofacial pain diagnosis in the medical history to allow for higher level of evidence in establishing reliable predictors of medication-induced oral health damage to facilitate clinical prevention and management.

Postgraduate dental resident education: A pilot in age-friendly "mentation" training.

OBJECTIVE: Postdoctoral dental education in caring for older adults lacks didactic and clinical training in mentation topics, one of the core elements of the Age-Friendly Health Systems (AFHS) framework. Our primary goal was to launch a pilot project in clinical geriatrics focusing on older adults' mentation concerns, with a secondary goal to improve dental residents' confidence and competence in dental care and oral health. BACKGROUND: Age-friendly care elements are not routinely incorporated into the dental education of residents caring for older adults with cognitive impairment or dementia. Therefore, we implemented a pilot educational project, providing the missing educational opportunity for residents in geriatric training covering cognitive impairment and focusing on Alzheimer's disease and related dementias. MATERIALS AND METHODS: We designed educational sessions through a needs assessment, focus group discussions, and expert validation. We developed three e-Learning modules covering mentation concerns and dementia screening. We tested the modules in a pilot study of 15 dental postdoctoral residents as an essential part of their clinical practice. RESULTS: The dementia dental learning module increased the residents' satisfaction with didactic preparedness (4.45  ± $ \pm \ $ 0.97) and knowledge acquisition (4.36  ± $ \pm \ $ 0.84). Residents strongly believed that learning about the AFHS-mentation topic would improve patient care. CONCLUSION: Our pilot study is a pioneer project in support of a new AFHS-themed dental curriculum for clinical education. Further expansion of the age-friendly principles to include mobility, medications, and what matters to older adults will establish a model framework of redesigned geriatric dental education for academic centers.

Anticholinergic Medication and Caries Status Predict Xerostomia under 65.

The use of anticholinergic medications is increasing in younger ages, yet information about xerostomia, the most common anticholinergic side effect, is limited. This case-control retrospective study examines the relationship between anticholinergic medication-induced xerostomia and caries status among adults between 18 and 65 years of age. The study sample comprised 649 cases with xerostomia and 649 age- and gender-matched controls. The anticholinergic burden was estimated using the anticholinergic drug scale (ADS). Caries experience was recorded by calculating the Decayed, Missing, Filled Tooth (DMFT) index. Individuals with xerostomia had a higher mean DMFT index (16.02 ± 9.50), which corresponded with a higher level of anticholinergic exposure from medications (3.26 ± 2.81) compared to their age and gender-matched controls without xerostomia (13.83 + 8.83 and 1.89 ± 2.45, respectively). Logistic regression analysis verified the effects of DMFT, the total number of AC medications, and the ADS burden on xerostomia status. Comparing adults with or without xerostomia revealed statistical differences in several risk factors, such as smoking, diabetes, sleep apnea, and the utilization of anticholinergic medications. A personalized dental care plan should include the evaluation of the anticholinergic burden from medications regardless of the patient's age to prevent increased caries severity.

Anticholinergic medication and dental caries status in middle-aged xerostomia patients-a retrospective study.

Background/purpose: Xerostomia is the most frequent side effect of anticholinergic (AC) medications, which block the cholinergic neurotransmission of saliva secretion. As the most significant increase in AC medications' usage reported in middle-aged adults, we aimed to explore whether the level of exposure to AC medication show association with the severity of caries status of middle-aged individuals who complained about medication-induced xerostomia. Materials and methods: Our retrospective study included 414 individuals (between 45 and 64 years) with self-reported xerostomia. We determined caries status by the Decayed, Missing, or Filled Teeth (DMFT) index and quantified the level of AC drug exposure by the AC Drug Scale (ADS), verified through electronic medication records. Statistical analyses were performed using chi-square and ANOVA tests. Covariates were age, gender, smoking, edentulism, comorbidities, polypharmacy, number, and the type of AC medications. Results: In total, 54% of patients were taking five or more AC drugs. The mean number of anticholinergics was 5.41 (±3.44), most frequently antidepressants and antipsychotics, among all medications 10.63 (±5.79). Higher ADS scores were associated (p = 0.006) with a higher number of missing teeth. Multiple linear regression model showed that the number of AC medications, age, and smoking status are associated with DMFT (mean of 18.7 ± 8.96) scores. Conclusion: Caries status of middle-aged xerostomia patients was found to be reflective of the level of AC exposure from medications. Our finding emphasizes the importance of assessing AC medication burden in affected dental patients to improve clinical prevention strategies and guide interdisciplinary treatment plans.

Orofacial Manifestation and Dental Management of Sickle Cell Disease: A Scoping Review.

