Report details 20 years of advances and challenges of Americans’ oral health

NIH’s new report, Oral Health in America: Advances and Challenges, provides a road map on how to improve the nation’s oral health. NIDCR

Despite important advances in the understanding and treatment of oral diseases and conditions, many people in the U.S. still have chronic oral health problems and lack of access to care, according to a report by the National Institutes of Health. Oral Health in America: Advances and Challenges, is a follow-up to the seminal 2000 Oral Health in America: A Report of the Surgeon General. The new report, which is intended to provide a road map on how to improve the nation’s oral health, draws primarily on information from public research and evidence-based practices and was compiled and reviewed by NIH’s National Institute of Dental and Craniofacial Research (NIDCR) and a large, diverse, multi-disciplinary team of more than 400 experts.

The report updates the findings of the 2000 publication and highlights the national importance of oral health and its relationship to overall health. It also focuses on new scientific and technological knowledge – as well as innovations in health care delivery – that offer promising new directions for improving oral health care and creating greater equity in oral health across communities. Achieving that equity is an ongoing challenge for many who struggle to obtain dental insurance and access to affordable care.

“This is a very significant report,” said NIH Acting Director Lawrence A. Tabak, D.D.S., Ph.D. “It is the most comprehensive assessment of oral health currently available in the United States and it shows, unequivocally, that oral health plays a central role in overall health. Yet millions of Americans still do not have access to routine and preventative oral care.”

The newly issued report provides a comprehensive snapshot of oral health in America, including an examination of oral health across the lifespan and a look at the impact the issue has on communities and the economy. Major take-aways from the report include:

• Healthy behaviors can improve and maintain an individual’s oral health, but these behaviors are also shaped by social and economic conditions.
• Oral and medical conditions often share common risk factors, and just as medical conditions and their treatments can influence oral health, so can oral conditions and their treatments affect other health issues.
• Substance misuse and mental health conditions negatively affect the oral health of many.
• Group disparities around oral health, identified 20 years ago, have not been adequately addressed, and greater efforts are needed to tackle both the social and commercial determinants that create these inequities and the systemic biases that perpetuate them.

“This is an in-depth review of the scientific knowledge surrounding oral health that has accumulated over the last two decades,” said Rena D’Souza D.D.S., Ph.D., director of NIDCR, which oversaw and funded the project’s three-year research program. “It provides an important window into how many societal factors intersect to create advantages and disadvantages with respect to oral health, and, critically, overall health.”

The COVID-19 pandemic emerged while the report was being written. The science around SARS-CoV-2 continues to come into focus in real-time, and, although data were only starting to surface about the oral implications of the disease, the authors included a preliminary analysis of it to assess initial impacts.

The authors make several recommendations to improve oral health in America, which include the need for health care professionals to work together to provide integrated oral, medical, and behavioral health care in schools, community health centers, nursing homes, and medical care settings, as well as dental clinics. They also identify the need to improve access to care by developing a more diverse oral health care workforce, addressing the rising cost of dental education, expanding insurance coverage, and improving the overall affordability of care.

“Although there are challenges ahead, the report gives us a starting point and some clear goals that offer reasons to be hopeful, despite those challenges,” added D’Souza. “It imagines a future, as I do, in which systemic inequities that affect oral health and access to care are more fully addressed, and one in which dental and medical professionals work together to provide integrated care for all.”

Scientists and public health professionals will use the report to identify areas of scientific inquiry and research as well as develop and implement programs that ultimately will improve the oral health of individuals, communities, and the nation.

To view or download the report, please visit the NIDCR website at https://www.nidcr.nih.gov/oralhealthinamerica.

Questions about the report? Email OralHealthReport@nih.gov(link sends e-mail) or call NIDCR at 1-866-232-4528.

About the National Institute of Dental and Craniofacial Research: NIDCR is the nation’s leading funder of research on oral, dental, and craniofacial health.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Gum disease increases risk of other illness such as mental health and heart conditions

A University of Birmingham-led study shows an increased risk of patients developing illnesses including mental ill-health and heart conditions if they have a GP-inputted medical history of periodontal (gum) disease

Experts carried out a first of its kind study of the GP records of 64,379 patients who had a GP-inputted recorded history of periodontal disease, including gingivitis and periodontitis (the condition that occurs if gum disease is left untreated and can lead to tooth loss).  Of these, 60,995 had gingivitis and 3,384 had periodontitis. These patients’ records were compared to those of 251,161 patients who had no record of periodontal disease. Across the cohorts, the average age was 44 years and 43% were male, while 30% were smokers. Body Mass Index (BMI), ethnicity and deprivation levels were also similar across the groups.

