Are parents of high caries risk Dutch children motivated to brush their children's teeth? An assessment using the health action process approach questionnaire.

PURPOSE: To assess the social cognitive constructs of the Health Action Process Approach (HAPA) of parents of high caries risk children to be treated under intravenous sedation (IVS) or with behavioural guidance techniques (BGT), and to assess the changes in these constructs for each treatment group after treatment. DESIGN: In this cohort study, 160 children aged 3-10 years were allocated by their paediatric dentist to either IVS (77.4%) or BGT. Their parents filled out a HAPA questionnaire, before (T1, n = 160), immediately (T2, n = 108) and three months (T3, n = 71) after their children's dental rehabilitation. RESULTS: Before treatment, all parents had high scores on all social cognitive constructs. There were no differences in mean HAPA scores between the treatment groups (p > 0.05). After treatment, mean scores changed in both groups. In the BGT group, action self-efficacy changed from 3.64 (T1) to 3.36(T2) (p = 0.027) and to 3.13 (T3) (p = 0.021) and coping self-efficacy changed from 3.63 (T1) to 3.23 (T2) (p = 0.015). In the IVS group, action planning changed from 3.25 (T1) to 3.05(T3) (p = 0.036) and action control changed from 2.58 (T1) to 2.82 (T2) (p = 0.012) and to 2.87 (T3) (p = 0.006). CONCLUSIONS: High scores on social cognitive constructs of parents of children referred to a paediatric dentist showed that they seem to be motivated to brush their children's teeth, irrespective of the treatment group. Small changes were observed in the HAPA constructs, however, these are not considered clinically relevant.

Parents' satisfaction on dental care of Dutch children with Autism Spectrum Disorder.

PURPOSE: To assess if Dutch children with Autism Spectrum Disorder (ASD) regularly visit a dentist and to evaluate parent's satisfaction on the care provided. METHODS: Parents of ASD children (2-18 years) were invited to fill out a survey. The survey consisted of questions regarding ASD severity, frequency of dental visits, history of dental pain, type of dental practice and parents' satisfaction. Results were analysed using Chi square and Mann-Whitney U tests (α = 5%). RESULTS: Of the 246 returned questionnaires, 19 were excluded (incomplete or unconfirmed ASD diagnosis). All children visited a dentist at least once and 5% of them had their last visit more than 12 months ago. According to parents, 15% of the children did not receive the needed care when they had toothache and 21% of the parents were unsatisfied with the current dental care provided. No difference was found between satisfied and unsatisfied parents in type of dental practice visited (p > 0.05). The children of unsatisfied parents reported more often pain during the last year (p = 0.013) and had a more severe type of ASD (p = 0.016). CONCLUSIONS: The majority of Dutch ASD children investigated regularly visit a dentist and 21% of the parents is unsatisfied with the dental care provided.

The effect of implant placement in patients with either Kennedy class II and III on oral health-related quality of life: a prospective clinical trial.

There is little evidence of the effect of implants restored with fixed partial dentures on oral health-related quality of life (OHRQoL) in partially edentulous Kennedy class II and III patients. The aim of this study was to determine the change in OHRQoL in Kennedy classification II and III patients treated with a two-implant-supported fixed dental prosthesis (FDP). Kennedy class II and III patients received dental implants and an FDP. Oral health-related quality of life was measured by administration of the Oral Health Impact Profile-14 (OHIP-14NL) questionnaire at intake (T1), 2 weeks after surgery (T2) and after 1 year of loading (T3). The mean OHIP score at T1 was 6·5 ± 1·2, 2·4 ± 1·0 at T2, and 0·9 ± 0·3 at T3. There was a statistically significant difference between T1 and T2 (P = 0·002) and T1 and T3 (P < 0·001) but not between T2 and T3 (P = 0·407). The OHIP score in Kennedy II patients decreased from 4·8 ± 3·2 at T1 to 1·5 ± 2·0 at T2 and 1·1 ± 1·8 at T3, and that in Kennedy III patients decreased from 8·9 ± 9·6 at T1 to 3·6 ± 8·9 at T2 and 0·8 ± 2·2 at T3. There were no statistically significant differences in the reductions in Kennedy II and III patients. Oral health-related quality of life changed positively in patients treated with implants and an FDP in both groups. There was no change in OHRQoL between the times of implant placement and FDP placement.

