A multi-faceted construct to guide geriatric dental education: Findings from a scoping review with consultation.

BACKGROUND AND OBJECTIVES: Older adults report unmet oral health care needs and barriers in access to care, due in part to provider attitudes and discomfort towards treating older patients. Our study asked: What is known from the literature about the use of undergraduate dentistry programmes to influence dental students' attitudes, perceptions and comfort towards treating geriatric patients? And how can interdisciplinary care facilitate the ability of dentists to work with geriatric patients? MATERIALS AND METHODS: A scoping review and stakeholder consultation followed established methodological guidelines. Four databases and two grey literature sources were searched. Two researchers independently selected articles using predefined inclusion criteria. Pertinent information was inputted into an iteratively developed extraction table. NVivo 12 was used to organise the extracted data into themes. Key findings were confirmed through stakeholder consultation. RESULTS: Sixty-eight articles were included in the scoping review. Five key themes emerged: (1) Curricular targets; (2) Intervention components; (3) Dentist and patient factors; (4) The role of interdisciplinary care; and (5) Post-graduation insights on knowledge-seeking patterns. Stakeholder consultations involved 19 participants from Southwestern Ontario and generally confirmed our findings. CONCLUSIONS: Inconsistent reporting of multiple intervention dimensions constrains our ability to strengthen this knowledge. Future interventions and their reporting could be improved by adopting "willingness to treat" as an overarching, multi-faceted concept which encompasses knowledge on ageing, attitudes towards older patients, perceived competence and empathy. Stakeholder interviews complemented these findings.

Exploring the acceptance of geriatric dentistry programming for undergraduate dental students through stakeholder interviews.

PURPOSE/OBJECTIVES: Older adults frequently report unmet oral healthcare needs. Current research suggests a lack of provider willingness to perform geriatric dental care plays a role in limiting older adults' access to dental services. To better understand the acceptance of geriatric dentistry programming in Ontario, and to explore considerations for successful implementation, we completed consultations with dental students and dental education stakeholders. Findings from a scoping review we conducted previously (Alicia C. Brandt and Cecilia S. Dong) were used to guide this research. METHODS: Consultations involved a questionnaire and semi-structured individual interviews. Descriptive and parametric statistics such as Pearson's bivariate correlation and One-way analysis of variance were completed on questionnaire data using SPSS V.28. Interview data were transcribed verbatim, and the content was analyzed using emergent coding and thematic analysis in NVivo. Student and faculty data were analyzed separately and then consolidated. RESULTS: Ten students and 12 dental faculty members completed the questionnaire of which ten students and nine faculty members also participated in interviews. Themes were organized into barriers and facilitators, with a subsection on interprofessional collaboration. Barriers included: 1. Student anxiety and skill level; 2. Constraints of the learning environment; 3. Patient factors; and 4. Knowledge gaps. Facilitators included: 1. Learning environment and culture; 2. Volume of exposure; 3. Soft skills; and 4. Desired interventions. CONCLUSIONS: Both students and faculty stakeholders demonstrated acceptance of geriatric dentistry programming at the undergraduate dentistry level that supports improved access to care for this population. Pilot programs integrating different intervention elements which were viewed as most promising would be beneficial.

A systematic review of caries risk in children <6 years of age.

BACKGROUND: For caries risk assessment (CRA) tools for young children to be evidence-based, it is important to systematically review the literature to identify factors associated with the onset of early childhood caries (ECC). AIM: This updated systematic review aimed to identify current evidence on caries risk in young children. DESIGN: A comprehensive and systematic literature search of relevant databases was conducted to update a previous systematic review and identify risk factors associated with ECC. Potential risk factors were identified based on strength of association using odds ratios, hazard ratios, relative risk, etc. GRADE was used for rating quality evidence through consensus. RESULTS: Twenty-two studies met inclusion criteria for the search from mid-2017 to 2021. Twenty-five publications from the prior systematic review, from 1997 to mid-2017, were also included. Several socioeconomic, behavioral, and clinical variables were identified as ECC risk factors. Factors included the following: age, socioeconomic status, frequency of and supervised toothbrushing, fluoride exposure, breast- and bottle-feeding, feeding habits, absence of a dental home, past caries experience, active non-cavitated lesions, visible plaque, enamel defects, and microbiome. CONCLUSION: This study provides updated evidence of risk factors for ECC that could be included in CRA tools.

