Patient-Centered Dentinal Hypersensitivity Treatment Outcomes: Results from the National Dental PBRN.

Dentinal hypersensitivity (DH) can have a significant impact on oral health and functioning, and it is a clinical symptom commonly managed by dentists during routine clinical practice. DH symptoms are typically elicited by otherwise innocuous, nonpainful stimuli applied to exposed dentin (e.g., tactile stimuli, warming or cooling temperatures or air puffs). Treatment approaches have sought to directly target the dentinal pulp tissues or close dentinal tubules via dental office care and treatment services (fluoride varnishes, glutaraldehydes, bonding agents, sealants, oxalates, or lasers) or home care services (toothpastes or dentifrices containing fluoride or potassium nitrate compounds). The purpose of this prospective multicenter cohort study was to assess how community-based dentists from the National Dental Practice-Based Research Network (National Dental PBRN) manage DH and whether the effectiveness of DH treatments can be assessed in those settings. A total of 171 dentists recruited 1862 subjects with DH from their existing patients. Dentists then recommended and provided DH treatment as appropriate. Treatment choice was at the discretion of the dentists. Patients rated their DH pain at baseline and 1, 4, and 8 wk during the course of their treatments. They used pain intensity and unpleasantness visual analog scales and 4 labeled magnitude scales and rated their satisfaction with treatment after 8 wk. Patients were provided reminders postbaseline via email, texting, or voice mail. These patient-centered outcomes served as the principal measures for the assessment of treatment because treatments sought to alleviate DH symptoms. The patients with DH who reported pain reduction from dentist-provided treatments (glutaraldehyde/HEMA [hydroxyethyl methacrylate] compounds, oxalates, and bonding agents), dentists' advice and counseling regarding oral habits and diet, and patient-applied fluoride toothpaste reported a concomitant positive rating of satisfaction with DH treatments. The results from this study support the feasibility of engaging network practices to assess the effectiveness of clinical DH treatments. Knowledge Transfer Statement: National Dental PBRN dentists provide a range of procedures to treat dentinal hypersensitivity. In this large nonrandomized study designed to assess clinical care and to capture patient-reported outcomes, about 60% of patients reported improvement in pain. This study demonstrated the feasibility of engaging network dentists and their patients to assess treatment effectiveness. Future studies will explore the feasibility of imposing randomization and measuring patient compliance with treatment in the manner that this treatment is provided.

Novel anticoagulants: general overview and practical considerations for dental practitioners.

Currently, 4 novel Direct Oral Anticoagulants (DOACs) were approved by the FDA. This review focuses on these agents and proposes a matrix for the general dentists to assess bleeding risk in dental management of patient on DOACs. The outline covers the pharmacology of DOACs (rivaroxaban, apixaban, edoxaban and dabigatran), bleeding complications, risk associated with discontinuation, monitoring/reversal, and implications for the dental practitioners. A total of 18 randomized controlled trials were identified with mixed results in regards to the risk for bleeding. Considering the pharmacology of DOACs and challenges in monitoring and reversing their effect, the dentist should consider carefully the management of patients on DOACs as it may differ from patients on conventional anticoagulants. Based on the type of dental procedure and the medical risk assessment, several general treatment approaches can be considered: continue DOACs, time dental treatment as late as possible after the last DOACs dose, discontinue DOACs for 24hrs, or discontinue DOACs for 48hrs. Based on the current reported dental literature, limited dental surgery may benefit from the first 2 conservative options. However, this needs to be proven in comparative clinical trials.

Putting an end to the silent epidemic.

Oral health care is at the core of wellness, but it is often the forgotten health concern in this country. In New York State, this view is reflected in the large disparity in access to oral health care services. Our most vulnerable populations suffer the most from the disease and complications attributed to poor oral health care. Although faced with a $45 million funding gap, The New York State Academic Dental Centers serve as the primary source of dental care for many of New York's underserved and uninsured.

Preventive dentistry: practitioners' recommendations for low-risk patients compared with scientific evidence and practice guidelines.

