Dental practitioner approaches to bruxism: Preliminary findings from the national dental practice-based research network.

OBJECTIVE: Bruxism is a repetitive masticatory muscle activity. This study investigates dental practitioners' approaches to bruxism assessment and treatment in practices. METHODS: A brief 5 question questionnaire ("Quick Poll") on bruxism was conducted. RESULTS: A total of 397 practitioners responded. More than half (55%) initiated treatment for bruxism on one to three patients per month. The majority believed that stress (97%) and sleep patterns (82%) affected bruxism in their patients. Interestingly, 96% offered an occlusal guard/appliance and 46% made occlusal adjustments. CONCLUSION: This study highlights inconsistencies in practitioner approaches to bruxism assessment and management in clinical settings, suggesting gaps in practitioner knowledge evidenced by the varied responses. ABBREVIATIONS: PBRN - Practice-Based Research NetworkMMA - Masticatory muscle activitySB - Sleep bruxismAB - Awake bruxismTMJ - Temporomandibular jointOSA - Obstructive sleep apnea.

Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review.

OBJECTIVE: A controversy exists concerning the relationship, if any, between obstructive sleep apnea (OSA) and the anatomical position of the anterior teeth. Specifically, there has been speculation that extraction orthodontics and retraction of the anterior teeth contributes to OSA by crowding the tongue and decreasing airway space. This retrospective study utilized electronic medical and dental health records to examine the association between missing premolars and OSA. METHODS: The sample (n = 5,584) was obtained from the electronic medical and dental health records of HealthPartners in Minnesota. Half of the subjects (n = 2,792) had one missing premolar in each quadrant. The other half had no missing premolars. Cases and controls were paired in a 1:1 match on age range, gender, and body mass index (BMI) range. The outcome was the presence or absence of a diagnosis of OSA confirmed by polysomnography. RESULTS: Of the subjects without missing premolars, 267 (9.56%) had received a diagnosis of OSA. Of the subjects with four missing premolars, 299 (10.71%) had received a diagnosis of OSA. The prevalence of OSA was not significantly different between the groups (OR = 1.14, p = 0.144). CONCLUSION: The absence of four premolars (one from each quadrant), and therefore a presumed indicator of past "extraction orthodontic treatment," is not supported as a significant factor in the cause of OSA.

Career transition and dental school faculty development program.

Academic dentistry, as a career track, is not attracting sufficient numbers of new recruits to maintain a corps of skilled dental educators. The Faculty Development Program (FDP) at the University of Texas Health Science Center at San Antonio Dental School received federal funds to institute a 7-component program to enhance faculty recruitment and retention and provide training in skills associated with success in academics including:(1) a Teaching Excellence and Academic Skills (TExAS)Fellowship, (2) training in research methodology,evidence-based practice research, and information management, (3) an annual dental hygiene faculty development workshop for dental hygiene faculty, (4) a Teaching Honors Program and Academic Dental Careers Fellowship to cultivate students' interest in educational careers, (5) an Interprofessional Primary Care Rotation,(6) advanced education support toward a master's degree in public health, and (7) a key focus of the entire FDP, an annual Career Transition Workshop to facilitate movement from the practice arena to the educational arm of the profession.The Career Transition Workshop is a cap stone for the FDP; its goal is to build a bridge from practice to academic environment. It will provide guidance for private practice, public health, and military dentists and hygienists considering a career transition into academic dentistry. Topics will be addressed including: academic culture, preparation for the academic environment,academic responsibilities, terms of employment,compensation and benefits, career planning, and job search / interviewing. Instructors for the workshop will include dental school faculty who have transitioned from the practice, military, and public health sectors into dental education.Objectives of the Overall Faculty Development Program:• Provide training in teaching and research skills,career planning, and leadership in order to address faculty shortages in dental schools and under representation of minority faculty.• Provide resident and faculty training in cultural and linguistic competency.• Develop and conduct a collaborative inter professional education project with a Pediatric Medicine department, a nursing school, and other health professions' education programs.• Provide faculty and residents with financial support to pursue a master's degree in public health; and • Provide support and assistance for dental practitioners desiring to explore a transition into the educational environment.

