Monday, March 19, 2018

Tooth health may indicate diabetes risk

Poor dental health may be linked with increased risk for diabetes, a new study suggests. The results will be presented in a poster Monday, March 19, at ENDO 2018, the 100th annual meeting of the Endocrine Society in Chicago, Ill.

"The health of your teeth maybe a sign of your risk for diabetes," said lead author Raynald Samoa, M.D., an assistant professor in the Department of Diabetes, Endocrinology & Metabolism at City of Hope National Medical Center in Duarte, Calif.

"Our findings suggest that dental exams may provide a way to identify someone at risk for developing diabetes. We found a progressive positive relationship between worsening glucose tolerance and the number of missing teeth. Although a causal relationship cannot be inferred from this cross-sectional study, it demonstrates that poor dental outcome can be observed before the onset of overt diabetes," he said.

Samoa and colleagues investigated the impact of glucose tolerance on dental health in a representative population in the United States.

The researchers reviewed the records of 9,670 adults 20 years of age and above who were examined by dentists during the 2009-2014 National Health and Nutrition Examination Survey. They analyzed their reported body mass index (BMI) and glucose tolerance states by fasting plasma glucose, two-hour postchallenge plasma glucose, hemoglobin A1c (HbA1c), established diabetes and whether the condition was treated with oral agents or insulin.

They recorded the numbers of missing teeth due to caries, or cavities, and periodontal disease for individual patients; and they determined the relationship between glucose tolerance and dental condition by considering age, gender, racial and ethnic group, family history of diabetes, smoking status, alcohol consumption, education and poverty index.

The authors found a progressive increase in the number of patients with missing teeth as glucose tolerance declined, from 45.57 percent in the group with normal glucose tolerance (NGT), to 67.61 percent in the group with abnormal glucose tolerance (AGT), to 82.87 percent in the group with diabetes mellitus (DM). Except for gender, all other covariates had significant impact on the number of missing teeth.

The differences in the average number of missing teeth among the three glucose tolerance groups were significant: 2.26 in the NGT group, 4.41 in the AGT group and 6.80 in those with DM.
The authors wrote in their abstract that as far back as the 1930s, periodontal disease and dental caries have been suggested to be linked with diabetes, and that that by 2050, one-third of Americans are expected to be affected by diabetes.

Primary care physicians report feeling unprepared for role in prenatal oral health

A new study from the University of North Carolina at Chapel Hill suggests that primary care physicians may feel underequipped to provide adequate oral health counseling to pregnant women. Poor maternal oral health can have significant impacts on a woman's overall health and the health of her children.

Dr. Gentry Byrd and Dr. Rocio Quinonez of the UNC-Chapel Hill School of Dentistry co-authored a paper, published in the Maternal and Child Health Journal on March 17, that investigates prenatal oral health counseling by primary care physicians. This is the first study to provide national estimates and predictors of their prenatal oral health counseling. The study used data from the 2013 Survey of Primary Care Physicians on Oral Health by the United States Department of Health and Human Services' (U.S. HHS) Office of Women's Health.

More than 350 primary care physicians across the country who treat pregnant women were surveyed. The authors found that while many primary care physicians addressed prenatal oral health in the form of counseling, and agreed that preventive dental care is very important, just 45 percent of respondents felt prepared to identify oral health issues and counsel pregnant patients on the importance of oral health.

With more than half of the surveyed primary care physicians saying they feel unprepared to address oral health issues with pregnant patients, this study illustrates the disconnect between prenatal oral health practice guidelines and primary care physician workforce preparedness.

"Pregnant women remain an underserved patient population, even after dentists from the American Dental Association (ADA) and physicians from the American College of Obstetrics and Gynecology (ACOG) came together on the national level to develop joint consensus practice guidelines for medical and dental providers that detail the safety of dental treatment in all trimesters," said Byrd.

Previous studies suggest there is an increased risk of pre-term birth among pregnant women with periodontal disease. We also know that mothers with untreated cavities and tooth decay have children with twice the likelihood of experiencing cavities and tooth decay with up to twice the severity. While there are many factors that contribute to the development of diseases, good oral health and nutritional practices of mothers may be modeled to their children.

