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New pathogen contributes to severe early childhood caries
Researchers at The Forsyth Institute have made a significant discovery about the nature of childhood dental disease. The scientific studies led by Anne Tanner, BDS, Ph.D., identified a new pathogen connected to severe early childhood caries (cavities). This bacterium, Scardovia wiggsiae, was present in the mouths of children with severe early childhood caries when other known pathogens such as Streptococcus mutans were not detected. This research may offer the potential to intervene and halt the progression of disease.
Early childhood caries, ECC, is the most common chronic infectious disease of childhood in the United States. Severe ECC can destroy primary teeth, cause painful abscesses and is the major reason for hospital visits for young children. This condition disproportionately affects disadvantaged socio-economic groups. This research, which will be published in the April issue of Journal of Clinical Microbiology, provides new insight on the microbiota of severe early childhood caries.
Dental caries is caused by an interaction between bacteria, host susceptibility and a carbohydrate diet that contains large amounts of sugar. Dr. Tanner published an updated evaluation of the diet associated with severe-ECC in collaboration with Dr. Carole Palmer at Tufts University in the Journal of Dental Research in 2010. The bacterial species Streptococcus mutans is widely recognized as the primary pathogen in early childhood caries. However, it is also present in people without disease and is not detected in all cases of childhood caries. This suggests that other species such as S. wiggsiae are also disease causing pathogens.
"In my work, I have seen the tremendous public health impact of severe early childhood caries," said. Dr. Anne Tanner, Senior Member of Staff, Department of Molecular Genetics, The Forsyth Institute.
"Understanding the causes of severe dental decay in young children is the first step in identifying an effective cure."
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Summary of Study
Severe early childhood caries (ECC), while strongly associated with Streptococcus mutans using selective detection methods (culture, PCR), has also been associated with other bacteria using molecular cloning approaches. The aim of this study was to evaluate the microbiota of severe-ECC using anaerobic culture. The microbial composition of dental plaque from 42 severe-ECC children was compared with that of caries-free children. Bacterial samples were cultured anaerobically on blood and acid (pH 5) agars. Isolates were purified, and partial sequences for the 16S rRNA gene were obtained from 5608 isolates. Sequence based analysis of the 16S rRNA isolate libraries from blood and acid agars of severe-ECC and caries-free children had >90% population coverage with greater diversity in the blood isolate library. Isolate sequences were compared with taxa sequences in the Human Oral Microbiome Database (HOMD) and 198 HOMD taxa were identified, including 45 previously uncultivated taxa, 29 extended HOMD taxa and 45 potential novel groups. The major species associated with severe-ECC included Streptococcus mutans, Scardovia wiggsiae, Veillonella parvula, Streptococcus cristatus and Actinomyces gerensceriae. S. wiggsiae was significantly associated with severe-ECC children in the presence and absence of S. mutans. Dr. Tanner and her team conclude that anaerobic culture detected as wide a diversity of species in ECC as observed using cloning approaches. Culture coupled with 16S rRNA identification identified over 74 isolates for human oral taxa without previously cultivated representatives. The major caries-associated species were S. mutans and S. wiggsiae, the latter of which is a candidate as a newly recognized caries pathogen.
This study was conducted with collaborators at the Goldman School of Dental Medicine, Boston University, and Tufts University School of Dental Medicine and with Dr. Floyd Dewhirst and resources of the Human Oral Microbiome Database (HOMD) at Forsyth Institute. HOMD links several types of information on oral microbes to a consistent naming system. HOMD contains descriptions of the microbes, their metabolism, and their ability to cause disease along with information on their DNA and proteins, as well as to the scientific literature.
Monday, February 28, 2011
Tuesday, February 22, 2011
Breaking Down Barriers to Oral Health
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The American Dental Association (ADA) today released the first in a series of papers examining the challenges and solutions to bringing good oral health to the millions of Americans—including as many as one-quarter of the nation’s children—who lack access to dental care, many of them suffering with untreated disease. The paper focuses on workforce, an umbrella term for the numbers, location and makeup of the teams comprising dentists, dental hygienists, dental assistants and other existing and proposed providers.