AIMS: Sickle cell disease (SCD) is an upcoming global health problem with rapid progress in therapy especially since 2017. However, systematic reviews found no clinical trials on the dental treatment of sickle cell disease (SCD). This article aims to outline the oral features of the sickle disease and discuss oral management strategies that can serve as guidelines for dental professionals. Material and Methods. A comprehensive literature review was conducted using PubMed, Google Scholar, and Web of Science. The search strategies were developed to cover publications from January 2010 to March 2020. With the help of keywords, multiple abstracts were identified. These abstracts were further reviewed, which included the information about the SCD manifestation, particularly about the oral health features. Based on all these articles and clinical experience, a narrative review was constructed, which summarizes all the aspects of the oral manifestation in people with SCD. RESULTS: The results of this study demonstrate that there is distinct evidence available, indicating the developmental enamel defect leading to hypoplasia and increasing susceptibility to dental caries. Another important result of this review found that people with SCD have a vaso-occlusive crisis in the microcirculation in the dental pulp leading to symptomatic and asymptomatic pulpal necrosis without any signs of odontogenic pathology in an apparently healthy tooth. The study also found that early detection, intervention, and prevention are crucial for improving oral health care, and involving a multidisciplinary approach plays an important role in managing people with SCD. CONCLUSION: Patients with sickle cell disease have chronic overall health problems. The hematological disorder becomes their main concern and impaired oral health becomes secondary, increasing the risk for dental caries at the most. This paper broadly describes the oral manifestations of SCD, additionally; this paper also provides recommendations for better dental management of patients with SCD. Patients with SCD are often misjudged and, due to lack of knowledge and guidelines, dental providers are not able to provide adequate care. This paper attempts to highlight the essential measures to provide better dental care.

Anticholinergic medication: Related dry mouth and effects on the salivary glands.

OBJECTIVE: Salivary glands are among the most sensitive target organs of medications with anticholinergic (AC) properties, interrupting the neural stimulation of saliva secretion and reducing saliva flow. Hyposalivation results in dry mouth, leading to dental caries, intraoral infection, orofacial pain, problems with speaking and swallowing, and diminished oral health--related quality of life. Current understanding of the pharmacokinetics of AC medications and their effect on muscarinic receptors in the salivary glands were reviewed to assist clinicians in predicting salivary damage in patients with AC medication-induced dry mouth. STUDY DESIGN: We summarized the literature related to the mechanisms and properties of AC medications, anticholinergic adverse effects, and their effect on salivary function and management strategies to prevent oral health damage. RESULTS: Although a large number of studies reported on the frequencies of medication-induced dry mouth, we found very limited data on predicting individual susceptibility to AC medication--caused hyposalivation and no prospective clinical studies addressing this issue. CONCLUSION: Dry mouth is most frequently caused by medications with AC properties, which interrupt the neural stimulation of saliva secretion. Interdisciplinary care should guide pharmacotherapeutics and dental interventions should aim in preventing AC salivary adverse effects and reducing the oral health burden from AC medication-induced dry mouth.

Predictors of dental complications post-dental treatment in patients with sickle cell disease.

OBJECTIVE: Our aim was to explore potential medical or dental indicators associated with dental complications and the utilization of emergency services in sickle cell disease (SCD), especially that clinical reports on adverse outcomes post-dental treatment are scarce. MATERIALS AND METHODS: A retrospective analysis of dental treatments of 47 eligible adults with confirmed SCD between May 2016 and October 2019. Logistic regression analysis was used whether clinical outcomes, course of dental treatment, and regularity of dental care are associated with dental complications after dental procedures and/or resulted in emergency care or hospital admissions. RESULTS: We identified a new, statistically significant association (p-value = .01) between the number of prescription medications taken and complications (10%) after dental procedures. The most frequent dental procedures were tooth extractions (36%) and pain management (28%) during a non-scheduled dental encounter (68%). The majority of cases did not participate in regular recall exams and periodical oral hygiene maintenance. CONCLUSIONS: A higher number of prescription medications was associated with an increased risk of post-dental complications in SCD patients. A thorough medical history, including a list of prescribed medications, and collaboration with the patient medical team are important to assess the risk of complications post-dental procedures and the need for antibiotic prophylaxis according to the case complexity.

Xerostomia and patients' satisfaction with removable denture performance: systematic review.