Association between extra- and intracranial calcifications of the internal carotid artery: a CBCT imaging study.

OBJECTIVES: This study aimed to evaluate the association between the extracranial and intracranial calcification depiction of the internal carotid artery (ICA), incidentally found in CBCT examinations in adults, and to discuss the conspicuous clinical implications. METHODS: Out of a series of 1085 CBCT examinations, 705 CBCT scans were selected according to pre-defined criteria. The extra- and intracranial calcifications depicted along the course of the ICA were documented according to a comprehensive set of descriptive criteria. RESULTS: In total, 799 findings were detected, 60.1% (n = 480) were intracranially and 39.9% (n = 319) were extracranially allocated. The χ(2) test showed associations between all variables (p < 0.001). Also, most of the combinations of variables showed statistically significant results in the McNemar's test (p < 0.001). CONCLUSIONS: We found that a significant correlation exists between extra- and intracranial calcifications of the ICA. It is clear that in cases of the presence of a calcification in the ICA extracranially, the artery's intracranial portion has an increased risk of showing the same findings. CBCT imaging is widely used as a diagnostic tool, thus, our results contribute to the identification of a subgroup of patients who should undergo further medical evaluation of the atherosclerosis of the ICAs.

Influence of object location in different FOVs on trabecular bone microstructure measurements of human mandible: a cone beam CT study.

The aim of this study was to assess the influence of different object locations in different fields of view (FOVs) of two cone beam CT (CBCT) systems on trabecular bone microstructure measurements of a human mandible. A block of dry human mandible was scanned at five different locations (centre, left, right, anterior and posterior) using five different FOVs of two CBCT systems (NewTom™ 5G; QR Verona, Verona, Italy and Accuitomo 170; Morita, Kyoto, Japan). Image analysis software (CTAn software v. 1.1; SkyScan, Kontich, Belgium) was used to assess the trabecular bone microstructural parameters (thickness, Tb.Th; spacing, Tb.Sp; number, Tb.N; bone volume density, BV/TV). All measurements were taken twice by one trained observer. Tb.Th, Tb.Sp and Tb.N varied significantly across different FOVs in the NewTom 5G (p < 0.001) and the Accuitomo 170 (p < 0.001). For location, a significant difference was observed only when measuring BV/TV (p = 0.03) using the NewTom 5G. The trabecular bone microstructural measurements obtained from CBCT systems are influenced by the size of FOVs. Not all trabecular bone parameters measured using different CBCT systems are affected when varying the object location within the FOVs.

Is dental phobia a blood-injection-injury phobia?

BACKGROUND: Dental phobia is part of the Blood-Injection-Injury (B-I-I) phobia subtype of specific phobia within DSM-IV-TR. To investigate the conceptual validity of this classification, the purpose of the present study was to determine the co-occurrence of dental phobia, typical dental (and B-I-I related) fears, vasovagal fainting, and avoidance of dental care. METHOD: Data were collected by an online survey in Dutch twin families (n = 11,213). RESULTS: Individuals with a positive screen of dental phobia (0.4% of the sample) rated typical B-I-I-related stimuli as relatively little anxiety provoking (e.g. of all 28 fears the stimulus "the sight of blood" was ranked lowest). Presence of dental phobia was significantly associated with a history of dizziness or fainting during dental treatment (OR = 3.4; 95% CI: 1.5-8.1), but of the dental phobic individuals only 13.0% reported a history of dizziness or fainting during dental treatment. Presence of dental phobia (OR = 5.0; 95% CI: 2.8-8.8) was found to be associated with avoidance of dental care, but a history of dizziness or fainting during dental treatment was not (OR = 1.0; 95% CI: 0.8-1.2). CONCLUSIONS: The present findings converge to the conclusion that dental phobia should be considered a specific phobia subtype independent of the B-I-I cluster within the DSM classification system.

Validity of the Oral Behaviours Checklist: correlations between OBC scores and intensity of facial pain.