The findings of Byrd and Quinonez's study are promising. 69 percent of primary care physicians acknowledged their role in oral health and that they should be able to identify oral health issues in adult patients. The authors' research also supported the results of a recent national survey, which found a general lack of primary care physician training in oral health. The authors found that primary care physicians who received oral health continuing education had a higher likelihood of counseling pregnant women on oral health than those who did not, suggesting that oral health continuing education is a key component to improving prenatal care.

This research illustrates the growing importance of interprofessional collaboration between health care professions, with a focus on oral health. Oral health content has increased in medical school education within the last decade. For instance, Smiles for Life, a national oral health curriculum, was designed to facilitate the integration of oral health into primary care provider training.

Quinonez and Dr. Kim Boggess developed the Prenatal Oral Health Program (pOHP), a collaboration between the UNC-Chapel Hill School of Dentistry's department of pediatric dentistry and the UNC-Chapel Hill School of Medicine's department of obstetrics and gynecology, to train medical and dental students on facilitating the delivery of essential dental services to pregnant women. The program's goal is to improve the health of every woman, fetus and child by educating and providing resources to providers.

"During pregnancy, some women may become eligible for insurance coverage for dental care that they may not get otherwise," said Byrd. "This is an opportune time for medical and dental providers to collaborate in ensuring pregnant patients have a dental home."

The authors address areas of future research, such as the quality of oral health counseling given by primary care providers and physicians, and barriers to addressing prenatal oral health. New studies using their findings may be done to help develop strategies to promote evidence-based practice, with more work needed to assure equitable and quality prenatal care.

Tuesday, March 13, 2018

Toothpaste alone does not prevent dental erosion or hypersensitivity

An analysis of nine toothpastes found that none of them protects enamel or prevents erosive wear. Specialists stress that diet and treatment by a dentist are key to avoid the problems originated by dentin exposure.
The rising prevalence of dental erosion and dentin hypersensitivity has led to the emergence of more and more toothpastes on the market that claim to treat these problems. While no such toothpaste existed 20 years ago, today, many brands with different attributes are being offered.

However, a study conducted at the University of Bern in Switzerland with the participation of a researcher supported by a scholarship from the São Paulo Research Foundation - FAPESP showed that none of the nine analyzed toothpastes was capable of mitigating enamel surface loss, a key factor in tooth erosion and dentin hypersensitivity.

"Research has shown that dentin must be exposed with open tubules in order for there to be hypersensitivity, and erosion is one of the causes of dentin exposure. This is why, in our study, we analyzed toothpastes that claim to be anti-erosive and/or desensitizing," said Samira Helena João-Souza, a PhD scholar at the University of São Paulo's School of Dentistry (FO-USP) in Brazil and first author of the article.

According to an article published in Scientific Reports, all of the tested toothpastes caused different amounts of enamel surface loss, and none of the toothpastes afforded protection against enamel erosion and abrasion.

The authors of the study stressed that these toothpastes perform a function but that they should be used as a complement, not as a treatment, strictly speaking. According to João-Souza, at least three factors are required: treatment prescribed by a dentist, use of an appropriate toothpaste, and a change in lifestyle, especially diet.

"Dental erosion is multifactorial. It has to do with brushing, and above all, with diet. Food and drink are increasingly acidic as a result of industrial processing", she said.

The researcher highlights that dental erosion is a chronic loss of dental hard tissue caused by acid without bacterial involvement - unlike caries, which is bacteria-related. When it is associated with mechanical action, such as brushing, it results in erosive wear. In these situations, patients typically experience discomfort when they drink or eat something cold, hot or sweet.

"They come to the clinic with the complaint that they have caries, but actually, the problem is caused by dentin exposure due to improper brushing with [a] very abrasive toothpaste, for example, combined with frequent consumption of large amounts of acidic foods and beverages," said Professor Ana Cecília Corrêa Aranha, João-Souza's supervisor and a co-author of the article.

In our clinical work, we see patients with this problem in the cervical region between [the] gum and tooth. The enamel in this region is thinner and more susceptible to the problem," she added.

The scientists tested eight anti-erosive and/or desensitizing toothpastes and one control toothpaste, all of which are available from pharmacies and drugstores in Brazil or Europe.

The research simulated the effect of brushing once a day with exposure to an acid solution for five consecutive days on tooth enamel. The study used human premolars donated for scientific research purposes, artificial saliva, and an automatic brushing machine.

"We used a microhardness test to calculate enamel loss due to brushing with the toothpastes tested. The chemical analysis consisted of measuring toothpaste pH and levels of tin, calcium, phosphate and fluoride," João-Souza explained.

