Monday, July 21, 2008

A virtual toothache helps student dentists

Masha is a dental patient. Her oral health problems continue to change as she meets new Case Western Reserve University student dentists in Second Life's virtual dental office.

The middle-aged avatar is an integral part of a new research project of the Case Western Reserve University School of Dental Medicine and the College of Arts and Sciences department of communication sciences to teach and give students practice time to communicate with mock patients.

Not only do findings from the study have potential to revolutionize dental education but also to change the way national testing is done for patient-side communication skills.

Kristin Z. Victoroff from the dental medicine's department of community dentistry will direct the three-year Innovative Dental Assessment Research and Development (IDEA) Grant project from the American Dental Association's Joint Commission on National Dental Examinations. She will develop patient communication scenarios for simulated education and test their effectiveness in preclinical training for students.

"More dental schools are experimenting with simulation as a way to teach," said Victoroff. She is joined in the research project by Roma Jasinevicius and Catherine Demko from the dental school faculty in testing and implementing simulations in dental education at the university.

Since 2001, the Case Western Reserve dental school has been on the forefront in using simulations in teaching the physical dexterity skills by using a technology called DentSim ( DentSim is a simulated and computerized training system that uses a simulated dental patient. The school's use of the technology in dental education was spearheaded by Jasinevicius.

From that technology, the attention turned to developing what Victoroff's describes simulated experiences for the "softer" skills of dental medicine—communicating with patients.

Victoroff enlisted virtual reality experts and Art and Sciences' communication disorder scientists Stacy Williams, who directs the Virtual Immersion Center for Simulation Research (VICSR), and Kyra Rothenberg, director of the health communications minor.

They will take three approaches to simulated communications training—live actors, the immersion theater where students interact with a virtual patient in a 180-degree surround theater and with avatars, like Masha, in Second Life.

Of the three simulation methods, Victoroff is interested in using the immersion theater and Second Life. She noted that paper-based, live actors and real patients present limitations from ethical issues to logistical challenges. Meanwhile, the interactive theater and Second Life have capabilities to assess competencies in a convenient, standardized and cost-effective situation.

According to Victoroff, if successful, the virtual scenarios in an immersion theater setting or the online Second Life community might provide a potentially better way of assessing a student's abilities to communicate with patients than the current multiple-choice questions on the national examinations required for practicing professionally.

During spring semester, 70 students in the third-year dental class participated in a pilot study to develop their communication skills with live actors and virtual patients during communication skills training at the Mt. Sinai Skills and Simulation Center at the Veterans Administration Hospital.

The research project focuses on developing scenarios that aid and test students in taking patient histories, providing oral health education like tobacco cessation counseling for smokers, explaining procedures, talking about healthcare options and obtaining informed consent, and working through situations that present ethical dilemmas. These are among the competencies outlined by the American Dental Education Association.

Along with communication sciences students, the use of the virtual reality theater by dental students will advance the researchers understanding in how this technology can be applied to teaching and assessing students in different disciplines. The dental students will use a portable 50-inch LCD panel instead of the larger fixed 180-degree theater. In real time, the students interact and communicate with Masha.

"Ideally it is not that we are out to prove that virtual worlds or the VICSR system is better than standard instruction, but that they are of equal value," said Williams, adding that students should be able to walk away learning the same types of knowledge they can learn from working with live patients.

Students are very accepting of the VICR environment and put a lot of reflection in their voices when they are talking to the animated characters, said Williams.

Rothenberg will piece together students' motivations and perceptions when using this technology for their education.

According to Rothenberg who works in health communications, VICSR is already showing positive results from communication science students and patients using the virtual theater for their education and speech therapy.

"Virtual patients have much to offer in training healthcare providers, and it is equally important to explore how interactive virtual reality technology can enhance assessment of competency," said Victoroff.

Tuesday, July 15, 2008

New, Improved 'OralLongevity' Web Site;

American Dental Association Launches New, Improved 'OralLongevity' Web Site; Refreshed Site Features New Content, Updated Design for Older Adult's Oral Health Care

The OralLongevity(tm) section of the American Dental Association (ADA) web site has received a "face-lift."