The first purpose of this study was to translate the Oral Behaviours Checklist (OBC) into Dutch and to examine its psychometric properties. The second purpose was to examine the correlations between scores on the OBC and facial pain, while controlling for the possible confounding effects of psychosocial factors, such as stress, depression, somatisation and anxiety. The OBC was translated, following the international RDC/TMD consortium guidelines. Its psychometric properties were examined by assessing the test-retest reliability and concurrent validity [correlations between the OBC and the previously developed Oral Parafunctions Questionnaire (OPQ)]. Participants were 155 patients with TMD (77% female; mean age and s.d. = 43.6 and 14.4 years). The translation of the OBC into Dutch proceeded satisfactorily. The psychometric properties of the Dutch OBC were good; test-retest reliability was excellent (ICC = 0.86, P < 0.001). Concurrent validity was good: the correlation between the OBC and OPQ was high (r = 0.757, P < 0.001), while the correlations between individual items ranged from 0.389 to 0.892 (P < 0.001). Similar to previous Dutch studies using the OPQ, no significant correlation was found between oral parafunctions and facial pain (r = 0.069, P = 0.892). No significant correlations could be found between oral parafunctional behaviours and facial pain.

The effect of scan parameters on cone beam CT trabecular bone microstructural measurements of the human mandible.

The objective of this study was to investigate the effect of different cone beam CT scan parameters on trabecular bone microstructure measurements. A human mandibular cadaver was scanned using a cone beam CT (3D Accuitomo 170; J.Morita, Kyota, Japan). 20 cone beam CT images were obtained using 5 different fields of view (4×4 cm, 6×6 cm, 8×8 cm, 10×10 cm and 10×5 cm), 2 types of rotation steps (180° and 360°) and 2 scanning resolutions (standard and high). Image analysis software was used to assess the trabecular bone microstructural parameters (number, thickness and spacing). All parameters were measured twice by one trained observer. Intraclass correlation coefficients showed high intraobserver repeatability (intraclass correlation coefficient, 0.95-0.97) in all parameters across all tested scan parameters. Trabecular bone microstructural measurements varied significantly, especially in smaller fields of view (p = 0.001). There was no significant difference in the trabecular parameters when using different resolutions (number, p = 0.988; thickness, p = 0.960; spacing, p = 0.831) and rotation steps (number, p = 1.000; thickness, p = 0.954; spacing, p = 0.759). The scan field of view significantly influences the trabecular bone microstructure measurements. Rotation steps (180° or 360°) and resolution (standard or high) selections are not relevant.

Pain-related behaviour in children: a randomised study during two sequential dental visits.

AIM: To determine the difference in pain- and distress-related behaviour in children between two consecutive dental treatment sessions using a computer-controlled local anaesthetic delivery system, with dental anxiety as co-variable. METHODS: A randomised prospective study over two sequential visits in three paediatric dental practices. For both visits 112 young, healthy children needing dental treatment were randomly assigned to either the use of the Wand(®) or the Sleeper One(®). All statistical analyses were performed using SPSS 17. A significance level of p < 0.01 was used, correcting for conducting a high number of tests. RESULTS: Children showed significantly more muscle tension, more verbal protest, and more crying or screaming during the second treatment. CONCLUSIONS: Sequential dental treatments seem to have a conditioning effect. It is important to know the level of dental anxiety to adjust the treatment sequence to the needs of the child.

Comparison of two computerised anaesthesia delivery systems: pain and pain-related behaviour in children during a dental injection.

AIM: The purpose of this study was to investigate whether there is a difference in pain and distress response of the child when using two different computer-controlled local analgesic delivery systems, the Sleeper One(®) and the WAND(®), and whether this was influenced by the anxiety level of the child. METHODS: This randomised controlled trial was conducted among 112 children (56 girls) aged 4-6 years (mean age 66 months, SD 9 months). All children needing at least one dental visit using local analgesia were randomly assigned to either the Sleeper One(®) or the WAND(®). RESULTS: During the injection phase, children expressed the same amount of disruptive behaviour using the Sleeper One(®) or the WAND(®) (Mann-Whitney U test, p > 0.05). The average injection time of the Sleeper One(®) (mean 2.49 min, SD 0.56) was significantly shorter than that of the WAND(®) (mean 3.20 min, SD 0.61; Mann-Whitney U test, p < 0.001). CONCLUSION: No significant difference was found in pain and distress reaction of the child between the WAND(®) and the Sleeper One(®). The average delivery time of the Sleeper One(®) was shorter.

Treatment results of CO2 laser vaporisation in a cohort of 35 patients with oral leukoplakia.