Transferring evidence-based information from dental school to practitioners: a pilot "academic detailing" program involving dental students.

An academic detailing program involving dental students as the academic detailers was conducted at the University of Texas Health Science Center at San Antonio Dental School in 2008 and 2009. Students were trained to visit general dentists and present critically appraised topic (CAT) documents in a face-to-face intervention. Thirty-eight students visited 143 general dentists during summer vacation breaks. Students reported that their participation in the project reinforced their commitment to evidence-based practice as taught in their coursework. The dentists also reported positively on the project.

Teaching evidence-based practice at the University of Texas Health Science Center at San Antonio dental school.

The overarching goal of the Evidence-Based Practice Program at San Antonio is to provide our graduates with life-long learning skills that will enable them to keep up-to-date and equip them with the best possible patient care skills during their 30-40 years of practice. Students are taught to (1) ask focused clinical questions, (2) search the biomedical research literature (PubMed) for the most recent and highest level of evidence, (3) critically evaluate the evidence, and (4) make clinical judgments about the applicability of the evidence for their patients. Students must demonstrate competency with these "just-in-time" learning skills through writing concise one-page Critically Appraised Topics (CATs) on focused clinical questions. The school has established an online searchable library of these Critically Appraised Topics. This library provides students and faculty with rapid, up-to-date evidence-based answers to clinical questions. The long-range plan is to make this online library available to practitioners and the public.

Validation of an instrument to assess evidence-based practice knowledge, attitudes, access, and confidence in the dental environment.

This article reports the validation of an assessment instrument designed to measure the outcomes of training in evidence-based practice (EBP) in the context of dentistry. Four EBP dimensions are measured by this instrument: 1) understanding of EBP concepts, 2) attitudes about EBP, 3) evidence-accessing methods, and 4) confidence in critical appraisal. The instrument-the Knowledge, Attitudes, Access, and Confidence Evaluation (KACE)-has four scales, with a total of thirty-five items: EBP knowledge (ten items), EBP attitudes (ten), accessing evidence (nine), and confidence (six). Four elements of validity were assessed: consistency of items within the KACE scales (extent to which items within a scale measure the same dimension), discrimination (capacity to detect differences between individuals with different training or experience), responsiveness (capacity to detect the effects of education on trainees), and test-retest reliability. Internal consistency of scales was assessed by analyzing responses of second-year dental students, dental residents, and dental faculty members using Cronbach coefficient alpha, a statistical measure of reliability. Discriminative validity was assessed by comparing KACE scores for the three groups. Responsiveness was assessed by comparing pre- and post-training responses for dental students and residents. To measure test-retest reliability, the full KACE was completed twice by a class of freshman dental students seventeen days apart, and the knowledge scale was completed twice by sixteen faculty members fourteen days apart. Item-to-scale consistency ranged from 0.21 to 0.78 for knowledge, 0.57 to 0.83 for attitude, 0.70 to 0.84 for accessing evidence, and 0.87 to 0.94 for confidence. For discrimination, ANOVA and post hoc testing by the Tukey-Kramer method revealed significant score differences among students, residents, and faculty members consistent with education and experience levels. For responsiveness to training, dental students and residents demonstrated statistically significant changes, in desired directions, from pre- to post-test. For the student test-retest, Pearson correlations for KACE scales were as follows: knowledge 0.66, attitudes 0.66, accessing evidence 0.74, and confidence 0.76. For the knowledge scale test-retest by faculty members, the Pearson correlation was 0.79. The construct validity of the KACE is equivalent to that of instruments that assess similar EBP dimensions in medicine. Item consistency for the knowledge scale was more variable than for other KACE scales, a finding also reported for medically oriented EBP instruments. We conclude that the KACE has good discriminative validity, responsiveness to training effects, and test-retest reliability.

The San Antonio CATs Initiative.

There is evidence from medicine that schools and practitioners are slow to adopt new and proven effective treatments while marketing efforts lead practitioners to too quickly adopt unproven modalities. To address these problems, the dental school at the University of Texas Health Sciences Center at San Antonio, has developed a program designed to teach students, faculty, and practitioners the skills of accessing the literature as an intrinsic part of treatment. The Critically Appraised Topics (CATs) program is described and evidence is presented showing that participants can be taught to prepare high-quality summaries of the literature pertinent to clinical problems.