Retaining its domain at , the refreshed site features an updated design, enhanced navigation and new content for the initiative that helps increase awareness about the importance of older Americans maintaining good oral health for a lifetime.

To create a user-friendly online experience and a more effective mechanism for distributing oral health messages to key audiences, the site is arranged in three distinct sections:

- OralLongevity landing page with an overview of the program objectives and information tools

- Resources for dental professionals to raise awareness of the special oral needs of an aging population

- Resources for consumers to empower seniors to take control of their oral health

For easy navigation, a link to the OralLongevity brochure and DVD appears on each page, along with anchor tags that jump directly into a specific topic within the section.

In addition, the web site offers presentation materials to assist dentists in educating other health professionals, older adult patients and caregivers about the importance of oral health. These online resources can be used in the dental office or in the community. New and expanded materials that may be downloaded and duplicated directly from the web site include:

- Commonly asked questions and answers for patients

- Program outlines for presenting the DVD to health professionals, patients or caregivers

- Post-test for consumers

- Sample press release to publicize your OralLongevity outreach activity

- Clinical articles from JADA and other dental publications

In the Consumer Resources section, visitors will find tips for taking care of their teeth, pointers on making the most of visiting the dentist, and a discussion of the connection between oral health and overall health. A reference list of articles on various oral health topics is provided for those seeking more in-depth information. A link to "Find an ADA Member Dentist" also can be found here.

About OralLongevity(tm)

OralLongevity(tm) is a cooperative initiative between the American Dental Association (ADA), the ADA Foundation (ADAF) and GlaxoSmithKline Consumer Healthcare (GSKCH). The OralLongevity initiative was designed to support dental professionals in enhancing and preserving the oral health of older Americans

About the American Dental Association

The not-for-profit ADA is the nation's largest dental association, representing more than 156,000 dentist members. The premier source of oral health information, the ADA has advocated for the public's health and promoted the art and science of dentistry since 1859. The ADA's state-of-the-art research facilities develop and test dental products and materials that have advanced the practice of dentistry and made the patient experience more positive. The ADA Seal of Acceptance long has been a valuable and respected guide to consumer dental care products. JADA, a monthly journal, is the ADA's flagship publication and the best-read scientific journal in dentistry. For more information about the ADA, visit the Association's Web site at .

Thursday, July 10, 2008

Oral Health Care Model in Rural Alaska Villages

Evaluation to Measure Effectiveness of Oral Health Care Model in Rural Alaska Native Villages; Communities Involved in Project Experience Nation's Highest Rate of Oral Health Disease

A model oral health program serving isolated Alaska Native communities is being evaluated for effectiveness with a goal of improving the quality of services to children and families vulnerable to some of the highest levels of measured oral health disease in the country.

Supported through a partnership of four foundations, the comprehensive evaluation will be conducted by RTI International of Research Triangle Park, North Carolina - a nonprofit research institute that provides research and technical services to governments and businesses worldwide. The two-year study offers an opportunity to determine the quality of service provided by the Alaska Native Tribal Health Consortium's Dental Health Aide Therapist Program.

"If the evaluation proves the viability of the dental health aide therapist model, the program has the potential to have the same impact on rural Alaska as the tuberculosis eradication program did in the 1940s and 1950s," said Jerry Drake, executive director of the Bethel Community Services Foundation, located in Bethel, Alaska.

Research will be guided by a National Advisory Committee and an Alaska Tribal Advisory Coordinating Committee - with members ranging from professional dentists to Alaska Native community members. The aim is to fully examine the program and its effectiveness, while assuring that cultural aspects of evaluation are done with respect, and within tribal tradition and custom.

Funding for the evaluation is being provided by the W.K. Kellogg Foundation of Battle Creek, Michigan, in partnership with the Rasmuson Foundation of Anchorage, Alaska; the Bethel Community Services Foundation Inc. of Bethel, Alaska; and the M.J. Murdock Charitable Trust of Vancouver, Washington.