Breaking Down Barriers to Oral Health for All Americans: The Role of Workforce also emphasizes that workforce changes alone can never overcome the many barriers that prevent too many Americans from attaining good oral health. It warns that focusing on only this one barrier is “the policy equivalent of bailing a leaky boat.” Future ADA papers will address those other barriers, including the tattered public health safety net, and the need to dramatically increase both disease prevention and financing.
The paper disputes the conventional wisdom of a coming shortage of dentists, projecting that later-than-predicted retirement, increased numbers of dental school applicants and the opening of new dental schools will provide an adequate number of dentists through 2030. Instead it argues that the challenges are 1) placing dentists—whether in private practice or government-assisted clinics—in more so-called “underserved areas” that otherwise cannot support a full-time dental practice, and 2) addressing issues that impede securing and keeping dental appointments, such as excessive paperwork, transportation, child care and permission to take time off from work or school.
“We know that the existing delivery model can accommodate millions more people, provided that we address administrative and financing barriers, and workforce distribution,” said ADA President Raymond F. Gist, DDS. “Everyone deserves good oral health, and everyone deserves a dentist.”
Several examples are cited in which states or municipalities have dramatically increased dental services provided to disadvantaged children through a combination of relatively minor funding increases and administrative reforms. They include the children’s dental Medicaid programs in Tennessee, Alabama and Michigan and the creation of a public-private dental clinic in Vermont. The improvements in these programs made it possible for much greater numbers of patients to receive care from the same population of dentists as existed before the reforms occurred.
The paper cautions against a rush to create so-called “midlevel” dental providers who, with as little as 18 months of post-high school training, could be allowed to perform such irreversible/surgical procedures as extracting teeth. Such experiments, it argues, are likely to sap resources better directed toward proven methods for extending the availability of care from fully trained dentists. It does however endorse such workforce innovations as the ADA’s own Community Dental Health Coordinator (CDHC) pilot project. CDHCs follow the highly successful (medical) community health worker model, providing health education and preventive services, identifying patients needing dental care and helping those patients secure and keep appointments with fully trained dentists.
“When all stakeholders—and we are all stakeholders—set aside lesser differences and recognize our aligned purpose, set ambitious yet realistic short- and long-term goals, and pursue those goals with renewed vigor, we can effectively end untreated dental disease in America,” said Dr. Gist.
The American Dental Association (ADA) today released the first in a series of papers examining the challenges and solutions to bringing good oral health to the millions of Americans—including as many as one-quarter of the nation’s children—who lack access to dental care, many of them suffering with untreated disease. The paper focuses on workforce, an umbrella term for the numbers, location and makeup of the teams comprising dentists, dental hygienists, dental assistants and other existing and proposed providers.
Breaking Down Barriers to Oral Health for All Americans: The Role of Workforce also emphasizes that workforce changes alone can never overcome the many barriers that prevent too many Americans from attaining good oral health. It warns that focusing on only this one barrier is “the policy equivalent of bailing a leaky boat.” Future ADA papers will address those other barriers, including the tattered public health safety net, and the need to dramatically increase both disease prevention and financing.
The paper disputes the conventional wisdom of a coming shortage of dentists, projecting that later-than-predicted retirement, increased numbers of dental school applicants and the opening of new dental schools will provide an adequate number of dentists through 2030. Instead it argues that the challenges are 1) placing dentists—whether in private practice or government-assisted clinics—in more so-called “underserved areas” that otherwise cannot support a full-time dental practice, and 2) addressing issues that impede securing and keeping dental appointments, such as excessive paperwork, transportation, child care and permission to take time off from work or school.