Ozone and TFA impacts in North America from degradation of 2,3,3,3-Tetrafluoropropene (HFO-1234yf), a potential greenhouse gas replacement.

We use a regional-scale, three-dimensional atmospheric model to evaluate U.S. air quality effects that would result from replacing HFC-134a in automobile air conditioners in the U.S. with HFO-1234yf. Although HFO-1234yf produces tropospheric ozone, the incremental amount is small, averaging less than 0.01% of total ozone formed during the simulation. We show that this production of ozone could be compensated for by a modest improvement in air conditioner efficiency. Atmospheric decomposition of HFO-1234yf produces trifluoroacetic acid (TFA), which is subject to wet and dry deposition. Deposition and concentrations of TFA are spatially variable due to HFO-1234yf's short atmospheric lifetime, with more localized peaks and less global transport when compared to HFC-134a. Over the 2.5 month simulation, deposition of TFA in the continental U.S. from mobile air conditioners averages 0.24 kg km(-2), substantially higher than previous estimates from all sources of current hydrofluorocarbons. Automobile air conditioning HFO-1234yf emissions are predicted to produce concentrations of TFA in Eastern U.S. rainfall at least double the values currently observed from all sources, natural and man-made. Our model predicts peak concentrations in rainfall of 1264 ng L(-1), a level that is 80x lower than the lowest level considered safe for the most sensitive aquatic organisms.

Relationship of body mass index to stability of mandibular advancement surgery with rigid fixation.

INTRODUCTION: Obesity is a growing problem in the United States. We examined patients undergoing orthognathic surgical correction for Class II skeletal malocclusions and assessed outcomes in relation to body mass index. METHODS: The patients (n = 78) were divided into 3 groups (obese, overweight, and normal or thin) based on body mass index score. They were treated with mandibular advancement (mean, 4.9 mm) with rigid fixation and evaluated cephalometrically for postsurgical changes over a 2-year period; a subset of 54 patients was followed for 5 years. RESULTS: Obese and overweight patients experienced relative postsurgical forward movements at B-point (means, 2.6 and 1.0 mm, respectively), whereas the normal or thin patients had relapses (mean, -0.7 mm) over the 2 years. This trend held up at 5 years, with the obese patients experiencing 3 mm of forward movement compared with the normal or thin patients. Potential reasons for this difference in postsurgical response are orthopedic effects of tongue posture and hormonal and biochemical differences caused by obesity. CONCLUSIONS: Obese and overweight patients have different responses to mandibular advancement with rigid fixation compared with normal or thin patients. These data should enable orthodontists and surgeons to more appropriately treat obese patients.

Esthetic preferences of European American, Hispanic American, Japanese, and African judges for soft-tissue profiles.

INTRODUCTION: Our objectives were to determine whether observer and patient sex and race or ethnicity determine esthetic preferences for lip positions. METHODS: Four independent panels each consisting of 30 lay judges viewed pretreatment silhouette profiles of 10 European American, 10 Japanese, and 10 African American Angle Class I and Class II orthodontic patients. The panels included European Americans, Hispanic Americans, Japanese, and Africans. Profiles were traced from lateral cephalograms and manipulated so that the lip profile lay on the Ricketts' E-line or at various distances from the E-line from -8 to +4 mm in 2-mm increments. The judges selected the profile that they considered the most attractive and then classified the remaining 6 profiles as either acceptable or unacceptable. RESULTS: The mean preferred lip positions (mean +/- SD) were -2.58 +/- 1.92 mm for European American, -3.28 +/- 2.26 mm for Hispanic American, -3.45 +/- 1.92 mm for Japanese, and -2.13 +/- 1.95 mm for African judges. The African judges preferred more protrusive profiles compared with the Hispanic American (P <0.01) and Japanese (P <0.001) judges. Patient race or ethnicity and sex also contributed significantly to the judgments of profile esthetics (P <0.001). CONCLUSIONS: Judge race or ethnicity and patient race or ethnicity and sex significantly influence laypersons' standards for lip profile esthetics.