"Through this research, we hope to establish a long-term process for continuous quality improvement to ensure that the best possible dental care is provided to Alaska Native patients in the state's more remote communities," said Al Yee, a Kellogg Foundation program director.

There are more than 200 Native villages in Alaska, many located in extremely remote sections of the state. Transportation is difficult and expensive, and health care services are often sparse and inconsistent. Most Alaska villages receive the services of a dentist for a week a year and often only the most urgent cases are seen.

According to the 1999 Indian Health Service Survey, the Alaska Native population has a high rate of oral disease. For example, children 2 to 5 years of age have almost five times the amount of tooth decay as do children of similar ages elsewhere in the United States. Children ages 6 to 14 have 4.5 times the amount of tooth decay and adult periodontal disease is 2.5 times higher than in the general population.

"Contributing to these unacceptable oral health statistics is the inability to recruit and retain an adequate dental health workforce in this isolated part of the country," said Yee.

"The Kellogg Foundation has a special interest in helping vulnerable children and their families succeed," said Sterling Speirn, the Kellogg Foundation's president and chief executive officer. "That's our primary organizational mission, so it's natural we would be interested in supporting programs such as this."

"Rasmuson Foundation has been unwavering in its support of improving oral health care access and outcomes in rural Alaska villages," said Diane Kaplan, Rasmuson Foundation president. "We are delighted that our partnership can have such far reaching benefits for Alaska."

Scott Wetterhall of RTI International, project director for the evaluation, said that the researchers will evaluate the implementation of the Dental Health Aide Therapist Program in communities where they work to assess its integrity to the overall program model, and identify barriers and facilitators for longer-term success.

"Among other things, we will look at patient access to care and the level of patient satisfaction from using dental therapists," Wetterhall said. "We'll also look at the quality of diagnosis and treatment, the development of community-based prevention programs and the general practice procedures used by the therapists."

In addition, he said, evaluators will examine the costs and explore the cost-effectiveness of the dental therapist program in Alaska. "Our overall approach to this evaluation will be participatory, transparent and thorough," Wetterhall said.

A final report of the results from this evaluation will be available in 2010.

About the Dental Health Aide Therapist Workforce Model

The Kellogg Foundation funds the Dental Health Aide Therapist training program through the Alaska Native Tribal Health Consortium, which is partnering with the University of Washington. Support is provided through a $2.7 million grant to the Alaska Native Tribal Health Consortium, along with additional funding of more than $1 million from the partner foundations.

The program trains mid-level oral health providers who live and work in the rural communities to provide prevention services, perform fillings, extractions and other limited dental services for children. It is based on a model program that was begun in New Zealand during the 1920s. The Alaska Native Tribal Health Consortium is currently working with the University of Washington to train approximately 24 dental health aid therapists from Alaska during a four-year period. Once trained, these therapists will work under the supervision of dentists who oversee the services in villages throughout the state.

"This model has succeeded in more than 40 countries," said Yee, "and holds great promise for improving dental access to underserved communities in Alaska."

Partners for the Evaluation

Bethel Community Services Foundation Inc. of Bethel, Alaska, is dedicated to the development, growth, continuance and enhancement of community based programs and services. In partnership with other communal institutions, foundations, restricted and unrestricted philanthropic donors, it seeks to support effective community growth and development. The Foundation was created in 1992 to manage the assets of, and contribute financial support for, the program of services offered through Bethel Community Services (BCS). BCS was founded in 1969 and introduced many human service programs to the Bethel community and the region. Visit .

The M. J. Murdock Charitable Trust seeks to enrich the quality of life in the Pacific Northwest by providing grants and enrichment programs to non-profit organizations that seek to strengthen the region's educational, spiritual, and cultural base in creative and sustainable ways. Since its establishment on June 30, 1975, the Trust has focused most of its grantmaking efforts in the five states of the Pacific Northwest: Alaska, Idaho, Montana, Oregon, and Washington. A historical emphasis in grantmaking has been in higher education, scientific research and development, human social services, health care, and the arts. Visit .

