Characteristics of Population Health Physicians and the Needs of Healthcare Organizations.

INTRODUCTION: Healthcare organizations are transitioning from fee-for-service, volume-based care toward value-based care and the Triple Aim. Physicians have critical roles as leaders and practitioners in this emerging field of population health management; however, the competencies required of these physicians are not well described. The purpose of this study is to explore the approaches of healthcare systems to population health-related functions, the competencies needed, and the characteristics of physicians who lead or staff these functions. METHODS: Investigators conducted semistructured interviews with a convenience sample of 14 healthcare executives and 15 Preventive Medicine physicians and a focus group with 9 healthcare executives. Interviews and the focus group were recorded, transcribed, and coded. Themes and notable quotes were identified. Data were collected and analyzed in 2019. RESULTS: Population health was variously defined by the healthcare executives, often naming specific components or activities. The typical population health activities described by healthcare executives (e.g., quality measurement and process improvement) were reported along with the skills of physicians performing these functions (e.g., data analysis, informatics, leadership, business acumen). A total of 2 types of population health physicians were described: the clinician leader and the population health specialist. CONCLUSIONS: This exploratory study identified several useful competencies for population health physicians in healthcare systems. Findings point to opportunities to promote a more systematic approach to population health and to prepare Preventive Medicine and other physicians for population health management positions.

Evaluation of Normal Morphology of Mandibular Condyle: A Radiographic Survey.

OBJECTIVES: The temporomandibular joint (TMJ) is a complex, highly specialized joint. Along with the teeth, these joints are considered to be a "tri-joint complex." Mandibular condyle morphology is characterized by a rounded bone projection with an upper biconvex and oval surface in axial plane. Anatomical knowledge of the TMJ is one of the basic foundations of clinical practice, allowing the understanding of TMJ pathologies and fabrication of condylar prostheses. The cross-sectional descriptive study was undertaken to evaluate normal variation in the condylar morphology on radiographs in persons without TMJ symptomatology and its relation to age, gender, dentition status, chewing habits, parafunctional habits, history of orthodontic treatment, and denture wearing was assessed. MATERIAL AND METHODS: A total of 350 subjects without TMJ symptomatology included in the study were further grouped by age, gender, dentition status, chewing habits, parafunctional habits, history of orthodontic treatment, and denture wearing history. Panoramic radiograph was taken for the assessment of condylar morphology. RESULTS: A significant association between dentition status and bilaterally similar condylar morphology was noticed. Bilaterally similar condyles were seen in 81.4% of subjects. Round-shaped condyles were seen in 176 (62%) persons. Loss of bilateral occlusion tends to alter the condylar morphology. Association between normal chewing habits and bilaterally similar condyle shapes was significant. CONCLUSION: The study describes the normal morphology of mandibular condyles in a population attending the tertiary dental care center, Kozhikode. The dentition status and chewing habits of individuals had a significant role in determining condylar morphology.

Hydroxyapatite carriers as drug eluting agents-An In Vitro analysis.

INTRODUCTION: Hydroxyapatite based drug carriers offer a customized alternative to the delivery of pharmacologic agents in the osseous skeleton. They have an added advantage of being biocompatible and osteoconductive. This in vitro study aims to quantify the drug eluting properties of HA granules by spectrophotometry. MATERIALS AND METHODS: HA and HASi beads were loaded with gentamicin/ amoxycillin- clavulanate/ vancomycin and grouped into 5. Drug elution was evaluated by means of UV spectrophotometry. RESULTS: Drug eluent levels were well above bactericidal levels in all 5 groups. CONCLUSION: HA and HASi are viable options for clinicians for targeted drug delivery.

Successful management of a case of true radicular dens invaginatus using platelet-rich fibrin and guided tissue regeneration.