Effects of surgical mandibular advancement and rotation on signs and symptoms of temporomandibular disorder: a 2-year follow-up study.

INTRODUCTION: The possible effects of orthognathic surgery on signs and symptoms of temporomandibular disorder (TMD) are still controversial. We prospectively investigated the association between the amount of advancement and rotation of the mandible during bilateral sagittal split osteotomy (BSSO) and the development of TMD signs and symptoms. METHODS: Class II patients (n = 127) received mandibular advancement with BSSO. We used factorial analysis of covariance to assess whether the magnitude (< or > or = 7 mm) and the direction (clockwise or counterclockwise) of the movement were associated with the onset or worsening of TMD signs and symptoms during 2 years of follow-up. RESULTS: Counterclockwise rotation of the mandible was associated with more muscle tenderness, especially in patients receiving long advancements. The combination of long advancement with counterclockwise rotation was also associated with increased joint symptoms. All symptoms declined over the 2-year follow-up period. CONCLUSIONS: Counterclockwise rotation of the mandible is related to a slight increase in muscle symptoms after BSSO. The combination of counterclockwise rotation with long advancement also might increase joint signs and symptoms. All symptomatology tended to decline over time, suggesting that the amount of advancement and mandibular rotation should not be considered as risk factors for the development of TMD in patients without preexisting conditions.

Practice-based comparison of direct and indirect bonding.

INTRODUCTION: The purpose of this study was to compare bond-failure prevalences, numbers of appointments, and treatment times between direct and indirect bracket bonding for patients treated in private orthodontic practices. METHODS: A convenience sample was collected from 11 orthodontic offices; 5 orthodontists (772 patients) used a direct bonding technique, and 6 (596 patients) used an indirect technique. Altogether, they examined 29,963 brackets in 1,368 patients. Bond failures were recorded by tooth number and by patient during 10 consecutive practice days. In addition, the orthodontists reported the treatment time and number of visits for each of their 10 most recently completed comprehensive patients. RESULTS: The per-patient debond prevalences were 1.17% +/- 3.62% for direct bonding and 1.21% +/- 3.81% for indirect bonding (P = .225). Direct-bonded patients required a mean (+/- SD) treatment time of 750 +/- 220 days and 22.0 +/- 7.3 visits; indirect bonding required a mean treatment time of 745 +/- 256 days and 22.2 +/- 7.3 visits (P = .691 and P = .653, respectively). CONCLUSIONS: This practice-based study showed no difference in the failure rates between direct and indirect bonding. Furthermore, total treatment times and numbers of appointments did not differ between the 2 techniques.

Alteration of the mandibular plane during sagittal split advancement: short- and long-term stability.

OBJECTIVES: We investigated predictors of long- and short-term stability of surgical mandibular advancements with bilateral sagittal split osteotomy (BSSO). STUDY DESIGN: Class II patients (n = 127) received mandibular advancement through BSSO with either rigid internal fixation or wire osteosynthesis. We used multiple linear regression analysis to assess the association of predictor variables with post-treatment horizontal and vertical B-point movement through 2 years. RESULTS: Counterclockwise rotation of the mandibular plane angulation (MPA) was associated with greater horizontal and vertical relapse at all time periods except 8 weeks. Wire osteosynthesis, larger advancements, younger age, and genioplasty were significantly associated with relapse. CONCLUSIONS: Surgically closing the MPA is associated with late horizontal and vertical relapse, whereas fixation type is related to early B-point movement. Large advancements with forward and upward repositioning of the mandible, genioplasty, and young age also play a role in relapse after BSSO.

Five-year outcome and predictability of soft tissue profiles when wire or rigid fixation is used in mandibular advancement surgery.