INTRODUCTION: The purpose of this article is to compare published evidence supporting procedures to prevent dental caries and periodontal disease, in low-risk patients, with the actual preventive recommendations of practicing dentists. METHODS: Methods included (1) a survey questionnaire of general dentists practicing in western New York State concerning the preventive procedures they would recommend and at what intervals for low-risk children, young adults, and older adults; and (2) review of the published, English-language literature for evidence supporting preventive dental interventions. RESULTS: The majority of dentists surveyed recommended semiannual visits for visual examination and probing to detect caries (73% to 79%), and scaling and polishing to prevent periodontal disease (83% to 86%) for low-risk patients of all ages. Bite-wing radiographs were recommended for all age groups at annual or semiannual intervals. In-office fluoride applications were recommended for low-risk children at intervals of 6 to 12 months by 73% of dentists but were recommended for low-risk older persons by only 22% of dentists. Application of sealants to prevent pit and fissure caries was recommended for low-risk children by 22% of dentists. Literature review found no studies comparing different frequencies of dental examinations and bite-wing radiographs to determine the optimal screening interval in low-risk patients. Two studies of the effect of scaling and polishing on the prevention of periodontal disease found no benefit from more frequent than annual treatments. Although fluoride is clearly a major reason for the decline in the prevalence of dental caries, there are no studies of the incremental benefit of in-office fluoride treatments for low-risk patients exposed to fluoridated water and using fluoridated toothpaste. CONCLUSIONS: Comparative studies using outcome end points are needed to determine the optimal frequency of dental examinations and bite-wing radiographs for the early detection of caries, and of scaling and polishing to prevent periodontal disease in low-risk persons. There is no scientific evidence that dental examinations, including scaling and polishing, at 6 month intervals, as recommended by the dentists surveyed in this study, is superior to annual or less frequent examinations for low-risk populations. There is also no evidence that in-office fluoride applications offer incremental benefit over less costly methods of delivering fluoride for low-risk populations.

Accreditation issues in post-doctoral general dentistry programs.

There has been increasing interest in the organization and accreditation of post-doctoral general dentistry programs (PGD). Numerous national organizations have called for increases in the number of PGD positions and programs. At the same time, there has been a movement to incorporate concepts of competency-based education into dental education programs to stress the outcomes of education rather then the process. These movements have coincided with the current accreditation standards revision cycles for GPR and AEGD programs. These events suggest that PGD educators have a major opportunity and responsibility to assess the goals and educational directions of PGD programs in light of the many changes in dental health care delivery, health policy, and dental education activities. These opportunities will be realized only if the organizations involved with PGD education can find common ground and pool their resources to promote the interests of PGD education.

Postdoctoral education in dentistry: preparing dental practitioners to meet the oral health needs of America in the 21st century.

There has been increasing interest in the organization and accreditation of Postdoctoral General Dentistry Programs (PGD). In addition, numerous national organizations have called for increases in the number of first postdoctoral year (PGY-1) positions and programs. At the same time there has been a movement to incorporate concepts of competency-based education into dental education programs in order to stress the outcomes of education rather then the process. These movements have coincided with an increased recognition that dental education will be affected by the changing demographics of our population, the emerging trends in health care delivery and financing, and the need for an increase in the number of primary care providers in dentistry, trained at an advanced level, who are capable of caring for an increasingly socially diverse and medically complex population in our country in the next century. This paper reviews the history of postdoctoral education programs in dentistry and medicine with a focus on PGD education, describes the changing health care environment in which future dental professionals will practice, and relates the dental postdoctoral experience to that in medicine. A strategy is presented for the dental profession to prepare dental practitioners with the competencies needed for the future and to create enough training opportunities to prepare these practitioners to care for the oral health needs of the nation. This proposal calls for a "National Consensus Development Conference on the Future of Postdoctoral Primary Care Education in Dentistry". This conference would define the strategies necessary to prepare dental practitioners with the competencies needed for the future and develop approaches to create enough training opportunities to prepare these practitioners to care for the oral health needs of the nation.

The efficacy of an intraoral fluoride-releasing system in irradiated head and neck cancer patients: a preliminary study.

This study compared the anticaries effectiveness of an intraoral fluoride-releasing system, or IFRS, with a standard regimen of daily application of a 1.1 percent neutral sodium fluoride gel in custom trays. Caries protection in subjects in the IFRS group was comparable to that in subjects in the 1.1 percent neutral sodium fluoride group. The subjects all had head or neck cancer and had received radiation therapy, but no more recently than three months before taking part in the study. Overall, IFRS devices were well-tolerated and patient satisfaction was high. The IFRS appears to offer several advantages over the daily application of fluoride gels in custom trays.