The physical analysis consisted of weighing the abrasive particles contained in the toothpastes, measuring their size, and testing wettability - the ease with which toothpaste mixed with artificial saliva could be spread on the tooth surface.

"During brushing with these toothpastes mixed with artificial saliva, we found that the properties of the toothpastes were different, so we decided to broaden the scope of the analysis to include chemical and physical factors. This [broadening] made the study more comprehensive," João-Souza said.
Statistically similar

All of the analyzed toothpastes caused progressive tooth surface loss in the five-day period. "None of them was better than the others. Indication will depend on each case. The test showed that some [toothpastes] caused less surface loss than others, but they all resembled the control toothpaste [for] this criterion. Statistically, they were all similar, although numerically, there were differences," Aranha said.

"We're now working on other studies relating to dentin in order to think about possibilities, given that none of these toothpastes was found capable of preventing dental erosion or dentin hypersensitivity, which is a cause of concern."

The researchers plan to begin a more specific in vivo study that will also include pain evaluations.

Wednesday, February 21, 2018

Wine polyphenols could fend off bacteria that cause cavities and gum disease

Sipping wine is good for your colon and heart, possibly because of the beverage's abundant and structurally diverse polyphenols. Now researchers report in ACS' Journal of Agricultural and Food Chemistry that wine polyphenols might also be good for your oral health.

Traditionally, some health benefits of polyphenols have been attributed to the fact that these compounds are antioxidants, meaning they likely protect the body from harm caused by free radicals. However, recent work indicates polyphenols might also promote health by actively interacting with bacteria in the gut. That makes sense because plants and fruits produce polyphenols to ward off infection by harmful bacteria and other pathogens. M. Victoria Moreno-Arribas and colleagues wanted to know whether wine and grape polyphenols would also protect teeth and gums, and how this could work on a molecular level.

The researchers checked out the effect of two red wine polyphenols, as well as commercially available grape seed and red wine extracts, on bacteria that stick to teeth and gums and cause dental plaque, cavities and periodontal disease. Working with cells that model gum tissue, they found that the two wine polyphenols in isolation -- caffeic and p-coumaric acids -- were generally better than the total wine extracts at cutting back on the bacteria's ability to stick to the cells. When combined with the Streptococcus dentisani, which is believed to be an oral probiotic, the polyphenols were even better at fending off the pathogenic bacteria. The researchers also showed that metabolites formed when digestion of the polyphenols begins in the mouth might be responsible for some of these effects.

Tuesday, February 20, 2018

Guidelines for fluoride intake -- Are they appropriate?

The appropriate use of fluoride has transformed oral health over the past 70 years, in part due to the guidelines created for fluoride intake. Recently, researchers are questioning these longstanding guidelines which served as advisory recommendations for decades. This issue of Advances in Dental Research, an e-Supplement to the Journal of Dental Research (JDR), presents the proceedings of a symposium at the 95th General Session of IADR in San Francisco, USA and includes reviews that critically examine the current guidelines for fluoride intake.

Since the benefits of fluoride in drinking water were first recognized, it has been accepted that fluoride is ingested and that remains the basis for automatic delivery. However, sources of ingested fluoride have changed and in parallel the prevalence and severity of dental caries and dental fluorosis have changed, leading to the idea that it is time to re-visit guidance on fluoride intake. Optimum fluoride intake should balance the prevention of dental caries with minimizing the occurrence of undesirable dental fluorosis.

"Guidelines for fluoride intake were first proposed when water was the only important source of fluoride. Now, there is a variety of ways of delivering fluoride and it was time to review these guidelines, considering current knowledge of the balance of benefit and risk," said guest editor Andrew Rugg-Gunn, Newcastle University, UK and the Borrow Foundation. "Experts from around the world gave reassurance that the current optimum range of fluoride intake is soundly based and that there is good evidence for raising the upper limit of fluoride intake. With the increase in the use of fluoride for preventing caries in adults, different guidance should be given for fluoride intake in adults compared with infants and young children."

"While changes to current guidance on adequate intake and upper limit of fluoride intake have not been settled, it was agreed that there are strong grounds for reconsidering current guidelines," said IADR President Angus William G. Walls, University of Edinburgh, who also contributed to this issue. "Further research and international discussion is needed to answer the question posed by the title of this symposium."