“We know that the existing delivery model can accommodate millions more people, provided that we address administrative and financing barriers, and workforce distribution,” said ADA President Raymond F. Gist, DDS. “Everyone deserves good oral health, and everyone deserves a dentist.”
Several examples are cited in which states or municipalities have dramatically increased dental services provided to disadvantaged children through a combination of relatively minor funding increases and administrative reforms. They include the children’s dental Medicaid programs in Tennessee, Alabama and Michigan and the creation of a public-private dental clinic in Vermont. The improvements in these programs made it possible for much greater numbers of patients to receive care from the same population of dentists as existed before the reforms occurred.
The paper cautions against a rush to create so-called “midlevel” dental providers who, with as little as 18 months of post-high school training, could be allowed to perform such irreversible/surgical procedures as extracting teeth. Such experiments, it argues, are likely to sap resources better directed toward proven methods for extending the availability of care from fully trained dentists. It does however endorse such workforce innovations as the ADA’s own Community Dental Health Coordinator (CDHC) pilot project. CDHCs follow the highly successful (medical) community health worker model, providing health education and preventive services, identifying patients needing dental care and helping those patients secure and keep appointments with fully trained dentists.
“When all stakeholders—and we are all stakeholders—set aside lesser differences and recognize our aligned purpose, set ambitious yet realistic short- and long-term goals, and pursue those goals with renewed vigor, we can effectively end untreated dental disease in America,” said Dr. Gist.
Monday, February 14, 2011
Commonly prescribed osteoporosis drug associated with very low risk of serious jaw disease
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A commonly prescribed osteoporosis drug is associated with a slightly elevated risk of developing the rare, but serious condition, osteonecrosis of the jaw; nonetheless the risk remains extremely low. These findings are published online in the Journal of Dental Research, the official journal of the International and American Associations for Dental Research. Although the findings are provocative, study authors say they should be carefully considered against the large benefit of these drugs to prevent and treat osteoporosis.
The study was funded by the National Institutes of Health and conducted by researchers from the Kaiser Permanente Center for Health Research and HealthPartners Research Foundation. The study examined medical records from nearly 600,000 patients and is part of the Dental Practice-Based Research Network — a consortium of participating practices and dental organizations committed to advancing knowledge of dental practice and ways to improve it.
"Oral bisphosphonates, usually prescribed for osteoporosis patients, appear to increase the risk of osteonecrosis of the jaw, but the risk is still very low," said the paper's lead author, Jeffrey Fellows, PhD, an investigator with the Kaiser Permanente Center for Health Research. "Previous studies suggested that about one percent of oral bisphosphonate users may develop osteonecrosis of the jaw, but our study found a much lower rate, less than one-tenth of one percent. The risk is still real and patients should take necessary precautions, but they shouldn't be alarmed."
"These drugs are very helpful in treating osteoporosis and preventing fractures so for the large majority of patients the benefits of taking them far outweigh the small risk found in this study," says Michael Herson, MD, Chief of Endocrinology and Metabolism, Northwest Permanente Medical Group, which was not involved in the study. "If patients have questions about taking these drugs they should consult with their physicians."
Osteonecrosis of the jaw is difficult to treat and occurs when blood flow to the bone is reduced, leaving an area of the jaw bone exposed for longer than 6-8 weeks. Most cases have been reported in cancer patients taking intravenous bisphosphonates; the risk associated with oral bisphosphonates is less clear. This study attempts to quantify that risk in a large, defined population. It is important to establish what the risk is because bisphosphonates are widely prescribed to osteoporosis patients. According to a 2009 paper in the American Journal of Health-System Pharmacy, 4.7 million Americans are taking oral bisphosphonates.
The new paper published in the Journal of Dental Research examined electronic medical records of 572,606 patients from 1995 to 2006. Researchers found 23 cases of osteonecrosis of the jaw, most among patients who were not taking oral bisphosphonates, but had other risk factors including cancer, head and neck radiation therapy, and osteoporosis.