Intersection of the iADH undergraduate curriculum in special care dentistry and the association of Canadian faculties of dentistry competencies framework.

AIMS: To map the International Association of Disability and Oral Health (iADH) curriculum to the Association of Canadian Faculties of Dentistry (ACFD) competencies framework to develop a strategy for teaching special care dentistry (SCD) using the International Classification of Functioning, Disability, and Health (ICF). To review the literature to identify educational methodologies that support teaching SCD competencies. METHODS: The 20 subdomains of the ACFD competencies framework were mapped to the 18 subdomains of the iADH competency matrix. A literature review of methods, techniques, or innovations used to teach SCD was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and the Sample, Phenomenon of Interest, Design, Evaluation, and Research Type (SPIDER) tool. RESULTS: The iADH curriculum was mapped to the ACFD competencies in the areas of patient care, professionalism, communication and collaboration, practice information management, and health promotion. A total of 176 articles from PubMed and 10 resources from MedEdPortal were identified in the literature search. Eleven articles met the inclusion and exclusion criteria. The overall quantity and quality of studies was low. Experiential learning in either a dental school or hospital-based program seemed to improve knowledge of SCD and to incite greater willingness to treat patients requiring SCD. CONCLUSIONS: Case-based learning, computer-based modules, standardized patients, and clinical practice are educational strategies for teaching SCD competencies. The integration of SCD into the undergraduate dental curriculum seems feasible, as most required competencies are transferable to all dental disciplines. Furthermore, the ICF provides a functional model that is a patient-centered approach and is applicable to dentistry beyond SCD.

Improving Compliance to Follow-Up Care After Primary Emergency Department Ophthalmic Consultation.

PURPOSE: To identify factors that affect the likelihood of follow-up after emergency department (ED) visit for ophthalmic complaints and to evaluate a protocol to improve compliance. DESIGN: Prospective interventional study with historical controls. METHODS: This study was conducted at Jamaica Hospital Medical Center in Jamaica, New York. The study population included 962 patients who presented to the ED and who required ophthalmology consultation. Participants in the control group were given only verbal follow-up instructions. Participants in the intervention group were given verbal instructions, written instructions, telephone calls, and, if not responding to calls, a mailed letter. The primary outcome was the overall follow-up rate. Secondary outcomes were follow-up rate by demographic subgroup. RESULTS: Patients in the intervention group were significantly more likely to follow up (68.8% vs 42.9%, P < .001). Nearly all subgroups exhibited significantly improved follow-up with the intervention, with the exception of patients 18 to 29 years of age, patients with diagnosis severity class III, patients with no insurance, patients with hospital financial aid, patients paying with workers' compensation, and patients with an unknown employment status. CONCLUSIONS: Before the intervention, most patients receiving ophthalmology consultation in the ED did not return for follow-up care. These patients tended to be young, unemployed, uninsured or use hospital financial aid, were in the control group, had good visual acuity, reported no change in vision, and had a condition that was not vision-threatening. Follow-up rates were improved in nearly all subgroups by providing written instructions, telephone calls, and mailed letters. Such instructions should be considered in similar populations.

A systematic review to inform the development of a Canadian caries risk assessment tool for use by primary healthcare providers.

BACKGROUND: Caries risk assessment (CRA) tools may assist in identifying children at risk of early childhood caries. AIM: To complete a systematic review of CRA and develop a Canadian CRA tool for preschool children for use in non-dental clinical settings. DESIGN: Systematic searches of relevant databases were conducted. Potential variables were based on strength of associations (odd ratios, relative risk, hazard ratios, etc), frequency of occurrence, and existing CRA tools. Quality of the evidence assessments were performed by at least two review teams through consensus following GRADE. RESULTS: Overall, 25 publications met the inclusion criteria, all prospective in design. Based on this review, variables to be considered when developing a new CRA tool for use with preschool children are as follows: age, socioeconomic status, family toothbrushing habits, fluoride exposure, infant feeding practices, dietary habits/behaviours, dental home, caries experience, visible plaque, and enamel defects. The environmental scan identified 22 CRA tools suggesting other additional variables to consider including in a CRA tool, including special healthcare needs, enamel defects, and dental attendance. CONCLUSIONS: This review informed the development of a Canadian CRA tool for use by primary healthcare professionals, which may improve access to oral health assessments and increase interprofessional collaboration.