OBJECTIVES: The aim of the present study was to evaluate the treatment results of CO2 laser vaporisation in a well-defined cohort of patients with oral leukoplakia (OL). MATERIAL AND METHODS: The group consisted of 35 patients. Before treatment, a clinical photograph and an incisional biopsy were performed in all cases. Also posttreatment results were documented with clinical photographs. The assessment of the treatment results was performed by an independent clinician who had not performed the treatment. The mean follow-up period was 61.9 months (range 12-179 months). RESULTS: In 14/35 patients, there was a recurrence between 1 and 43 months (mean 18.7 months), the annual recurrence rate being approximately 8%. In three of these patients, malignant transformation occurred at a later stage. In two other patients, a malignancy occurred without a prior recurrence. In altogether 5 of 35 patients, malignant transformation occurred in a mean period of 54 months, the annual malignant transformation rate being approximately 3%. CONCLUSIONS: The results in the present study are worse than those reported in the literature, perhaps owing to the use of different diagnostic criteria for OL, differences in the employed laser technique and assessment of possible recurrences by an independent clinician.

The effect of scan parameters on cone beam CT trabecular bone microstructural measurements of human mandible.

The objective of this study was to investigate the effect of different cone beam CT scan parameters on trabecular bone microstructure measurements. A human mandibular cadaver was scanned using a cone beam CT (3D Accuitomo 170; J.Morita, Kyota, Japan). 20 cone beam CT images were obtained using 5 different fields of view (4×4 cm, 6×6 cm, 8×8 cm, 10×10 cm and 10×5 cm), 2 types of rotation steps (180° and 360°) and 2 scanning resolutions (standard and high). Image analysis software was used to assess the trabecular bone microstructural parameters (number, thickness and spacing). All parameters were measured twice by one trained observer. Intraclass correlation coefficients showed high intraobserver repeatability (intraclass correlation coefficient, 0.95­0.97) in all parameters across all tested scan parameters. Trabecular bone microstructural measurements varied significantly, especially in smaller fields of view (p = 0.001). There was no significant difference in the trabecular parameters when using different resolutions (number, p = 0.988; thickness, p = 0.960; spacing, p = 0.831) and rotation steps (number, p = 1.000; thickness, p = 0.954; spacing, p = 0.759). The scan field of view significantly influences the trabecular bone microstructure measurements. Rotation steps (180° or 360°) and resolution (standard or high) selections are not relevant.

DNA ploidy measurement in oral leukoplakia: different results between flow and image cytometry.

The estimated prevalence of oral leukoplakia is worldwide approximately 2%, with an annual malignant transformation rate of approximately 1%. The aim of the present study was to evaluate the possible contribution of ploidy measurement to the prediction of the clinical course, in a well defined cohort of patients with oral leukoplakia. Ploidy was measured by both flow cytometry (FCM-DNA) and image cytometry (ICM-DNA) and we focussed on the comparison of the two different techniques to determine ploidy. A total of 41 patients have been included, with a mean age of 59 years (range 36-78 years). With FCM-DNA, three lesions were aneuploid, with ICM-DNA, 19 lesions were aneuploid. DNA ploidy was compared with clinicopathological and patients parameters. There were no statistically significant differences between DNA ploidy and any patient factor with both FCM-DNA and ICM-DNA. Using FCM-DNA, DNA aneuploid lesions showed statistically significant more dysplasia (p=0.04) than diploid lesions. Furthermore, DNA aneuploid lesions were more frequently encountered at high-risk locations (p=0.03) as being determined with FCM-DNA. These relations were not found when DNA ploidy was determined with ICM-DNA.

Dental fear in children with a cleft lip and/or cleft palate.