A radicular variant of dens invaginatus (DI) is a rare form of dens invaginatus which develops in the root of the tooth after the crown development is completed. This report involves successful management of a case with guided tissue regeneration and describes the cone beam computed tomography (CBCT) characteristics of true radicular DI. A 20-year-old woman reported with recurrent swelling and pus discharge associated with her maxillary left central incisor (#21). Cone beam computed tomography (CBCT) of the region revealed #21 had an invagination in the mesial aspect of the coronal third of the root with a para radicular low-density region perforating both the cortices. A diagnosis of true radicular variant of DI was made by exclusion. The case was managed with Biodentine® , platelet-rich fibrin and freeze-dried demineralised bone graft. A 2-year review showed that the tooth was functional with normal periodontal parameters and normal response to electric pulp sensibility test.

Great Radiologic Imitators: Arteriovenous Malformation of Mandible - A Case Series.

An arteriovenous malformation (AVM) is a vascular malformation characterized by anomalous communications between arteries and veins without the normal intervening capillary bed. AVMs of jaw are extremely rare conditions that can give rise to dreadful complications if handled carelessly. Fifty percent of all intraosseous AVMs occur in the maxillofacial region and are extremely infrequent in the mandible. Only six cases of extraosseous submandibular AVMs have been mentioned in the literature. Three cases of AVMs involving the mandible, with a massive case involving both the mandible and submandibular region is reported. To the best of our knowledge, only one case is documented as a combined AVM involving both the mandible and submandibular region in literature.

A potential side effect of oral topical steroids: Central serous chorioretinopathy.

Topical corticosteroids are some of the most common drugs used in oral medicine for treating atrophic and erosive lesions that affect the mucosa. Adverse effects of these drugs include oral candidiasis with associated burning mouth and hypogeusia, hypersensitive reactions to the drug, and inhibition of the hypothalamic-pituitary-adrenal axis and secondary adrenal insufficiency. The ocular side effects of oral topical steroids are less documented. This short communication describes a case of central serous retinopathy that developed following administration of oral topical steroid.

Use of Cone-Beam Computed Tomography in the Diagnosis and Treatment of an Unusual Canine Abnormality.

Diagnosis and treatment planning are important for successful endodontic treatment. We report a 24-year old male who presented to the Government Dental College in Kozhikode, Kerala, India, in 2015 with pain in his right upper canine. A digital periapical radiograph indicated the presence of a supernumerary tooth superimposing the root of the canine. However, cone-beam computed tomography (CBCT) confirmed that the supernumerary tooth was an illusion and that the canine root had a sharp invagination involving the labial and pulpal dentin surfaces, with evidence of periapical bone destruction. A blunt resection was performed at the level of the invagination and the resected end was filled with a dentin substitute. At a one-year follow-up, the patient was asymptomatic and the periapical region appeared to be healing well. This report highlights the importance of CBCT in visualising abnormal canine morphology, thus allowing appropriate endodontic treatment.

Keratoacanthoma of Upper Lip: Review and Report of Case Managed Surgically.

Keratoacanthoma is a benign lesion usually presenting as a solitary, dome shaped nodule with a central crater filled with keratin. It frequently occurs on the sun exposed areas of the skin. Keratoacanthoma can be difficult to differentiate from oral squamous cell carcinoma both clinically and microscopically. A case of keratoacanthoma involving the upper lip in a 51-year-old male is reported presenting as an exophytic growth that resolved after excisional biopsy.

A randomized double-blind, multiple-arm trial comparing the efficacy of submucosal injections of hyaluronidase, dexamethasone, and combination of dexamethasone and hyaluronidase in the management of oral submucous fibrosis.

OBJECTIVE: Numerous treatment modalities for oral submucous fibrosis (OSF) have been advocated over the years. However, its medical treatment is not yet fully standardized. This randomized double-blind trial assessed and compared the effects of two commonly used drugs, independently and in combination. METHODS: Forty-five patients were staged clinically and histopathologically for OSF and were randomly divided into three groups of 15 each by permuted block randomization. Each group received biweekly submucosal injections of hyaluronidase (1500 IU), dexamethasone (8 mg) or a combination of both (750 IU and 4 mg), respectively, for a period of 5 weeks. Improvement in pain upon opening, burning sensation, and tightness of mucosa as perceived by the patient, as well as improvement in mouth opening measured clinically were determined at the end of week 2, months 1, 2, 3, and 6 after the final injection. Results were compared and statistically analyzed using analysis of variance. RESULTS: Submucosal injection of hyaluronidase gave a quicker and better improvement of measured symptoms. CONCLUSIONS: Biweekly submucosal injection of hyaluronidase over a period of 5 weeks appears to be a viable treatment option for OSF.