Oral microbiome link to neurodegeneration in glaucoma.

BACKGROUND: Glaucoma is a progressive optic nerve degenerative disease that often leads to blindness. Local inflammatory responses are implicated in the pathology of glaucoma. Although inflammatory episodes outside the CNS, such as those due to acute systemic infections, have been linked to central neurodegeneration, they do not appear to be relevant to glaucoma. Based on clinical observations, we hypothesized that chronic subclinical peripheral inflammation contributes to neurodegeneration in glaucoma. METHODS: Mouthwash specimens from patients with glaucoma and control subjects were analyzed for the amount of bacteria. To determine a possible pathogenic mechanism, low-dose subcutaneous lipopolysaccharide (LPS) was administered in two separate animal models of glaucoma. Glaucomatous neurodegeneration was assessed in the retina and optic nerve two months later. Changes in gene expression of toll-like receptor 4 (TLR4) signaling pathway and complement as well as changes in microglial numbers and morphology were analyzed in the retina and optic nerve. The effect of pharmacologic blockade of TLR4 with naloxone was determined. FINDINGS: Patients with glaucoma had higher bacterial oral counts compared to control subjects (p<0.017). Low-dose LPS administration in glaucoma animal models resulted in enhancement of axonal degeneration and neuronal loss. Microglial activation in the optic nerve and retina as well as upregulation of TLR4 signaling and complement system were observed. Pharmacologic blockade of TLR4 partially ameliorated the enhanced damage. CONCLUSIONS: The above findings suggest that the oral microbiome contributes to glaucoma pathophysiology. A plausible mechanism by which increased bacterial loads can lead to neurodegeneration is provided by experiments in animal models of the disease and involves activation of microglia in the retina and optic nerve, mediated through TLR4 signaling and complement upregulation. The finding that commensal bacteria may play a role in the development and/or progression of glaucomatous pathology may also be relevant to other chronic neurodegenerative disorders.

Complement expression in the retina is not influenced by short-term pressure elevation.

PURPOSE: To determine whether short-term pressure elevation affects complement gene expression in the retina in vitro and in vivo. METHODS: Muller cell (TR-MUL5) cultures and organotypic retinal cultures from adult mice and monkeys were subjected to either 24-h or 72-h of pressure at 0, 15, 30, and 45 mmHg above ambient. C57BL/6 mice were subjected to microbead-induced intraocular pressure (IOP) elevation for 7 days. RNA and protein were extracted and used for analysis of expression levels of complement component genes and complement component 1, q subcomponent (C1q) and complement factor H (CFH) immunoblotting. RESULTS: mRNA levels of complement genes and C1q protein levels in Muller cell cultures remained the same for all pressure levels after exposure for either 24 or 72 h. In primate and murine organotypic cultures, pressure elevation did not produce changes in complement gene expression or C1q and CFH protein levels at either the 24-h or 72-h time points. Pressure-related glial fibrillary acidic protein (GFAP) mRNA expression changes were detected in primate retinal organotypic cultures (analysis of variance [ANOVA]; p<0.05). mRNA expression of several other genes changed as a result of time in culture. Eyes subjected to microbead-induced IOP elevation had no differences in mRNA expression of complement genes and C1q protein levels (ANOVA; p>0.05 for both) with contralateral control and naïve control eyes. CONCLUSIONS: Short-term elevation of pressure in vitro as well as short-term (1 week) IOP elevation in vivo does not seem to dramatically alter complement system gene expression in the retina. Prolonged expression to elevated pressure may be necessary to affect the complement system expression.

Pseudoexfoliation syndrome, a systemic disorder with ocular manifestations.