OBJECTIVE: To assess the level of dental fear in children with a cleft lip and/or palate, to compare this level with that of a normative group testing the hypothesis that children with a cleft lip and/or palate have a higher level of dental anxiety than children from the general population, and to assess the relation between dental fear and coping. DESIGN: Cross-sectional study. SETTING: VU Medical Centre University Amsterdam. PATIENTS: A total of 110 children (4 to 12 years old, 50 girls) with a cleft lip and/or palate. INTERVENTIONS: Dental fear in the study group was compared with a normative group of Dutch children. MAIN OUTCOME MEASURES: Dental fear was investigated using the parental version of the dental subscale of the Children's Fear Survey Schedule for children aged 4 and 5 years old (n = 36). Also the Inventory of Stressful Situations was completed. Children aged 6 to 12 years old also completed the Dental Cope Questionnaire. RESULTS: Young children with a cleft lip and/or palate experience more dental fear compared with children in a normative control group (Children's Fear Survey Schedule dental subscale scores: 30.3 ± 14.6 compared with 24.6 ± 8.6, p < .01). A weak correlation was found between the child's dental anxiety (Children's Fear Survey Schedule dental subscale) and his or her coping behavior (Dental Coping Questionnaire) (r = .196 p < .05). A clear correlation exists between the total Inventory of Stressful Situations and total Children's Fear Survey Schedule scores of the youngest age group (r = .507 p < .01). CONCLUSIONS: Findings support the hypothesis that dental anxiety is related to a higher level of exposure to medical interventions at a young age.

A test of Berggren's model of dental fear and anxiety.

Berggren's (1984) model of dental fear and anxiety predicts that dentally anxious individuals postpone treatment, leading to a deteriorating dental state and subsequently to fear of negative evaluations in relation to their oral condition. The present study aimed to test one of the core assumptions of this model, namely that deterioration of dental health status would mediate the effects of avoidance of dental care on self-reported fear of negative evaluation. Participants were 73 patients (mean age 38.5 yr) meeting the diagnostic and statistical manual of mental disorders - 4th edn - Text Revision (DSM-IV-TR) criteria of dental phobia. Variables in the theoretical model were operationalized with multiple measures. A series of Sobel tests indicated that mediation was present for the relationship between years of avoidance and fear of negative self-evaluation when dental health status was based on the assessment of dentists or patients' opinion of their own dental state, but not when dental health status was operationalized as decayed, missing or filled surfaces (DMFS). Although the findings are supportive of Berggren's model, other causal pathways that contribute to the perpetuation of anxiety and fear still need to be tested. The results suggest that individuals with high levels of dental anxiety would particularly benefit from interventions specifically designed to break their avoidance pattern.

[Satisfaction among parents about treatment-teams of childeren with a cleft lip and/or palate]. / Tevredenheid van ouders over het schisisteam.

In this contribution, the results are presented of a study of the degree of satisfaction among parents of children with a cleft lip and/or palate with care provided for their children. A questionnaire with declarative statements and a number of open questions relevant to treatment received was sent to the 213 members of the workgroup Cleft Lip and/or Palate of the society of the motor-handicapped and their parents. In addition, parents were asked to give a grade for the team who treated their child. The results (response n = 101) indicate that, with respect to a number of aspects, there are differences in satisfaction concerning the care which was provided among the 5 treatment-teams with the most responses. The average grade given by parents for the care provided by Dutch cleft lip and/or palate teams was 7.4. Parents would like to be better informed and treated in a friendlier way.

Validity of scoring caries and primary molar hypomineralization (DMH) on intraoral photographs.

AIM: The aims of this study were to assess whether intraoral photographs could be used to score caries and hypomineralization on primary molars (Using adapted Molar Incisor Hypomineralization (MIH)-criteria), and also to assess the reliability and validity in 3-7 year-old Dutch children of these scores by comparing them to direct clinical scorings. STUDY DESIGN: Cross-sectional study. METHODS: In this study 62 children (38.7% girls) with a mean age of 4.96 years (SD 1.27) participated. The children were rated clinically by their own dentist (authors JV or ME) for caries reaching the dentine in their primary molars (WHO criteria) and also for primary molar hypomineralization using the adapted MIH-criteria. For the intraoral photographs, a digital intraoral camera was used. The two paediatric dentists rated all the intraoral photographs on caries and hypomineralizations on the second primary molars, using the same criteria for the clinical scoring as for the scoring of the photographs. They scored independently, at least 2 weeks after the initial clinical scoring to avoid observational bias with the clinical scoring. STATISTICS: This clinical observation was used as the gold standard from which sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and the Positive and Negative Likelihood Ratio were computed. To test the intra-observer agreement 25 % of the photographs were scored again, at least 2 weeks after the initial scoring of the images. Inter- and intra-observer agreement were tested using Cohen's Kappa. RESULTS: The mean prevalence of clinically detected caries at tooth level was 46.7% and the mean prevalence of clinically detected hypomineralizations in second primary molars at tooth level was 21.8%. The sensitivity of assessing caries using intraoral photographs was 85.5%, the specificity 83.6%, the positive likelihood ratio 5.2 and the negative likelihood ratio was 0.17. For Primary Molar Hypomineralization (DMH) the sensitivity was 72.3%, the specificity 92.8%, the positive likelihood ratio 10.1 and the negative likelihood ratio was 0.30. The inter-observer agreement yielded the following Cohen's Kappa scores: for caries 0.76 and for DMH 0.62. The intra-observer agreement was for caries 0.80 (ME) and 0.72 (JV) and for DMH 0.95 (both ME and JV). CONCLUSIONS: From this investigation it was concluded that the sensitivity, specificity and the likelihood ratio of scoring caries and DMH on photographs made with an intraoral camera were good. The inter- and intra-observer reliability for caries and DMH were good to excellent. These findings suggest that intraoral photographs may be used in clinical practice and large epidemiological studies.