The purpose of this study was to follow the covariation of hard and soft tissue changes in Class II malocclusion subjects who received a bilateral sagittal split osteotomy. The subjects were randomized to receive wire or rigid fixation after the surgery. Subjects in the rigid group (n = 78) received 2-mm bicortical position screws, and those in the wire group (n = 49) received inferior border wires and 6 weeks of skeletal intermaxillary fixation with 24-gauge wires. Additionally, some subjects received genioplasty in both the rigid (n = 35) and the wire groups (n = 24). Soft and hard tissue profile changes were obtained from cephalometric films immediately before surgery and at various times up to 5 years postsurgery. Soft and hard tissue profile changes were referenced to a cranial-base X-Y coordinate system. Horizontal changes in mandibular incisor, lower lip, B-point, soft tissue B-point, pogonion, and soft tissue pogonion were calculated at each time. There was considerable skeletal relapse in the wire fixation group. Bivariate correlations and ratios between the hard and soft tissue changes were calculated for each time period. Hard to soft tissue correlations were the highest at the earlier times, although the ratios varied among the 4 groups. These results provide a solid basis for both short-term and long-term prediction.

Health-related quality of life and psychosocial function 5 years after orthognathic surgery.

This prospective, multisite, randomized clinical trial evaluated the long-term health-related quality of life and psychosocial function of 93 patients after bilateral sagittal split osteotomy to correct Class II malocclusion. Patients were evaluated approximately 2 weeks before surgery, and 2 and 5 years after surgery. Scores from the Sickness Impact Profile psychosocial dimension and all of its components showed significant improvement from presurgery to 2 and 5 years postsurgery (P <.05). The overall dimension score also showed significant improvement (P <.05). Change between 2 and 5 years postsurgery was not significant, demonstrating that the improvement was stable between 2 and 5 years. The Oral Health Status Questionnaire showed significant improvement at 2 and 5 years relative to presurgery (P <.05). These improvements also remained stable between 2 and 5 years, with the exception of general oral health. The Symptom Checklist 90 Revised demonstrated significant improvements from presurgery to 2 and 5 years after surgery (P <.05) in all areas except somatization. Results other than somatization did not change significantly between 2 and 5 years, showing that improvements were stable. The 7-point satisfaction scale showed that patients were satisfied with postsurgical results, and their satisfaction was maintained 5 years after surgery. It is concluded that general health-related quality of life, oral health-related quality of life, and psychosocial function show significant improvements after bilateral sagittal split osteotomy, and the improvements are stable between 2 and 5 years after surgery.

Reliability of the craniomandibular index.

AIMS: To examine various dimensions of reliability of the Craniomandibular Index, a commonly used instrument for quantifying the severity of signs and symptoms of temporomandibular disorders. METHODS: Classical psychometric theory and generalizability theory were used to assess the reliability of data obtained from a calibration study of examiners participating in a multi-site clinical trial and from a random community sample. RESULTS: The reliability of aggregate scores formed by summing individual binary scored items was high, with intraclass correlations ranging from 0.81 to 0.88. When it was required that examiners recognize and agree upon a specific pattern of signs and symptoms exhibited by a patient, however, reliability dropped dramatically (multivariate kappas ranged from 0.26 to 0.32). A group of practicing examiners also showed limited ability to agree with the pattern of signs and symptoms identified by a "gold standard" examiner (multivariate kappas ranging from 0.25 to 0.32). Generalizability analysis failed to identify the specific sources of measurement error that played a major role in limiting reliability but demonstrated that generalizability of aggregate scores was very high. CONCLUSION: Methods of classical psychometric theory and generalizability theory support the conclusion that the reliability of aggregate scores is acceptably high. Individual items assessing certain aspects of jaw mobility and joint sounds are measured with poor reliability. Reliability declines when it is defined as the ability of examiners to agree among themselves upon a specific constellation of signs and symptoms or their ability to identify correctly a "correct" constellation identified by an expert examiner.

Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy.