Objectives: Patients with xerostomia manifest various clinical signs of oral dryness, which has an impact on oral functions and wearing of dental prosthese?s, but the evidence of xerostomia-related changes in denture performance is unsatisfactorily documented. The purpose of this systematic review was to evaluate whether the available literature can answer the focused question "Is there an association between xerostomia and decreased denture performance among patients wearing removable dentures?" Data sources: Indexed databases were explored without time or language restrictions up to and including March 2019. All levels of available evidence including experimental studies, case reports, and case series were searched using different combinations of the following keywords: saliva, xerostomia, dentures, personal satisfaction, quality of life, oral dryness, and oral complaints. Nine studies were included for qualitative synthesis. Overall, five studies had a cross-sectional design and four studies were case-control studies. In these studies, the number of participants ranged between 35 patients and 493 patients with mean ages ?from 56 to 82 years; 66% of the patients were completely and 34% were partially edentulous.
Conclusion: All studies included patient satisfaction with dentures and recorded the presence of oral dryness. Six out of nine studies demonstrated that xerostomia is significantly associated with the decreased performance of removable dentures. Although the available evidence lacks feedback from randomized, controlled clinical studies, it implies a negative impact of oral dryness on specific denture functions such as speaking, chewing, and retention, which affects both complete and partial denture wearers.

Nanoparticle-mediated gene silencing confers radioprotection to salivary glands in vivo.

Radiation treatment of head and neck cancers causes irreversible damage of the salivary glands (SG). Here, we introduce a preclinical mouse model for small-interfering RNA (siRNA)-based gene silencing to provide protection of SG from radiation-induced apoptosis. Novel, pH-responsive nanoparticles complexed with siRNAs were introduced into mouse submandibular glands (SMG) by retroductal injection to modulate gene expression in vivo. To validate this approach, we first targeted Nkcc1, an ion transporter that is essential for saliva secretion. Nkcc1 siRNA delivery resulted in efficient knockdown, as quantified at the mRNA and the protein levels, and the functional result of Nkcc1 knockdown phenocopied the severe decrease in saliva secretion, characteristic of the systemic Nkcc1 gene knockout. To establish a strategy to prevent apoptotic cell loss due to radiation damage, siRNAs targeting the proapoptotic Pkcδ gene were administered into SMG before ionizing radiation. Knockdown of Pkcδ not only reduced the number of apoptotic cells during the acute phase of radiation damage, but also markedly improved saliva secretion at 3 months in irradiated animals, indicating that this treatment confers protection from hyposalivation. These results demonstrate that nanoparticle delivery of siRNAs targeting a proapoptotic gene is a localized, nonviral, and effective means of conferring radioprotection to the SGs.

Hyperosmotic stress induces cell death in an odontoblast-lineage cell line.

INTRODUCTION: Osmotic stress is one of the stimulations related to dental pain caused by caries or dentin hypersensitivity. The mechanism of osmotic-induced dental pain is not completely understood. The purpose of this study was to examine the responses of odontoblasts under sucrose-induced hyperosmotic stress. METHODS: We used an odontoblast-lineage cell (OLC) line in our experiments. OLCs were stimulated with sucrose to produce hyperosmotic stress. The expressions of dentin sialophosphoprotein (DSPP) and dentin matrix protein 1 (DMP 1) were detected by using reverse transcriptase polymerase chain reaction assay. The cell viability of OLCs was detected by using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium assay. The responses accompanied with cell death were detected by using 4-6-diamidino-2-phenylindole staining, Western blotting of caspase-3, and annexin V assay. The expression of mitogen-activated protein kinases (MAPKs) was detected by using Western blot analysis. RESULTS: DSPP and DMP 1 were not affected by hyperosmotic stress in OLCs. Cell viability decreased over 700 mOsm for 3 hours of cell culture. The shapes of cells and nuclei became irregular and vacuolar under hyperosmotic stress. The expression of cleaved caspase-3 was increased after treatment with hyperosmotic stress. Some propidium iodide-positive cells were detected in flow cytometry analysis. Phosphorylation of 3 MAPKs was induced by hyperosmotic stress. Inhibitors of 3 MAPKs inhibited the hyperosmotic stress-induced decline in cell viability at 500 and 700 mOsm. CONCLUSIONS: Hyperosmotic stress induces cell death of OLCs with sucrose through a MAPK pathway.

Pro-apoptotic gene knockdown mediated by nanocomplexed siRNA reduces radiation damage in primary salivary gland cultures.

A critical issue in the management of head and neck tumors is radioprotection of the salivary glands. We have investigated whether siRNA-mediated gene knock down of pro-apoptotic mediators can reduce radiation-induced cellular apoptosis in salivary gland cells in vitro. We used novel, pH-responsive nanoparticles to deliver functionally active siRNAs into cultures of salivary gland cells. The nanoparticle molecules are comprised of cationic micelles that electrostatically interact with the siRNA, protecting it from nuclease attack, and also include pH-responsive endosomolytic constituents that promote release of the siRNA into the target cell cytoplasm. Transfection controls with Cy3-tagged siRNA/nanoparticle complexes showed efficiently internalized siRNAs in more than 70% of the submandibular gland cells. We found that introduction of siRNAs specifically targeting the Pkcδ or Bax genes significantly blocked the induction of these pro-apoptotic proteins that normally occurs after radiation in cultured salivary gland cells. Furthermore, the level of cell death from subsequent radiation, as measured by caspase-3, TUNEL, and mitochondrial disruption assays, was significantly decreased. Thus, we have successfully demonstrated that the siRNA/nanoparticle-mediated knock down of pro-apoptotic genes can prevent radiation-induced damage in submandibular gland primary cell cultures.