Quantification of tumor vascularity and flow with amplitude color Doppler sonography in an experimental model: preliminary results.

This study was designed to evaluate a system to quantitate vascularity and tumor blood flow with amplitude (power) color Doppler sonography. The vascularity of nine transplanted murine tumors was determined with quantitated amplitude color Doppler sonography and compared to tumor vascularity estimated by histologic examination. The system used seemed to provide an accurate depiction of the vascularity of tumor vis-àa-vis histologic estimation of vessel density (r = 0.80). Time-activity curves showed greater flow in the experimental group injected with an exotoxin than in the group injected with saline solution. Vascular density quantification with amplitude color Doppler sonography also was more accurate when an intravascular agent (such as an exotoxin) was used than when saline infusions were given. This quantification scheme may allow the development of a system to assess the probability of malignancy and to monitor tumor response to treatment on the basis of the vascularity of the mass.

Effect of sucralose--alone or bulked with maltodextrin and/or dextrose--on plaque pH in humans.

Sucralose is a safe, intensely sweet, noncaloric sucrose derivative that has been shown to be noncariogenic. The purpose of the present study was to compare the effects on plaque pH in vivo of sucralose in iced tea (alone or bulked with maltodextrin or with maltodextrin/dextrose) with sucrose in iced tea. Fourteen subjects, with DMFT > 7 and an acidogenic plaque, participated in the study. Plaque pH response to one of five solutions: unsweetened tea, tea with sucralose (final concentration 0.007% by weight), tea with sucralose/maltodextrin (final concentrations 0.007% and 0.59% by weight, respectively), tea with sucralose/maltodextrin/dextrose (final concentrations 0.007, 0.018 and 0.57% by weight, respectively) and tea with sucrose (final concentration 4.7% by weight); was assessed in five experimental sessions. All solutions, except the unsweetened tea, had a sweetness equivalent to 2 teaspoons of sucrose in 6 OZ of beverage. Using a touch electrode, plaque pH was measured at baseline and at specific time intervals up to 60 min after rinsing with the test solution for 1 min. Comparisons between groups were done for minimum pH, delta pH, and area under the pH curve (AUC), by using the nonparametric Friedman's test and the Wilcoxon signed rank test. Rinsing with tea and sucrose resulted in significantly lower minimum pH, higher delta pH and larger AUC than rinsing with the solutions containing sucralose. It can be concluded that sucralose alone or in combination with maltodextrin or with maltodextrin/dextrose is significantly less acidogenic than sucrose when used as a sweetener in iced tea.

Evaluation of myocardial ischemia using a rest metabolism/stress perfusion protocol with fluorine-18 deoxyglucose/technetium-99m MIBI and dual-isotope simultaneous-acquisition single-photon emission computed tomography.

OBJECTIVES: This study sought to develop a dual-isotope single-acquisition single-photon emission computed tomographic (SPECT) protocol using a multihead SPECT camera equipped with an ultra-high energy collimator to evaluate rest metabolism/stress perfusion simultaneously with fluorine-18 (F-18) deoxyglucose/technetium-99m (Tc-99m) 2-hexakis-2-methoxy-2-methylpropyl isonitrile (MIBI). BACKGROUND: The most accurate and logistic method of identifying injured but viable myocardium remains a diagnostic challenge. METHODS: Sixty-five patients were given 25 to 50 g of glucose and, after approximately 60 min, an injection of 370 MBq (10 mCi) of F-18 fluorodeoxyglucose. After a 35-min distribution phase, patients underwent exercise or pharmacologic stress followed by administration of 925 MBq (25 mCi) of Tc-99m MIBI. Five patients underwent F-18 fluorodeoxyglucose position emission tomography before dual-isotope SPECT: RESULTS: With a window of 20% for both photopeaks and a technetium-99m/fluorine-18 concentration of 3.2:1, the "spillover" from fluorine-18 into the technetium-99m window is < 6% of the total counts in the window in patients with a normal distribution of both radiopharmaceuticals. Phantom images clearly demonstrated cardiac defects measuring 2 x 1 and 2 x 0.5 cm. There was no significant difference in the images of the five patients who underwent both positron emission tomography and SPECT: Fifty-seven patients (mean [+/- SD] age 55 +/- 15 years, range 25 to 83; 38 men, 19 women) had satisfactory images and were included in the study. Twenty-one patients had normal study results; 15 had mismatched defects; 14 had matched defects; and 7 had both matched and mismatched defects. Twenty-three patients (mean age 54 +/- 6 years, range 30 to 83; 14 men, 9 women) underwent coronary angiography within 3 months of dual-isotope SPECT: There were seven normal studies, eight with mismatched defects, one with a matched defect and seven with matched and mismatched defects. When stenosis > 70% was used as the criterion for a diagnosis of coronary artery disease, dual-isotope SPECT had a sensitivity of 100%, specificity of 88%, positive predictive value of 93%, negative predictive value of 100% and an accuracy of 96%. CONCLUSIONS: Dual-isotope SPECT may provide an alternative, accurate, cost-effective method to nitrogen-13 ammonia/F-18 fluorodeoxyglucose positron emission tomography or thallium-201 reinjection for identifying injured or dysfunctional but viable myocardium.