The Rasmuson Foundation of Anchorage, Alaska, is a private foundation that works as a catalyst to promote a better life for Alaskans. Since its founding and first grant of $125 in 1955, the Rasmuson Foundation has supported Alaskan non-profit organizations in the pursuit of their goals, with particular emphasis on organizations that demonstrate strong leadership, clarity of purpose, and cautious use of resources. The vision and values established by Elmer Rasmuson continue to guide the Foundation today. The Foundation awards approximately $20 million annually to help improve the quality of life in Alaska. Visit .

Established in 1930, the W.K. Kellogg Foundation of Battle Creek, Michigan, supports children, families and communities as they strengthen and create conditions that propel vulnerable children to achieve success as individuals and as contributors to the larger community and society. Grants are concentrated in the United States, Latin America and the Caribbean, and the southern African countries of Botswana, Lesotho, Malawi, Mozambique, South Africa, Swaziland and Zimbabwe. Visit .

RTI International is one of the world's leading research institutes, dedicated to improving the human condition by turning knowledge into practice. A staff of more than 2,600 provides research and technical services to governments and businesses worldwide in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy, and the environment. RTI also employs about 1,200 term employees who support projects in more than 40 countries. Visit .

The Alaska Native Tribal Health Consortium is a non-profit health organization owned and managed by Alaska Native tribal governments and their regional health organizations. The Consortium was created in 1997 to provide statewide Native health services. To achieve its goals, ANTHC works closely with tribes, Native health organizations, the state of Alaska, and municipalities. Visit .

Wednesday, July 9, 2008


When it comes to the attractiveness of orthodontic braces, less metal is better, according to a recent survey.

The study of the public’s attitude about the attractiveness of various styles of braces indicates that the types of dental appliances with no visible metal were considered the most attractive. Braces that combine clear ceramic brackets with thin metal or clear wires were a less desirable option, and braces with metal brackets and metal wires were rated as the least aesthetic combination.

“The paradox is that the more aesthetic these dental appliances are, the more difficult they are to manage for the orthodontist,” said senior study author Henry Fields, professor and division chair of orthodontics at Ohio State University. “But those are what people like the most.”

The survey did not ask respondents about the attractiveness of decorative and colorful elastic modules that attach the wires to the braces, which have become popular among some teen-agers in the past few years.

The study findings were published in a recent issue of the American Journal of Orthodontics and Dentofacial Orthopedics.

Fields and colleagues questioned 200 adults using a computer-based survey that presented standardized images of teeth with a variety of orthodontic appliances. The images did not show the patients’ faces, so the attractiveness of the person wearing the appliances was not a factor.

Respondents were asked to rate the appliances using a range from “extremely unattractive” to “extremely attractive” on a scale of 1 to 100.

The responses fell into three clear categories, Fields said. The stainless steel appliances were considered the least attractive, with average ratings hovering between about 25 and 40 on the 100-point scale. Ceramic appliances, which are often clear or tooth-colored and less visible than metal, received average ratings of between about 55 and 70 on the scale. Ceramic brackets with clear or white wires were considered more attractive than ceramic brackets with metal wires. Clear tooth trays and teeth with no visible appliances ranked as the most attractive, with the average of most scores exceeding 90. Appliances called lingual braces are invisible because they are applied behind the teeth, creating the appearance of appliance-free teeth.

The researchers collected demographic information on the adult respondents, but any differences in demographic influences were insignificant in the overall analysis.

“The general trends of appliance attractiveness are universal,” Fields said. “The stainless steel that we like to use, which is the most durable and efficient, is often ranked the lowest in attractiveness. These braces don’t wear out and you can get total control with them.

“The most aesthetic ones, the trays, have limitations on the types of movements you can make and forces you can deliver, and the efficiency. And the ceramics sometimes have breakage problems, and they tend to just be a little bit more delicate.”

Standard braces consist of metal or ceramic brackets that are cemented to each tooth. A metal wire is laced through each bracket to exert force on the teeth to correct their placement. Braces are used to tip teeth in one direction or another, to rotate one or several teeth, or to shift the location of a tooth forward, backward, sideways, up or down in the mouth. Each kind of correction requires specific manipulation of the wires in the brackets, and some require specially shaped wires to perform the task. Fields said the ideal is to move teeth about 1 millimeter, a little less than the thickness of a dime, every four weeks.