Nearly 4 percent of the patients, or 21,164 people, were prescribed oral bisphosphonates, but only six of those patients, or about one in 3,500, developed osteonecrosis of the jaw. Patients taking oral bisphosphonates were nine times more likely than those who didn't to develop the condition.
"Invasive dental procedures may also increase the risk of osteonecrosis of the jaw, so patients who need those procedures may want to get them before starting on oral bisphosphonates," said Dr. Daniel Pihlstrom, a co-author on the study and associate director for Evidence Based Care and Oral Health Research at Permanente Dental Associates. "Patients who are already taking these drugs don't need to stop in order to get dental care, but if they need an invasive dental procedure they should inform their dentist or oral surgeon that they are taking the drugs," added Pihlstrom.
The authors caution that their confidence in the association between oral bisphosphonates and osteonecrosis of the jaw is limited because they found so few cases. The small number of cases also limited their ability to control for other risk factors. Also, since osteonecrosis of the jaw did not have a diagnosis code before 2007, the authors used a computer program to search medical records for any diagnosis, procedure, or physician chart note that could indicate a possible case. Manual chart review was used to confirm osteonecrosis of the jaw among patients identified by the computer. Some additional cases were found through conversations with general dentists and oral surgeons serving patients from each health care organization. While the search was extensive, there is a chance that some cases were missed.
A commonly prescribed osteoporosis drug is associated with a slightly elevated risk of developing the rare, but serious condition, osteonecrosis of the jaw; nonetheless the risk remains extremely low. These findings are published online in the Journal of Dental Research, the official journal of the International and American Associations for Dental Research. Although the findings are provocative, study authors say they should be carefully considered against the large benefit of these drugs to prevent and treat osteoporosis.
The study was funded by the National Institutes of Health and conducted by researchers from the Kaiser Permanente Center for Health Research and HealthPartners Research Foundation. The study examined medical records from nearly 600,000 patients and is part of the Dental Practice-Based Research Network — a consortium of participating practices and dental organizations committed to advancing knowledge of dental practice and ways to improve it.
"Oral bisphosphonates, usually prescribed for osteoporosis patients, appear to increase the risk of osteonecrosis of the jaw, but the risk is still very low," said the paper's lead author, Jeffrey Fellows, PhD, an investigator with the Kaiser Permanente Center for Health Research. "Previous studies suggested that about one percent of oral bisphosphonate users may develop osteonecrosis of the jaw, but our study found a much lower rate, less than one-tenth of one percent. The risk is still real and patients should take necessary precautions, but they shouldn't be alarmed."
"These drugs are very helpful in treating osteoporosis and preventing fractures so for the large majority of patients the benefits of taking them far outweigh the small risk found in this study," says Michael Herson, MD, Chief of Endocrinology and Metabolism, Northwest Permanente Medical Group, which was not involved in the study. "If patients have questions about taking these drugs they should consult with their physicians."
Osteonecrosis of the jaw is difficult to treat and occurs when blood flow to the bone is reduced, leaving an area of the jaw bone exposed for longer than 6-8 weeks. Most cases have been reported in cancer patients taking intravenous bisphosphonates; the risk associated with oral bisphosphonates is less clear. This study attempts to quantify that risk in a large, defined population. It is important to establish what the risk is because bisphosphonates are widely prescribed to osteoporosis patients. According to a 2009 paper in the American Journal of Health-System Pharmacy, 4.7 million Americans are taking oral bisphosphonates.
The new paper published in the Journal of Dental Research examined electronic medical records of 572,606 patients from 1995 to 2006. Researchers found 23 cases of osteonecrosis of the jaw, most among patients who were not taking oral bisphosphonates, but had other risk factors including cancer, head and neck radiation therapy, and osteoporosis.
Nearly 4 percent of the patients, or 21,164 people, were prescribed oral bisphosphonates, but only six of those patients, or about one in 3,500, developed osteonecrosis of the jaw. Patients taking oral bisphosphonates were nine times more likely than those who didn't to develop the condition.