The expression of retinoblastoma tumor suppressor protein in oral cancers and precancers: A clinicopathological study.

BACKGROUND: The role of retinoblastoma (Rb) protein in cell cycle regulation prompted us to take up this study with the aim of assessing its role in the progression of oral cancer and to correlate with various clinicopathological parameters, including habits such as smoking, Paan chewing, and alcoholism. MATERIALS AND METHODS: This observational study included surgical specimens from 10 apparently normal oral mucosa, 14 oral reactive lesions (ORL), 29 precancerous lesions and 43 oral cancers. The expression of Rb protein in tissue samples were evaluated by immunohistochemistry and correlated with clinicopathological data. The percentage and mean expression of Rb protein were statistically analyzed using Student's t-test and P < 0.05 was considered as statistically significant difference. RESULTS: The expression of Rb protein was found to increase from normal, ORL, precancerous lesions to cancers. A consistently high expression of Rb protein was seen in oral cancers, with an increase in well-differentiated and moderately differentiated tumors. Patients with combined habits of Paan chewing, smoking, and alcohol consumption had a higher expression compared with those without habits. CONCLUSION: Within the limitations of this study, it seems that overexpression of Rb protein noted in oral cancer, with an increase in well and moderately differentiated tumors suggest a possible role of Rb in differentiation. The high expression of Rb in patients with combined habits of Paan chewing, smoking and alcohol consumption indicates that Rb pathway may be altered in habit-related oral malignancies.

The early manifestation, tumor-specific occurrence and prognostic significance of TGFBR2 aberrant splicing in oral carcinoma.

Alternative splicing is an important mechanism that can disrupt cell cycle control resulting in tumorigenesis. Although many alterations of Transforming Growth Factor Beta (TGFß) signaling are reported in cancers, the role of splice aberrations in destabilizing this signaling is the least understood mechanism. In this study, we compared TGFBR2 alternative splicing events in potentially malignant oral disorders (PMDs) and oral squamous cell carcinoma (OSCC) samples with those in normal samples. Interestingly, there were five alternatively spliced forms of TGFBR2 with a deficient kinase domain in OSCCs. The TGFBR2 aberrant splicing was tumor-specific, suggesting that selective splicing out of TGFBR2 kinase domain could be a mechanism misused by cancer cells for evading TGFß signaling-mediated anti-tumor activities. Moreover, these aberrant transcripts were present in PMDs as well, suggesting an early occurrence of these events during oral carcinogenesis and offering the possibility of early diagnosis of malignancy. Furthermore, OSCC patients who harbored these aberrantly spliced transcripts exhibited poor disease free survival (p=0.028) and poor overall survival (p=0.013). Thus, assessing the presence of these TGFBR2 transcripts can serve as a prognostic marker for oral cancer.

Autofluorescence spectroscopy augmented by multivariate analysis as a potential noninvasive tool for early diagnosis of oral cavity disorders.

OBJECTIVE: Oral leukoplakia is one of the common potentially malignant lesions encountered worldwide. We report the results of an in vivo clinical evaluation of autofluorescence (AF) spectroscopy for differential diagnosis of oral leukoplakia. Multivariate analysis of spectral data has been incorporated to improve the efficacy of the technique. The results of this noninvasive study are expected to provide potential for extending the technique to other disorders. MATERIALS AND METHODS: A total of 18 patients and 30 normal volunteers participated in this study. AF spectra were acquired from affected sites of patients and from right and left buccal mucosa of normal volunteers. Diagnostic performance was analyzed using spectral intensity ratio (SIR), and principal component analysis followed by linear discriminant analysis (PCA-LDA). RESULTS: AF spectra of leukoplakic patients showed characteristic emissions from flavin adenine dinucleotide (FAD) and porphyrin at 500 and 630 nm, respectively. But the emission from porphyrin is not very prominent in the case of healthy volunteers. Also, significant decrease in spectral intensity is observed for leukoplakia compared with normal volunteers in the unprocessed spectra. Method of SIR yielded 96% sensitivity and 100% specificity and an overall 100% for PCA-LDA respectively for efficient differentiation of the lesions. CONCLUSIONS: The result of this preliminary study shows that PCA-LDA or SIR applied to AF spectroscopy is a useful tool for the differential diagnosis of oral cavity disorders. This has been demonstrated in leukoplakia in a clinical setting, and it is expected that the technique can be extended to other oral cavity disorders as well.