The clear tray appliances reposition multiple teeth in tiny increments of about a quarter of a millimeter every two weeks, he said. Patients receive an assortment of trays that they change every two weeks. They wear the trays all day and night, removing them to eat and brush their teeth.

Adults make up about one in four patients being fitted with braces, Fields said. And adults may be more concerned about aesthetics of braces than are adolescents, who, if they require braces, typically get them between the ages of 10 and 13.

Fields said some kids tend to go a different route, thinking of their braces as accessories that should be enhanced rather than hidden.

“Some of the kids are going for braces made in the shape of a star, or have colors put on the ties that hold the wires to their brackets,” he said. “Some people are decorating their braces.”

He and colleagues are also exploring attitudes about how much patients are willing to pay for more expensive dental appliances. The more aesthetically pleasing options often are more costly, as well. The group’s data suggest that adults are willing to pay several hundred dollars extra for more attractive appliances for themselves or their children.

Monday, July 7, 2008

Mother's vitamin D status = baby's dental health

Low maternal vitamin D levels during pregnancy may affect primary tooth calcification, leading to enamel defects, which are a risk factor for early-childhood tooth decay. Today, during the 86th General Session of the International Association for Dental Research, investigators from the University of Manitoba (Winnipeg and Victoria) present the results of a study they conducted to determine the vitamin D status of pregnant women, the incidence of enamel defects and early-childhood tooth decay among their infants, and the relationship with pre-natal vitamin D levels.

Two hundred six pregnant women in their second trimester participated in the study. Only 21 women (10.5%) were found to have adequate vitamin D levels. Vitamin D concentrations were related to the frequency of milk consumption and pre-natal vitamin use. The investigators examined 135 infants (55.6% male) at 16.1 ± 7.4 months of age, and found that 21.6% of them had enamel defects, while 33.6% had early-childhood tooth decay. Mothers of children with enamel defects had lower, but not significantly different, mean vitamin D concentrations during pregnancy than those of children without defects.

However, mothers of children with early-childhood tooth decay had significantly lower vitamin D levels than those whose children were cavity-free. Infants with enamel defects were significantly more likely to have early-childhood tooth decay.

This is the first study to show that maternal vitamin D levels may have an influence on primary teeth and the development of early-childhood tooth decay.

Dental referrals by primary care physicians

How effective are dental referrals by primary care physicians?

Young children from low-income families experience high levels of tooth decay and face many barriers to getting dental treatment and preventive services. Because these children usually visit their pediatrician or other primary care provider far more frequently than a dentist, the primary care medical setting is gaining popularity as a place to provide preventive dental services. Currently, physicians in more than 400 pediatric primary care offices in North Carolina (NC) have been trained to screen for tooth decay, so that referrals for those in need can be made to dentists. This effort is part of a preventive dental program known as "Into the Mouths of Babes" (IMB).

In a study undertaken by investigators at the University of North Carolina at Chapel Hill and Duke University, researchers examined factors that lead to dental referrals by physicians and whether these referrals result in dental office visits for children who received IMB services. The study used information from Medicaid reimbursement claims for IMB services provided during 2001 and 2002 and patient records completed by physicians for 24,403 children. The patient records provide information on the child's tooth decay experience, results of a dental risk assessment, and whether the child was referred to a dentist.

The investigators report their results today during the 86th General Session of the International Association for Dental Research. Of the 24,403 children in the study, about 5% had tooth decay, 2.8% were referred to a dentist, and 3.5% made a dental visit before 42 months of age. Among children with tooth decay, 32% were referred, and a higher percentage of children with a referral visited a dentist (35.6%) than those not referred (12.0%). Several factors were associated with whether a child received a referral to a dentist besides the presence of any decayed teeth, including increasing age of child, the availability of a general dentist in the county where the child received IMB services, and whether the child was seen in a practice located in a rural area.