"Invasive dental procedures may also increase the risk of osteonecrosis of the jaw, so patients who need those procedures may want to get them before starting on oral bisphosphonates," said Dr. Daniel Pihlstrom, a co-author on the study and associate director for Evidence Based Care and Oral Health Research at Permanente Dental Associates. "Patients who are already taking these drugs don't need to stop in order to get dental care, but if they need an invasive dental procedure they should inform their dentist or oral surgeon that they are taking the drugs," added Pihlstrom.
The authors caution that their confidence in the association between oral bisphosphonates and osteonecrosis of the jaw is limited because they found so few cases. The small number of cases also limited their ability to control for other risk factors. Also, since osteonecrosis of the jaw did not have a diagnosis code before 2007, the authors used a computer program to search medical records for any diagnosis, procedure, or physician chart note that could indicate a possible case. Manual chart review was used to confirm osteonecrosis of the jaw among patients identified by the computer. Some additional cases were found through conversations with general dentists and oral surgeons serving patients from each health care organization. While the search was extensive, there is a chance that some cases were missed.
Thursday, February 3, 2011
Dental Coverage Pays Off in Long Run for Older Americans
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Older Americans could likely have lower overall dental expenses with preventive dental care and more routine dental visits, as indicated by a new study of public records of Medicare beneficiaries, says John Moeller, PhD, MA, research professor at the University of Maryland Dental School.
Moeller and colleagues in the School's Health Services Research Division conducted a uniquely comprehensive analysis of a sample of 10,582 representatives of the nearly 34 million Medicare beneficiaries in community-based homes.
Private insurance records are generally not available for such a national study, says Moeller. But researchers say the Medicare records are frequently reliable as indicative of national trends.
The Dental School study published in the American Journal of Public Health showed that Medicare beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems.
"For many retirees, paying for dental care treatment can be difficult," says Moeller. "Without assistance, older Americans who are poorer may choose to delay or forgo dental care, but postponing dental care may lead to expensive complications."
He recommends that adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.
Moeller and colleagues Haiyan Chen, MD, PhD, research assistant professor, and Richard Manski, DDS, PhD, MBA, professor, conducted the study because younger people have primarily been the focus of previous studies of the impact of preventive dental care visits. "We felt that insufficient attention has been paid to the possibility that preventive dental care may limit expensive nonpreventive dental care procedures among an older population," the team wrote.
To fill the information gap, the team identified characteristics of older adults who used preventive and nonpreventive dental care as well as those who used no dental care at all, using data from the Medicare Current Beneficiary Survey. MCBS is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries.
MCBS, sponsored by the Centers for Medicare Medicaid Services, is the only comprehensive source of information on the health status, health care use, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries._
Older Americans could likely have lower overall dental expenses with preventive dental care and more routine dental visits, as indicated by a new study of public records of Medicare beneficiaries, says John Moeller, PhD, MA, research professor at the University of Maryland Dental School.
Moeller and colleagues in the School's Health Services Research Division conducted a uniquely comprehensive analysis of a sample of 10,582 representatives of the nearly 34 million Medicare beneficiaries in community-based homes.
Private insurance records are generally not available for such a national study, says Moeller. But researchers say the Medicare records are frequently reliable as indicative of national trends.
The Dental School study published in the American Journal of Public Health showed that Medicare beneficiaries who used preventive dental care had more dental visits but fewer visits for expensive nonpreventive procedures and lower dental expenses than beneficiaries who saw the dentist only for treatment of oral problems.
"For many retirees, paying for dental care treatment can be difficult," says Moeller. "Without assistance, older Americans who are poorer may choose to delay or forgo dental care, but postponing dental care may lead to expensive complications."
He recommends that adding dental coverage for preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and limiting the costs of expensive nonpreventive dental care for the dentate beneficiary population.