Symptoms of body dysmorphic disorder among people presenting for cosmetic dental treatment: a comparative study of cosmetic dental patients and a general population sample.

OBJECTIVES: To determine appearance concerns of patients presenting for cosmetic treatment. METHODS: This cross-sectional comparative study included consecutive patients of six different cosmetic clinics (n = 170), and a sample of the general population (n = 878). A study-specific self-report questionnaire was administered to document demographic and appearance concerns. Presence of body dysmorphic disorder (BDD) was assessed based on DSM-IV criteria. RESULTS: Cosmetic dental patients did not differ from the reference sample with regard to happiness and satisfaction as regards their appearance. However, differences were found with regard to frequency of previous general cosmetic (16.5% versus 5.9%) and cosmetic dental (47.9% versus 24.8%) procedures. Furthermore, a significantly higher proportion of the cosmetic dental patients sufficed for the two key screening criteria of BDD (9.5% versus 5.5%), and for the full diagnostic screening of BDD (4.2% versus 1.5%) compared with the respondents of the reference group. CONCLUSIONS: The results suggest that symptoms of BDD are relatively common among patients attending cosmetic clinics. It is important to assess the long-term effects of comprehensive cosmetic procedures, particularly in patients with disproportionate appearance concerns.

Negative events and their potential risk of precipitating pathological forms of dental anxiety.

The purpose of the present study was to assess which types of experiences are most closely associated with pathological forms of dental anxiety. Data came from a sample of dental patients (n=1462). Pathological dental anxiety was operationalized in two ways: (1) a score of > or =36 on the Short form of the Dental Anxiety Inventory (S-DAI; high dental anxiety, HDA), or (2) fulfilling the screening criteria of specific phobia (DSM-IV-TR; dental phobia, DP). A wide variety of dental experiences appeared to be significantly related with both HDA and DP, while general traumatic experiences were not. No differences were found between women and men. Retrospective accounts of dental experiences involving helplessness were most strongly associated with having HDA [OR=8.2] and positive screens of DP [OR=16.2]. The results suggest that disruptive emotional and interoceptive reactions during dental treatment (particularly helplessness) have the greatest potential risk of precipitating pathological forms of dental anxiety.

Preoccupation with one's appearance: a motivating factor for cosmetic dental treatment?

BACKGROUND: It has been estimated that among patients presenting for cosmetic treatments up to 15% suffer from Body Dysmorphic Disorder (BDD), a psychiatric condition characterised by a preoccupation with an imagined defect in appearance. OBJECTIVES: The main purpose of the current study was to establish the relationship between presence of BDD characteristics and interest in aesthetically motivated dental treatments. METHODS: Data were obtained by means of a survey within a sample of 879 Dutch citizens of 16 years and older. Characteristics of BDD were assessed based on DSM-IV criteria. RESULTS: Only one of the BDD features (ie a preoccupation with a defect of appearance) emerged as a significant predictor of undergoing cosmetic dental treatments. Patients with such preoccupation were nine times more likely to consider tooth whitening, and six times more likely to consider orthodontic treatment. They were also five times more likely to be dissatisfied about their most recent treatment. CONCLUSIONS: The results suggest that preoccupation with one's physical appearance is a motivating factor for undergoing certain types of cosmetic dental procedures.