Age estimation of bloodstains: a preliminary report based on aspartic acid racemization rate.

This study describes an innovative application of a well-established method of age determination. The conventional method of aspartic acid racemization (AAR) is based on estimation of the d-l-aspartic acid ratio in slow turnover tissues, such as tooth tissue, to reflect the age of an individual. This method has been recently applied to age estimation in forensic investigations, and is also widely used for archeological dating of fossils. We suggest that the aspartic acid racemization method could be applied to a significant, although unresolved, forensic issue: that of bloodstain dating. Standard kinetic experiments were used to describe the characteristics of the racemization reaction in bloodstains, which were then employed to estimate the age of various samples. The soluble protein fraction of a bloodstain produced a stronger correlation between elapsed time and d-aspartic acid content than total amino acid fractions. According to our preliminary results, the time lapse after the creation of a bloodstain can be determined ex vivo by measuring the extent of aspartic acid racemization. Our analysis highlights the need for further study into the preservation and composition of bloodstains to assist in further development of this pioneering application.

Ascl3 knockout and cell ablation models reveal complexity of salivary gland maintenance and regeneration.

Expression of the transcription factor, Ascl3, marks a population of adult progenitor cells, which can give rise to both acinar and duct cell types in the murine salivary glands. Using a previously reported Ascl3(EGFP-Cre/+) knock-in strain, we demonstrate that Ascl3-expressing cells represent a molecularly distinct, and proliferating population of progenitor cells located in salivary gland ducts. To investigate both the role of the Ascl3 transcription factor, and the role of the cells in which it is expressed, we generated knockout and cell-specific ablation models. Ascl3 knockout mice develop smaller salivary glands than wild type littermates, but secrete saliva normally. They display a lower level of cell proliferation, consistent with their smaller size. In the absence of Ascl3, the cells maintain their progenitor function and continue to generate both acinar and duct cells. To directly test the role of the progenitor cells, themselves, in salivary gland development and regeneration, we used Cre-activated expression of diphtheria toxin (DTA) in the Ascl3-expressing (Ascl3+) cell population, resulting in specific cell ablation of Ascl3+ cells. In the absence of the Ascl3+ progenitor cells, the mice developed morphologically normal, albeit smaller, salivary glands able to secrete saliva. Furthermore, in a ductal ligation model of salivary gland injury, the glands of these mice were able to regenerate acinar cells. Our results indicate that Ascl3+ cells are active proliferating progenitors, but they are not the only precursors for salivary gland development or regeneration. We conclude that maintenance of tissue homeostasis in the salivary gland must involve more than one progenitor cell population.

Age estimation by racemization method in teeth: application of aspartic acid, glutamate, and alanine.

Here, we report on an experimental approach of simultaneous determination of various amino acids racemization (AAR) rates in teeth. We evaluated the measurements of aspartic acid (Asp), glutamate (Glu), and alanine (Ala) isolated from dentin. Asx D/L rates from total amino acid fraction, generally used for age estimation, showed high correlation (r = 0.98) with age. As Glx and Ala showed very slow racemization kinetics in TA, we performed further analysis of the acid-soluble protein (SP) fraction. The results supported improved correlation between age and D/L rates for Glu (r = 0.84) and Ala (r = 0.85), as well as for Asp (r = 0.98). By providing further elucidation on dentin protein racemization, the technique offers a considerable opportunity to involve other amino acids in age estimation studies. As the process does not require additional separation steps, the method can be easily adapted to existing protocols.

Application of spontaneously immortalized odontoblast cells in tooth regeneration.

Here, we report on the first attempt to bioengineer tooth using a spontaneously immortalized mesenchymal cell line. To assess the odontogenic potential of this cell line, odontoblast-lineage cells (OLC) were re-associated with competent dental epithelium isolated from E14.5 mice. A novel three-dimensional organ germ culture method was applied to nurture the constructs in vitro. Additionally, recombinants were transplanted under the kidney capsule in host animals for 2 weeks. Transplants developed into tooth tissues in one-third of the cases. OLC-derived GFP-positive cells could be identified in mineralizing tooth germs by immunohistochemistry. OLCs were capable of intercellular and cell-matrix communication, thus they eventually differentiated into functional odontoblasts. In summary, we managed to utilize OLCs for dental mesenchyme substitution in tooth regeneration experiments. Therefore, our spontaneously transformed cell line proved its potential for future complex, tooth developmental and bioengineering studies.