Intraosseous lipoma of mandible presenting as a swelling.

Lipomas are the most common form of benign mesenchymal tumors and are composed of mature adipocytes. They can occur anywhere in the body where fat is found and thus, called as the 'universal tumor' or the 'ubiquitous tumor'. Intraosseous lipomas (IOL) are among the rarest (0.1%) of primary bone tumors and are very rarely seen in head and neck bones. They have been subdivided based on the site of origin within bone, into intramedullary and intracortical. Of the two, few cases of intramedullary lipoma have been reported intraorally and none of the latter. Intraosseous lipomas are usually asymptomatic and are detected incidentally on radiographs taken for other complaints. Here, we report a case of intraosseous lipoma in the mandible presenting as a large swelling.

Osteomyelitis of Maxilla in Infantile Osteopetrosis: A Case Report with Review of Literature.

Osteopetrosis is a rare genetic disorder that causes generalized sclerosis of bone due to a defect in bone resorption and remodeling. It is usually manifesting in two basic forms: An autosomal dominant benign form (osteopetrosis tarda) and an autosomal recessive malignant form (osteopetrosis congenita). A third form, the intermediate recessive type, has also been reported. Dental abnormality may be attributed to pathological changes in bone remodeling. Osteomyelitis is well documented as a complication of osteopetrosis and is severe and difficult to treat. This is a case of 8-year-old boy with osteopetrosis presenting with the complaint of swelling of left side of face.

Effectiveness of triclosan in the management of radiation-induced oral mucositis: a randomized clinical trial.

INTRODUCTION: Oral care in cancer patients is an important aspect in the quality of life of patients undergoing cancer therapy. Mucositis, trismus, salivary gland dysfunction are the main complications of the cancer therapy, which lead to long-term complications such as radiation caries, poor oral hygiene and osteoradionecrosis. A timely oral evaluation and intervention in these patients can reduce the severity of the potential complications. Triclosan is an antibacterial agent widely used in periodontal therapy, the effectiveness of triclosan in the management of radiation induced oral mucositis is evaluated here. AIMS: 1) To determine the effectiveness of triclosan in the management of radiation-induced oral mucositis. 2) To compare the effectiveness of triclosan mouth rinse with conventional sodium bicarbonate mouth rinse. MATERIALS AND METHODS: Twenty-four patients who underwent radiation therapy for oral cancer and subsequently developed oral mucositis were included in the study. They were randomly allocated into two groups on noticing grade I mucositis (erythema). The study group was advised to use triclosan mouthwash containing triclosan 0.03% W/V and sodium bicarbonate 2 mg mouth wash for the control group. A weekly follow-up evaluation of body weight, food intake, pain and grading of mucositis were made during the radiation treatment period and post radiation treatment period. RESULTS: Both the groups were statistically identical. All the 24 patients in both the groups passed through grade 3 mucositis on the last day of radiotherapy. However, 10 patients in the control group and only one patient in the study group entered to grade 4 mucositis. A definite change was noticed in the severity of the mucositis, food intake and weight loss. The control group took more than 45 days to resolve while the study group took only less than 28 days. DISCUSSION: The results of the study were evaluated and tried to formulate a hypothesis so as to explain the less severity and early resolution of mucositis in the study group. CONCLUSION: Triclosan mouthwash was found to be effective in reducing the severity of radiation- induced oral mucositis and helped in early reversal of symptoms during post treatment period. However, further studies are necessary to confirm this observation.