In a second analysis, child tooth decay, a referral, increasing age of child, availability of a general dentist in the county, and having a dental visit prior to the first IMB visit were related to shorter time intervals between the referral and a dental visit.

The authors concluded that referrals by physicians increased access to dentists for children with tooth decay, but use of dentist services for those needing care remained low.

Novel hydrogel systems for dentin regeneration

Dental caries, or tooth decay, continues to be the most prevalent infectious disease in the world, presenting significant public health challenges and socio-economic consequences. It leads to the loss of the hard tissues of the tooth, followed by inflammation and necrosis of the subjacent dental pulp. In the U.S. alone, over 20 million dental restorations are placed each year, with failure rates of up to 60%. Hence, there exists a critical need for better biologic therapeutics to restore the damaged dentin-pulp complex to its original form and function. However, progress in this area has been slow compared with that in other fields of regenerative medicine.

Tissue-engineering strategies directed at mimicking the natural extracellular matrix have utilized synthetic and non-synthetic scaffolds to direct cell differentiation and matrix mineralization (in the case of bone). The most promising among the new generation of delivery systems are synthetic peptide hydrogels, which provide a nanostructured matrix highly similar to natural matrix. Short peptides can be designed to self-assemble into nanofibers, form macroscopic gels, and entrap living cells. With single amino acids as building blocks, the resulting materials are non-toxic, non-inflammatory, and biodegradable. The modular concept allows for high control over the system and, at the same time, makes it extremely versatile.

Speaking today during the 86th General Session of the International Association for Dental Research, a team of investigators from Baylor College of Dentistry (Dallas), the University of Regensburg (Germany), and Rice University (Houston) presents its preliminary data describing the results of studies on hydrogels made of peptide amphiphiles, where a short peptide sequence is attached to a fatty acid, which provides the driving force for self-assembly. However, they recently applied a different design concept, where the self-assembly of peptide chains is achieved without attaching a hydrophobic tail. Based on their design, the chains can include bioactive peptide sequences for cell adhesion, binding of growth factors, or other biological molecules with therapeutic potential. Hence, multidomain peptide hydrogels represent a novel and highly versatile material offering a higher degree of control over nanofiber architecture and better chemical functionality.

The overarching goal of this research is to utilize these multidomain peptides as a biomimetic scaffold, along with dental stem cell therapy, to provide a natural 3D environment that can control and direct the differentiation and function of dental stem cells for the targeted regeneration of the dentin-pulp complex.

This work is highly translational and innovative, since it capitalizes on a new and previously untested material with novel properties for the regeneration of the dentin-pulp complex. Importantly, the results will provide the foundation for developing multidomain peptide scaffolds as novel therapeutics for the regeneration of the dentin-pulp complex.

Topical oral syrup prevents early childhood caries

Dental researchers at the University of Washington have reported a significant reduction of tooth decay in toddlers who were treated with the topical syrup xylitol, a naturally occurring non-cavity-causing sweetener. Their results were presented today during the 86th General Session of the International Association for Dental Research.

In a recent clinical trial in the Republic of the Marshall Islands, children 6 to 15 months old were given oral doses of xylitol in fruit-flavored syrup daily to determine whether the substance can prevent early-childhood tooth decay, or "caries".

Researchers reported that nearly 76% of the children in the group who received xylitol were free of tooth decay by the end of the study, compared with 48% of the children in the group that did not receive the substance.

The Marshall Islands in the Pacific were chosen for the study because it is an area where childhood tooth decay is a serious public health problem. The average child entering Head Start at age 5 has 6.8 cavities—two to three times the rate in a typical mainland community. Researchers came from the Northwest/Alaska Center to Reduce Oral Health Disparities and the Department of Dental Public Health Sciences at the University of Washington, Seattle.

Xylitol can be administered in the form of chewing gum, lozenges, or syrup. The U.S. Food and Drug Administration has approved xylitol's use in food since 1963 and classifies the substance as safe.

According to researchers, at the end of the trial nearly 76% of the children in the study group were caries-free, compared with 48% in a comparable group that did not receive treatment.

Xylitol is a five-carbon sugar alcohol that is used as a sugar substitute.