Optimal cutoff levels of F-18 fluorodeoxyglucose uptake in the differentiation of low-grade from high-grade brain tumors with PET.

PURPOSE: To determine the optimal cutoff level of fluorine-18-labeled fluorodeoxyglucose (FDG) uptake in the differentiation of low-grade from high-grade cerebral tumors at position emission tomography (PET). MATERIALS AND METHODS: The authors retrospectively reviewed images from PET, magnetic resonance imaging, and computed tomography performed in 58 consecutive patients with histologically proved brain tumors. There were 32 high-grade tumors (20 gliomas) and 26 low-grade tumors (18 gliomas). RESULTS: The best cutoff level of FDG uptake ratios in the differentiation of high-grade from low-grade tumors was 1.5 for tumor-to-white matter (T/WM) ratios and 0.6 for tumor-to-cortex (T/C) ratios. These levels were the same when only gliomas were analyzed and when all tumors were analyzed. When a T/WM ratio of more than 1.5 was considered indicative of a high-grade tumor, the sensitivity and specificity were 94% and 77%, respectively. The results were similar for the T/C ratio. CONCLUSION: Cutoff levels of 1.5 for the T/WM FDG uptake ratio and 0.6 for the T/C ratio are useful in the differentiation of low-grade from high-grade gliomas with PET.

The growth of postdoctoral general dentistry programs.

From 1972 to 1990, the number of Postdoctoral General Dentistry (PGD) programs increased by 57% and enrollment increased by 57% and enrollment increased by 131% for a total of 118 PGD programs and 1,367 positions. Although there has been some increase in military and Veterans Affairs (VA) programs, the major increase was in civilian programs. From 1972-78, the major impetus for growth was hospital sponsorship of General Practice Residency (GPR) programs. With federal funding of PGD programs, civilian GPR programs continued to be the main source of growth until the accreditation of Advanced Education in General Dentistry (AEGD) programs in 1981. Subsequently, almost all increases were in AEGD programs. Over the 12-year period of federal funding (1978-90), there was an increase of 406 civilian PGD positions to make a total of 925 positions. The increase in enrollment directly attributable to federal funding was 242. The "unmet demand" for PGD programs was estimated to be approximately 300 positions for 1990, from data derived from the Survey of Dental Seniors and the Matching Program. Assuming that the number of PGD positions continues to increase by 35 positions a year, as it has in the past 12 years, the unmet demand would be met in slightly less than 10 years. If, however, a postdoctoral year was mandated for licensure, the increase in the number of positions would be far short of projected need.

Preliminary results of a pilot study using WR-2721 before fractionated irradiation of the head and neck to reduce salivary gland dysfunction.