Autofluorescence spectroscopy for the in vivo evaluation of oral submucous fibrosis.

OBJECTIVES: The goal of this study was to analyze the autofluorescence spectrum of oral submucous fibrosis (OSF); in order to find out whether the technique is effective for the in vivo detection of OSF and for the early detection of malignant changes in OSF. BACKGROUND: The feasibility of autofluorescence spectroscopy to detect subtle alterations in tissue architecture and biochemical composition induced by dysplasia and inflammation has been studied in the field of oral oncology. Because early detection and proper treatment of common oral precancerous conditions such as OSF and any malignant transformation are important, autofluorescence spectroscopy was applied to detect OSF in this study. METHODS: In vivo autofluorescence emission spectra were collected at excitation wavelength of 320 nm from buccal mucosa from patients grouped as normal, OSF, or OSF with malignancy. The emission spectra were recorded and analyzed for variations from normal spectra with respect to spectral profile and intensity. RESULTS: The emission spectrum of OSF had a significantly higher emission peak around 380 nm and 460 nm when compared with the normal mucosal spectrum. The carcinoma spectrum also had two peaks around 380 and 460 nm regions with reduced intensity. The spectrum of carcinoma in OSF was significantly different from spectrum of carcinoma arising from otherwise normal mucosa and also from the spectrum of normal mucosa. The difference in spectral intensities between normal, OSF, and carcinoma in OSF was found to be highly significant (p < 0.001). CONCLUSION: Autofluorescence spectroscopy has been proved to be a promising technique that can successfully differentiate precancerous and cancerous changes from normal mucosa. The spectra from each group studied (normal mucosa, OSF, and OSF with carcinoma) showed distinct features that made it possible to differentiate OSF from normal mucosa and also to detect malignant changes in OSF noninvasively and in real time.

Radiation induced oral mucositis.

PATIENTS RECEIVING RADIOTHERAPY OR CHEMOTHERAPY WILL RECEIVE SOME DEGREE OF ORAL MUCOSITIS THE INCIDENCE OF ORAL MUCOSITIS WAS ESPECIALLY HIGH IN PATIENTS: (i) With primary tumors in the oral cavity, oropharynx, or nasopharynx; (ii) who also received concomitant chemotherapy; (iii) who received a total dose over 5,000 cGy; and (iv) who were treated with altered fractionation radiation schedules. Radiation-induced oral mucositis affects the quality of life of the patients and the family concerned. The present day management of oral mucositis is mostly palliative and or supportive care. The newer guidelines are suggesting Palifermin, which is the first active mucositis drug as well as Amifostine, for radiation protection and cryotherapy. The current management should focus more on palliative measures, such as pain management, nutritional support, and maintenance, of good oral hygiene.

Three-year follow-up of oral leukoplakia after neodymium:yttrium aluminum garnet (Nd:YAG) laser surgery.

Oral leukoplakia is a relatively common lesion with a significant proportion of cases changing into cancer. Since most leukoplakias are asymptomatic, the primary objective of treatment must aim at the prevention of such malignant transformation. The main objectives of the study are to observe (1) the efficacy, safety and acceptability of the neodymium:yttrium aluminum garnet (Nd:YAG) laser in the management of oral leukoplakia; (2) the nature of postoperative complications, if any, associated with laser ablation, and (3) the 3-year prognosis of oral leukoplakia treated with laser. Twenty-eight patients with histologically proven leukoplakia were treated with Nd:YAG laser. From this study, we observed that the patients treated with Nd:YAG laser had only mild to moderate pain, swelling and restricted mouth opening, which peaked between 72 h and 1 week. In a majority of the patients the healing was prolonged, to a maximum of 5 weeks, and there was no clinical evidence of scarring in 26 out of 28 cases. In this study we achieved a cure rate of 92.86% in a 6-month period. Further follow-up after 3 years yielded almost the same result, except that one patient was not available for follow-up. We concluded that Nd:YAG laser is an effective device in the management of oral leukoplakia, which is one of the major pre-cancerous lesions in our country.