PURPOSE: There are numerous risks for developing neurosensory deficits after a bilateral sagittal split osteotomy (BSSO). The purpose of this study was to evaluate the effects of genioplasty, length of advancement, and age and their interactions in a group of patients undergoing BSSO advancement and followed up for 2 years. MATERIALS AND METHODS: Patients were examined at multiple time intervals during the 2 years. Measuring in the mental nerve distribution assessed damage. 127 subjects were divided into the following 3 age groups: younger than 24 years, 24 to 35 years, and older than 35 years old. They also were divided into small (< or =7 mm) and large (>7 mm) advancements and genioplasty and no genioplasty. Change in tactile sensitivity from presurgical to the subsequent time periods is reported as a function of these variable and interactions among the variables. Data were analyzed using the Kruskal-Wallis test and the Friedman test, all at an alpha level of 0.05. RESULTS: Older subjects had greater sensory losses than younger subjects. Patients with a genioplasty had a greater loss of sensation initially. For all subjects, the sensory function of those receiving large and small advancements was not significantly different. Among subjects receiving small advancements there was no significant difference among the 3 age groups. However, among patients receiving advancements greater than 7 mm, older patients did worse. Among patients not receiving genioplasty, there was no significant difference among the 3 age groups. In contrast, older subjects with a genioplasty had significantly greater sensory deficits. CONCLUSIONS: Age at the time of surgery and addition of a genioplasty increases the risk of a neurosensory injury. Large advancements further increase the risk of injury in older patients.

Dietary intake in edentulous subjects with good and poor quality complete dentures.

STATEMENT OF PROBLEM: Previous studies in complete denture wearers evaluated the relationship between diet and measures of chewing, yet only isolated nutrient intake was considered. This limited information makes the assessment of overall diet quality and the planning of interventions difficult. PURPOSE: This study investigated the relationship of complete denture quality to masticatory performance, perceived ability to chew, and diet quality as measured by the Healthy Eating Index (HEI), an overall diet quality index. MATERIAL AND METHOD: The study population comprised 54 complete denture wearers. Data were obtained from clinical examinations, masticatory performance measurements, and 2 non-consecutive 24-hour dietary recalls. (Masticatory performance data were not collected for 9 subjects because of time constraints, patient fatigue, or patient refusal. Statistical analysis showed no significant effect of their absence on the reported findings.) Based on a composite rating scale, subjects were divided into 3 denture quality groups described as good, medium, and poor. The outcome variables were the HEI and its components, plus selected nutrient and non-nutrient intake. Explanatory variables were quality of complete dentures, masticatory performance, and reported chewing ability. Data were analyzed with Kruskal-Wallis tests, Mann-Whitney U-tests, and Fisher exact tests. Because a large number of dietary components were examined, results were considered significant at alpha=.01. RESULTS: Masticatory performance and perceived ability to chew were unrelated to diet quality. The good quality denture group had significantly better masticatory performance than the medium and poor quality groups, but the median HEI scores and dietary intakes were not significantly different among these 3 groups. Milk, vegetable, fruit, and grain intake scores were mainly responsible for the low overall HEI scores. CONCLUSION: In the population evaluated, complete denture quality, food comminution capacity, and perceived chewing ability were not related to diet quality. The majority of subjects had deficient diets regardless of the technical quality of their dentures.

Rigid versus wire fixation for mandibular advancement: skeletal and dental changes after 5 years.

The bilateral sagittal split osteotomy (BSSO) is the most common surgical procedure for the correction of mandibular retrognathism. Commonly, the proximal and distal segments are fixated together with either wire or rigid screws or plates. The purpose of this study was to compare long-term (5 years) skeletal and dental changes between wire and rigid fixation after BSSO. In this multisite, prospective, randomized clinical trial, the rigid fixation group received three 2-mm bicortical position screws, and the wire fixation group received inferior border wires and 6 weeks of skeletal maxillomandibular fixation with 24-gauge wires. Cephalometric films were obtained 2 weeks before surgery and at 1 week, 8 weeks, 6 months, 1 year, 2 years, and 5 years after surgery. Linear cephalometric changes were referenced to a cranial base coordinate system. Before surgery, both groups were comparable with respect to linear and angular measurements of craniofacial morphology. Both groups underwent similar surgical changes. Skeletal and dental movements occurred in both groups throughout the study period. Five years after surgery, the wire group had 2.2 mm (42%) of sagittal skeletal relapse, while the rigid group remained unchanged from immediately postsurgery. Surprisingly, at 5 years, both groups had similar changes in overbite and overjet. This was attributed to dental changes in the maxillary and mandibular incisors. Although rigid fixation is more stable than wire fixation for maintaining the skeletal advancement after a BSSO, the incisor changes made the resultant occlusions of the 2 groups indistinguishable.