PURPOSE: Based on in vivo evidence of radioprotection of the salivary glands using WR-2721, a pilot study was undertaken to determine the feasibility, toxicity, and salivary function of patients receiving WR-2721, while undergoing radiation therapy to the head and neck. METHODS AND MATERIALS: Patients undergoing radiation therapy for cancer of the head and neck were eligible if the major salivary glands received more than 45 Gy. WR-2721 was administered over 6 min IV, 10-15 min prior to each dose of radiation five times per week. Saliva was collected and measured prior to radiation therapy, weekly during radiation therapy, 1 month postradiation therapy, and every 3 months thereafter. Flow rates of unstimulated whole saliva, stimulated whole saliva, and stimulated parotid saliva were measured using standard techniques. 99mTc salivary scintiscans were performed prior to radiation therapy, 1 month postradiation therapy and every 3 months thereafter. Nine patients are presently enrolled on the first dose level (100 mg/m2) of this study. Eight completed per protocol, two with minor decreases of total WR-2721 doses. Two patients progressed with distant metastases soon after completion of therapy. All available data are included in the analysis. Median follow-up for all patients is 18 months. RESULTS: Flow rates of unstimulated whole saliva decreased significantly during radiation therapy reaching 5.6% of baseline at 9 months postradiation therapy, subsequently recovering to 20% of baseline, then remaining stable over time. Stimulated whole salivary flow rate similarly decreased during radiation therapy and reached its nadir (11% of baseline) at 3 months postradiation therapy, improving to 27% of baseline by 2 years. The stimulated parotid flow rate decreased during radiation therapy to 1.4% of pretreatment levels. Significant recovery took place 6 months postradiation therapy and by 18 months values had recovered to 54% of baseline. 99mTc salivary scintiscans confirmed this rebound of parotid function postradiation therapy. Toxicity was minimal with the exception of one patient who received only 27% of the planned total drug dose due to grade 3 hypotension after the eighth treatment. No recovery of salivary function has been seen in this patient; flow rates remain zero in all three areas tested 21 months after radiation. CONCLUSIONS: Administration of WR-2721 prior to each dose of radiation was feasible and without significant toxicity at 100 mg/m2. Salivary gland function improved over time after completion of radiation, particularly the parotid. Future directions include escalation of WR-2721 dose to 200 mg/m2 and then 300 mg/m2, and a Phase III randomized trial will be undertaken once the optimal dose is established.

Practice characteristics of graduates of postdoctoral general dentistry programs.

A mail questionnaire was sent to 900 dentists who completed a Postdoctoral General Dentistry (PGD) program in 1985 and 900 dentists who graduated from dental school in 1985 but did not participate in a PGD program. The response rate was 57 percent. Three-quarters of the PGD graduates trained in civilian programs with the remainder being equally divided between military and Veterans Administration (VA) programs. Graduates of military programs continued to be employed by the military five years after graduation in contrast to the VA where less than 2 percent of graduates were employed after five years. The percent of dentists who are specialists or are enrolled in specialty programs five years after graduation was approximately 13 percent and the rates were similar for PGD and non-PGD dentists. The patterns of care in private practice tended to be similar for both groups; however, in institutions GPR graduates provided more treatment for special care patients and patients who were economically disadvantaged. GPR graduates also were more involved in teaching and in hospital activities.

Assessment of aortic regurgitation by transesophageal echocardiography: correlation with angiographic determination.

Transthoracic echocardiographic studies have shown that color Doppler mapping of the aortic regurgitation (AR) jet correlated well with the severity of regurgitation as assessed by contrast aortography. The present study was performed to assess whether these parameters could be similarly applied to measurements determined by transesophageal echocardiography (TEE). In order to determine and validate criteria for the assessment of AR severity, 39 clinically stable patients with a TEE color Doppler study and contrast aortography within a 2-week period were identified. The ratio of the jet area (JA) to left ventricular diastolic area (LVDA) had the best correlation to AR severity as determined by contrast aortography (r = 0.89). Jet length, JA, the ratio of jet width to the width of the left ventricular outflow tract and jet width had r values of 0.88, 0.88, 0.83, and 0.84, respectively. The best sensitivity and specificity for the assessment of AR by TEE were obtained as follows: JA/LVDA ratio of 0%-7% predicts 0-1 + AR; 8%-20% 2-3 + AR, and greater than 20% 4 + AR. Of the three patients miscategorized, none was misgraded by more than one angiographic grade of AR. Jets that measure more than 6 cm in length or have an area of greater than 10 cm 2 have a 100% sensitivity and specificity for diagnosing 4 + AR. In the present study the ratio of JA to LVDA area correlates best with AR severity as determined by angiography.