Pseudoexfoliation syndrome (PXS) is a systemic condition with eye manifestations. In the eye, pseudoexfoliation material deposits on various structures of the anterior segment. The nature of this material is mostly fibrillar with fibers made up of microfibrils and coated with amorphous material. The composition of these fibrils is diverse and includes basement membrane components as well as enzymes involved in extracellular matrix maintenance. Pseudoexfoliation is the most common cause of secondary open-angle glaucoma (pseudoexfoliation glaucoma, PXG) worldwide. The goal of this review is to summarize our knowledge on the genetics of this systemic disorder and its resultant ocular manifestations. PXS familial aggregation suggests genetic inheritance. PXS has been strongly associated with single nucleotide polymorphisms (SNPs) of the lysyl oxidase-like 1 (LOXL1) gene on chromosome 15q24.1. Two of these SNPs confer a higher than 99% population attributable risk for PXS and PXG in the Nordic population; however, they carry different risks in different populations. The high risk haplotypes also vary among different populations. LOXL1 is one of group of the enzymes involved in the cross-linking of collagen and elastin in the extracellular matrix. Its function in connective tissue maintenance has been confirmed in mice; however, its actual role in PXS remains unclear. Contactin-associated protein-like 2 also has a strong genetic association with PXS in a German cohort and is an attractive candidate molecule. It encodes for a protein involved in potassium channel trafficking. Other candidate genes linked to PXS include lysosomal trafficking regulator, clusterin, adenosine receptors, matrix metalloproteinase-1 (MMP1), and glutathione transferase. These genes may be modifying genes for development of PXS and PXG.

Determining the effect of calculus, hypocalcification, and stain on using optical coherence tomography and polarized Raman spectroscopy for detecting white spot lesions.

Optical coherence tomography (OCT) and polarized Raman spectroscopy (PRS) have been shown as useful methods for distinguishing sound enamel from carious lesions ex vivo. However, factors in the oral environment such as calculus, hypocalcification, and stain could lead to false-positive results. OCT and PRS were used to investigate extracted human teeth clinically examined for sound enamel, white spot lesion (WSL), calculus, hypocalcification, and stain to determine whether these factors would confound WSL detection with these optical methods. Results indicate that OCT allowed differentiating caries from sound enamel, hypocalcification, and stain, with calculus deposits recognizable on OCT images. ANOVA and post-hoc unequal N HSD analyses to compare the mean Raman depolarization ratios from the various groups showed that the mean values were statistically significant at P < .05, except for several comparison pairs. With the current PRS analysis method, the mean depolarization ratios of stained enamel and caries are not significantly different due to the sloping background in the stained enamel spectra. Overall, calculus and hypocalcification are not confounding factors affecting WSL detection using OCT and PRS. Stain does not influence WSL detection with OCT. Improved PRS analysis methods are needed to differentiate carious from stained enamel.

Early dental caries detection using a fibre-optic coupled polarization-resolved Raman spectroscopic system.

A new fibre-optic coupled polarization-resolved Raman spectroscopic system was developed for simultaneous collection of orthogonally polarized Raman spectra in a single measurement. An application of detecting incipient dental caries based on changes observed in Raman polarization anisotropy was also demonstrated using the developed fibre-optic Raman spectroscopic system. The predicted reduction of polarization anisotropy in the Raman spectra of caries lesions was observed and the results were consistent with those reported previously with Raman microspectroscopy. The capability of simultaneous collection of parallel- and cross-polarized Raman spectra of tooth enamel in a single measurement and the improved laser excitation delivery through fibre-optics demonstrated in this new design illustrates its future clinical potential.

Shedding new light on early caries detection.

Dental caries continues to be a common chronic disease among various population groups. Patient care can be improved with detection at the earliest stage. However, current techniques do not have sufficient sensitivity and specificity. We discuss 2 new methods - optical coherence tomography (OCT) and polarized Raman spectroscopy (PRS) - that are potentially useful for early caries detection and monitoring. OCT produces morphologic depth images of near-surface tissue structures with a resolution that is an order of magnitude greater than ultrasound imaging. Based on measurement of back-scattered near infrared light, OCT shows that sound enamel causes high-intensity back-scattering at the tooth surface that decreases rapidly with depth. In contrast, incipient lesions cause higher light back-scattering at the tooth surface and subsurface scattering indicative of porosity caused by demineralization. The scatter region within the enamel correlates well with the classical triangular shape of subsurface lesions observed in histologic sections. OCT imaging not only allows identification of incipient lesions, but also provides information on surface integrity and lesion depth. PRS furnishes biochemical information about the tooth"s composition, mineral content and crystallinity. The depolarization ratio derived from the dominant phosphate peak of hydroxyapatite in sound teeth is consistently lower than that from incipient caries. This difference is attributed to the change in enamel crystallite morphology or orientation that occurs with acid demineralization. Thus, PRS can be used to confirm suspect lesions determined by OCT and rule out false-positive signals from non-carious anomalies. The combination of OCT and PRS provides a new detection method with high sensitivity and specificity that will improve caries management and patient care. Future studies are aimed at developing intraoral probes to validate the findings in vivo.