Importantly, the symposium prioritized the following research gaps:

What level of dental fluorosis is acceptable to populations globally given the benefit of caries reduction?
What is the best method for measuring total fluoride intake and exposure?
What is the best way to estimate total fluoride intake in children from birth to 3 to 4 y of age exposed to fluoridated or nonfluoridated water or fluoridated salt?
What is the best method to evaluate the patterns of fluid intake of children across different zones with different outdoor air temperatures?
Do we need periodical analyses of fluoride concentrations in infant formula, bottled water, and infant foods?
Do we need to validate biomarkers of exposure to fluoride?
What is the effect of different types of exercise on the metabolism of fluoride?
What is the relationship between gene polymorphisms and enamel fluorosis?
What is the relationship between malnutrition and enamel fluorosis?
Is supplementation with calcium helpful to reduce enamel fluorosis?
What are the pre-eruptive effects of fluoride on caries progression into dentin?
What is the efficacy of low-fluoride toothpastes whose formulations have been modified to increase the anticaries efficacy?
These reviews, as well as summary of the discussion during the symposium, are included in this issue of Advances in Dental Research, an e-supplement to the Journal of Dental Research.

Monday, February 19, 2018

Lack of guidance may delay a child's first trip to the dentist

IMAGE: What age kids should start dentist visits? view more 

Credit: C.S. Mott Children's Hospital National Poll on Children's Health.
Without a doctor or dentist's guidance, some parents don't follow national recommendations for early dental care for their children, a new national poll finds.

One in 6 parents who did not receive advice from a health care provider believed children should delay dentist visits until age 4 or older - years later than what experts recommend - according to this month's C.S. Mott Children's Hospital National Poll on Children's Health.

The American Academy of Pediatrics and the American Dental Association both recommend starting dental visits around age one when baby teeth emerge.

"Visiting the dentist at an early age is an essential part of children's health care," says Mott poll co-director Sarah Clark. "These visits are important for the detection and treatment of early childhood tooth decay and also a valuable opportunity to educate parents on key aspects of oral health."

"Our poll finds that when parents get clear guidance from their child's doctor or dentist, they understand the first dental visit should take place at an early age. Without such guidance, some parents turn to family or friends for advice. As recommendations change, they may be hearing outdated information and not getting their kids to the dentist early enough."

The nationally representative poll is based on responses from 790 parents with at least one child aged 0-5.

More than half of parents did not receive guidance from their child's doctor or a dentist about when to start dentist visits. Among parents who were not prompted by a doctor or dentist, only 35 percent believed dentist visits should start when children are a year or younger as is recommended.

Over half of parents (60 percent) reported their child has had a dental visit with most parents (79 percent) believing the dentist visit was worthwhile.

Among the 40 percent of parents whose child has not had a dental visit, common reasons for not going were that the child is not old enough (42 percent), the child's teeth are healthy (25 percent), and the child would be scared of the dentist (15 percent).

Experts say starting dental visits early helps set children up for healthy oral hygiene, with parents learning about correct brushing techniques, the importance of limiting sugary drinks, and the need to avoid putting children to bed with a bottle.

Early childhood caries (dental decay in baby teeth) may also be detected at young ages, allowing for treatment of decay to avoid more serious problems. In young children with healthy teeth, dentists may apply fluoride varnish to prevent future decay.

A quarter of parents who had delayed dental visits said their child's teeth are healthy but Clark notes it is unlikely that a parent could detect early tooth decay.

"Parents may not notice decay until there's discoloration, and by then the problem has likely become significant," she says. "Immediate dental treatment at the first sign of decay can prevent more significant dental problems down the road, which is why having regular dentist visits throughout early childhood is so important."

Another factor that may delay dental care is that healthcare recommendations for early childhood are often focused on well-child visits with medical providers, Clark notes.

"Parents hear clear guidelines on when they should begin well-child visits for their child's health and often schedule the first visit before they even bring their baby home from the hospital. Doctors typically prompt parents to stick to a standard schedule for immunizations and other preventive care," she says.

"Parents get much less guidance, however, on when to start taking their child to the dentist, with less than half saying they have received professional advice. This lack of guidance may mean many parents delay the start of dental visits past the recommended age."

Parents with higher income and education, and those with private dental insurance, were more likely to report that a doctor or dentist provided guidance on when to start dental visits.