Moeller and colleagues Haiyan Chen, MD, PhD, research assistant professor, and Richard Manski, DDS, PhD, MBA, professor, conducted the study because younger people have primarily been the focus of previous studies of the impact of preventive dental care visits. "We felt that insufficient attention has been paid to the possibility that preventive dental care may limit expensive nonpreventive dental care procedures among an older population," the team wrote.
To fill the information gap, the team identified characteristics of older adults who used preventive and nonpreventive dental care as well as those who used no dental care at all, using data from the Medicare Current Beneficiary Survey. MCBS is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries.
MCBS, sponsored by the Centers for Medicare Medicaid Services, is the only comprehensive source of information on the health status, health care use, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries._
Wednesday, February 2, 2011
Dental Implants Can be Successful with Less Root than Crown
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Dental implants are now a common way to replace a tooth. But a dentist must first determine that an implant restoration can be successful for a particular patient. As an indicator, dentists use the crown-to-root ratio—how much of the tooth extends above the jawbone and how much is in the bone. However, the ideal crown-to-implant ratio for the replacement tooth has yet to be determined.
A new study in the current issue of the Journal of Oral Implantology evaluated the health of implants that had been in place more than 5 years. By examining the crown-to-implant ratios in these cases, the authors found that this factor was not as important to the success of implants as previously thought.
Radiographs were used to examine 309 single-tooth short-length implant-supported restorations in 194 patients. All the implants had been surgically placed between February 1997 and December 2005.
The ideal crown-to-root ratio for a tooth to serve as an abutment for a partial denture is considered 1 to 2—twice as much root as crown. But previous studies have given mixed results about ratios for implanted teeth. Excessive crown-to-implant ratios have been named as detrimental to long-term survival of an implant, while disproportionate ratios have been noted in high rates of implant survival.
The current study found an average crown-to-implant ratio of 2 to 1. Natural teeth with such ratios would often be recommended for extraction and replacement. The authors found that stable implants could be produced with less of the tooth serving as root. Additionally, the study found no statistically significant relationship between increasing crown-to-implant ratios and decreasing bone-to-implant contact levels around the implant.
Full text of the article, “Crown-to-Implant Ratios of Short-Length Implants,” Journal of Oral Implantology, Vol. 36, No. 6, 2010, is available at http://www2.allenpress.com/pdf/orim-36-06-425-433.pdf.
Dental implants are now a common way to replace a tooth. But a dentist must first determine that an implant restoration can be successful for a particular patient. As an indicator, dentists use the crown-to-root ratio—how much of the tooth extends above the jawbone and how much is in the bone. However, the ideal crown-to-implant ratio for the replacement tooth has yet to be determined.
A new study in the current issue of the Journal of Oral Implantology evaluated the health of implants that had been in place more than 5 years. By examining the crown-to-implant ratios in these cases, the authors found that this factor was not as important to the success of implants as previously thought.
Radiographs were used to examine 309 single-tooth short-length implant-supported restorations in 194 patients. All the implants had been surgically placed between February 1997 and December 2005.
The ideal crown-to-root ratio for a tooth to serve as an abutment for a partial denture is considered 1 to 2—twice as much root as crown. But previous studies have given mixed results about ratios for implanted teeth. Excessive crown-to-implant ratios have been named as detrimental to long-term survival of an implant, while disproportionate ratios have been noted in high rates of implant survival.
The current study found an average crown-to-implant ratio of 2 to 1. Natural teeth with such ratios would often be recommended for extraction and replacement. The authors found that stable implants could be produced with less of the tooth serving as root. Additionally, the study found no statistically significant relationship between increasing crown-to-implant ratios and decreasing bone-to-implant contact levels around the implant.
Full text of the article, “Crown-to-Implant Ratios of Short-Length Implants,” Journal of Oral Implantology, Vol. 36, No. 6, 2010, is available at http://www2.allenpress.com/pdf/orim-36-06-425-433.pdf.
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