The root and root canal morphology of the human mandibular second premolar: a literature review.

The objective was to review thoroughly the literature of the root and root canal morphology of the human mandibular second premolar and compare the results with the mandibular first premolar. Published studies cite the anatomy and morphology of the mandibular second premolar tooth for more than 7700 teeth. These studies were divided into anatomic studies reporting the number of roots, number of canals, and apical anatomy. Differences caused by gender and ethnicity have also been reported. Individual case reports of anomalies were included to demonstrate the extreme range of variation. Almost all of the teeth in the anatomic studies were single-rooted (99.6%). The incidence of 2 roots (0.3%) and 3 roots (0.1%) was extremely rare. Anatomic studies of the internal canal morphology found that a single canal was present in 91.0% of the teeth. A single apical foramen was found in 91.8% of the teeth. The incidence of more than 1 root (0.4%), more than 1 canal system (9.9%), and more than 1 foramen (8.2%) is lower than that of the mandibular first premolar tooth (2.0%, 24.2%, and 21.1%, respectively). However, the root and root canal morphology of the mandibular second premolar can be extremely complex and requires careful assessment.

The root and root canal morphology of the human mandibular first premolar: a literature review.

The purpose of this study was to undertake a comprehensive literature review of the root and root canal morphology of the mandibular first premolar. Published studies citing the anatomy and morphology of mandibular premolars report data for over 6,700 teeth. These studies were divided into anatomical studies reporting number of roots, number of canals, and apical morphology. Variations because of sex and ethnic background have also been reported, along with case reports of anomalies. Approximately 98% of the teeth in these studies were single-rooted. The incidence of two roots was 1.8%. Three roots when reported were found in 0.2% of the teeth studied. Four roots were rare and were found in less than 0.1% of the teeth studied. Studies of the internal canal morphology revealed that a single canal was present in 75.8% of the teeth. Two or more canals were found in 24.2% of the teeth studied. A single apical foramen was found in 78.9% of the teeth, whereas 21.1% had two or more apical foramina. The role of genetics and racial variation may result in differences of incidence of root number and canal number in human populations. The dental literature is not unique in studying ethnicity and sex variations. Higher incidences of teeth with additional canals and roots have been reported in Chinese, Australian, and sub-Sahara African populations. Physical anthropology studies seem to show the lowest incidence in Western Eurasian, Japanese and American Arctic populations. The root and root canal morphology of this tooth can be complex and requires careful evaluation prior to root canal therapy.

Precision of Raman depolarization and optical attenuation measurements of sound tooth enamel.

The demineralization of enamel that is associated with early caries formation affects the optical properties of the enamel. Polarized Raman spectroscopy and optical coherence tomography have been used to detect these changes and potentially offer a means to detect and monitor early caries development. The total optical attenuation coefficient as measured by optical coherence tomography and the polarization anisotropy of the Raman peak arising from the symmetric nu(1) vibration of PO4(3-) at approximately 959 cm(-1) have been demonstrated as being sensitive markers of early caries. This ex vivo study on extracted human teeth demonstrates that these measurements can be made with reasonable precision with concomitantly good repeatability and reproducibility in sound enamel. Such reliability is crucial for these techniques to have a practical clinical value.

Root and root canal morphology of the human permanent maxillary first molar: a literature review.