"Our poll suggests that families who are low-income, less educated, and on Medicaid are less likely to receive professional guidance on dental care. This is particularly problematic because low-income children have higher rates of early childhood tooth decay and would benefit from early dental care," Clark says.

"Providers who care for at-risk populations should dedicate time to focus on the importance of dental visits. Parents should also ask their child's doctor or their own dentist about when to start dentist visits and how to keep their child's teeth healthy."

Tuesday, January 30, 2018

Patient exposure to X-rays depends on how dentists are paid

A major study looking into how financial arrangements with dentists affect what goes on in the dentist's chair has found a marked increase in the number of X-rays when dentists receive payment for them.
The research, reported today in the Journal of Health Economics, examined extensive data from dentists and patients over a 10-year period and found a significant increase in the number of X-rays given to patients when dentists were paid on a 'fee-for-service' basis, where each item of treatment delivered is charged for, compared to when they are on a fixed salary.

The researchers detected the biggest increase in the rates of X-rays when patients were also exempt from charges.

While X-rays are a useful diagnostic tool to allow dentists to examine bones and dental tissues, they also expose patients to potentially harmful radiation. A known carcinogen, X-rays can cause damage to DNA and inhibit the mechanisms cells use to repair themselves.

The authors of the report are calling for a review into how dentists are paid and whether current guidelines go far enough to protect the public.

Co-lead author of the study Professor Martin Chalkley from the Centre for Health Economics at the University of York said: "Our study clearly shows that a potentially harmful treatment is being given in varying quantities according to how dentists are paid for it and we believe this is a genuine cause for concern.

"Dental X-rays deliver a very small dose of radiation, but there are no safe levels - every last bit of radiation is potentially harmful. Each dentist has to weigh up the risks versus the benefits before they take the decision to X-ray and our findings indicate that this calculation is being distorted by financial incentives."

The study examined a uniquely detailed data set gathered between 1998 and 2007 by NHS Scotland on Scottish dentists and their patients. Scotland employs a mixture of 'fee-for-service' and salaried dentists.

This means that some dentists are able to charge separately for each service they provide- a cost that is then normally shared between the patient and the NHS - while other dentists receive a fixed wage regardless of the treatments they provide.

The presence of the two payment methods in Scotland allowed the researchers to compare their effect on dentist's behaviour.

Fee-for-service is a prevalent billing system in dentistry worldwide; Scottish data was used for the study because it is uniquely detailed.

Tracking dentists and patients over a long period of time allowed the researchers to observe the same dentists switching between 'fee-for-service' and salaried payment, as well as patients who changed dentists and moved from co-payment to exemption from charges. This enabled the researchers to isolate payment as the influencing factor on numbers of X-rays, as the trends the study observes can't be explained by varying professional approaches and personality types between dentists or the demands of different patients.

"It could be argued for example that what we have observed is due to the fact that dentists who opt for salaries naturally tend to have more risk averse personalities, but as we were tracking the same dentists switching between payment methods that criticism does not apply to our study.

"Equally we also observed the same patients receiving an increased number of X-rays when they were with a fee-for-service dentist and particularly when they were exempt from charges - perhaps because exempt patients will offer the least resistance and may even welcome additional procedures," added Professor Chalkley.

Co-lead author of the study Professor Stefan Listl said: "While dental X-rays are an important diagnostic tool and are important for some procedures such as root-canal treatment, current regulations and guidelines state that any unnecessary x-ray exposure should be avoided. We can't say whether our study observed excessive X-raying, but we can say that the amount of X-raying differed according to the financial arrangement. "

The researchers suggest that there are a number of deliverable and low-cost reforms that would address the issues their research raises. These would require concerted actions from regulators, funders, and government. For example, improvements to IT and administrative systems could increase sharing of dental records between practices leading to a reduction in the numbers of X-rays at times when patients are more likely to receive one - such as when they first sign up to a new dentist.

Richard Niederman, professor and chair of epidemiology and health promotion at New York University College of Dentistry as well as director of the WHO Collaborating Center for Quality-improvement & Evidence-based Dentistry, added: "Patient safety is always of paramount importance. This study suggests that regulators need to pay careful attention to what clinicians are paid, if safety is to be assured. In addition to health care regulators, dental x-ray guideline developers also need to be cognizant of these financial incentives for doctors and patients. It is morally and ethically unacceptable for financial interests to supersede patient safety."