The objective of this study was to review the literature with respect to the root and canal systems in the maxillary first molar. Root anatomy studies were divided into laboratory studies (in vitro), clinical root canal system anatomy studies (in vivo) and clinical case reports of anomalies. Over 95% (95.9%) of maxillary first molars had three roots and 3.9% had two roots. The incidence of fusion of any two or three roots was approximately 5.2%. Conical and C-shaped roots and canals were rarely found (0.12%). This review contained the most data on the canal morphology of the mesiobuccal root with a total of 8399 teeth from 34 studies. The incidence of two canals in the mesiobuccal root was 56.8% and of one canal was 43.1% in a weighted average of all reported studies. The incidence of two canals in the mesiobuccal root was higher in laboratory studies (60.5%) compared to clinical studies (54.7%). Less variation was found in the distobuccal and palatal roots and the results were reported from fourteen studies consisting of 2576 teeth. One canal was found in the distobuccal root in 98.3% of teeth whereas the palatal root had one canal in over 99% of the teeth studied.

Detection of early dental caries using polarized Raman spectroscopy.

A new technique based on polarized Raman spectroscopy is demonstrated for detecting early dental caries on extracted human teeth. Sound tooth enamel exhibited strong Raman polarization anisotropy whereas early caries consistently showed a lower degree of Raman polarization anisotropy. In particular, for sound enamel, the Raman peak arising from the symmetric nu1 vibration of PO(4) (3-) at 959 cm(-1) is strongly polarized. This is in contrast to the spectra of carious lesions that displayed weaker polarization dependence at 959 cm(-1). Such difference in the degree of Raman polarization anisotropy allows for discrimination between early dental caries and sound enamel.

Ex vivo detection and characterization of early dental caries by optical coherence tomography and Raman spectroscopy.

Early dental caries detection will facilitate implementation of nonsurgical methods for arresting caries progression and promoting tooth remineralization. We present a method that combines optical coherence tomography (OCT) and Raman spectroscopy to provide morphological information and biochemical specificity for detecting and characterizing incipient carious lesions found in extracted human teeth. OCT imaging of tooth samples demonstrated increased light backscattering intensity at sites of carious lesions as compared to the sound enamel. The observed lesion depth on an OCT image was approximately 290 microm matching those previously documented for incipient caries. Using Raman microspectroscopy and fiber-optic-based Raman spectroscopy to characterize the caries further, spectral changes were observed in PO4 (3-) vibrations arising from hydroxyapatite of mineralized tooth tissue. Examination of various ratios of PO4 (3-) nu2, nu3, nu4 vibrations against the nu1 vibration showed consistent increases in carious lesions compared to sound enamel. The changes were attributed to demineralization-induced alterations of enamel crystallite morphology and/or orientation. OCT imaging is useful for screening carious sites and determining lesion depth, with Raman spectroscopy providing biochemical confirmation of caries. The combination has potential for development into a new fiber-optic diagnostic tool enabling dentists to identify early caries lesions with greater sensitivity and specificity.

Effect of mode of polymerization of bonding agent on shear bond strength of autocured resin composite luting cements.

PURPOSE: There have been anecdotal reports of low bond strength with autocured resin composite materials, particularly when light-cured bonding agents that combine primer and adhesive in a 1-bottle preparation are used. The objective of this study was to determine if the mode of polymerization of the bonding agent influences the strength of the attachment of autocured resin composite luting cements to dentin. METHODS: The shear bond strength of 2 resin luting cements, Calibra and RelyX ARC, polymerized by autocuring, in combination with 4 different bonding agents, Scotchbond Multipurpose Plus, Prime & Bond NT, IntegraBond and Single Bond, polymerized to bovine dentin by light-curing, autocuring or dual-curing, was determined. The pH of each bonding agent and its components was measured. Two-way analysis of variance was used to test the effect of cement and adhesive on shear bond strength. For each bonding agent, the adhesive variable combined the factors product brand and mode of polymerization. With significant interaction among the above variables, the least square means of the 16 combinations of resin cement and adhesive were compared. RESULTS: There was no consistent relationship between shear bond strength and mode of polymerization of the bonding agent. Significant differences in bond strength were specific to the proprietary brand of bonding agent. The pH of the bonding agent depends on the manufacturer's formulation, and low pH may contribute to low bond strength. CONCLUSIONS: The low in vitro bond strength occurring with some combinations of bonding agent and resin cement could be clinically significant.