The researchers examined the data to establish how many of the patients with and without periodontal disease go on to develop cardiovascular disease (e.g., heart failure, stroke, vascular dementia), cardiometabolic disorders (e.g., high blood pressure, Type 2 diabetes), autoimmune conditions (e.g., arthritis, Type 1 diabetes, psoriasis), and mental ill-health (e.g., depression, anxiety and serious mental illness) over an average follow-up of around three years.

From the research, published today in journal BMJ Open, the team discovered that those patients with a recorded history of periodontal disease at the start of the study were more likely to go on and be diagnosed with one of these additional conditions over an average of three years, compared to those in the cohort without periodontal disease at the beginning of the research.  The results of the study showed, in patients with a recorded history of periodontal disease at the start of the study, the increased risk of developing mental ill-health was 37%, while the risk of developing autoimmune disease was increased by 33%, and the risk of developing cardiovascular disease was raised by 18%, while the risk of having a cardiometabolic disorder was increased by 7% (with the increased risk much higher for Type 2 diabetes at 26%).

Co-first author, Dr Joht Singh Chandan, of the University of Birmingham’s Institute of Applied Health Research, said: “Poor oral health is extremely common, both here in the UK and globally.  When oral ill-health progresses, it can lead to a substantially reduced quality of life.  However, until now, not much has been known about the association of poor oral health and many chronic diseases, particularly mental ill-health.  Therefore, we conducted one of the largest epidemiological studies of its kind to date, using UK primary care data to explore the association between periodontal disease and several chronic conditions.  We found evidence that periodontal disease appears to be associated with an increased risk of developing these associated chronic diseases. As periodontal diseases are very common, an increased risk of other chronic diseases may represent a substantial public health burden.”

Co-first author, Dr Dawit Zemedikun, of the University of Birmingham’s Institute of Applied Health Research, said: “Our study was the most comprehensive study of its kind and the results provided vital confirmation of evidence which has previously either been lacking in strength or has had gaps – particularly the association between oral ill-health and mental ill-health.”

Co-senior author, Professor Krish Nirantharakumar, also of the University of Birmingham’s Institute of Applied Health Research, said:  “An important implication of our findings is the need for effective communication between dental and other healthcare professionals to ensure patients obtain an effective treatment plan targeting both oral and wider health to improve their existing overall health and reduce the risk of future illness.”

Periodontal specialist, Dr Devan Raindi, of the University of Birmingham’s School of Dentistry, said: “This study strengthens the continually evolving research associating periodontal disease, in particular periodontitis, and various general health conditions. It reinforces the importance of prevention, early identification and treatment of periodontitis and the need for members of the public to attend regular oral health checks with a dentist or dental care professional.”

The research was partly funded by Versus Arthritis’s Centre for Musculoskeletal Ageing Research based at the University of Birmingham, and supported by the National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre.

Caroline Aylott, Head of Research Delivery at Versus Arthritis, said: “Some of the biggest challenges of arthritis, especially auto-immune conditions like rheumatoid arthritis (RA) which affects 400,000 people in the UK, is being able to know who is more at risk of developing it, and finding ways to prevent it. Previous studies have shown that people with RA were four times more likely to have gum disease than their RA-free counterparts and it tended to be more severe. This research provides further clear evidence why healthcare professionals need to be vigilant for early signs of gum disease and how it can have wide-reaching implications for a person’s health, reinforcing the importance of taking a holistic approach when treating people.”

“Good job brushing your teeth!”

 

Study Shows Parent Praise Might Encourage Children’s Persistence

To become healthy and successful adults, children need to persist on tasks that they might not necessarily consider easy or fun, like studying, exercising, or brushing one’s teeth. Throughout childhood, persistence behavior changes daily, but the factors that shape this variability in persistence are understudied. A new study published in Child Development by researchers at the University of Pennsylvania, Yale University and the Sante Fe Institute, analyzed daily toothbrushing behaviors in three-year-olds and examined the relationship between their persistence on the task and parental praise.

“Our work is the first to show that fluctuations in parent praise relate to fluctuations in child persistence,” said Allyson Mackey, assistant professor of psychology at the University of Pennsylvania. “We examined how variations in parent talk and stress, and child mood and sleep, separately impacted fluctuations in brushing time. Surprisingly, parents were not able to accurately predict which variables shaped brushing in their own children.”

The study included eight-one three-year-olds learning to brush their own teeth. The sample was 80% White, 14% Multiracial, 10% Hispanic or Latinx, 2% Asian, 1% Black and 1% preferred not to answer. Data was collected from families in Pennsylvania (94%) with the remaining in New Jersey, Delaware, Massachusetts, Maryland, and Florida. Parental education averaged from 12 to 20 years and the annual income ranged from $14,000 to $200,000. Data were collected throughout a 16-day period in two waves: January-June 2019 and March-May 2020 (during the COVID-19 pandemic). Families were recruited through partnerships with local preschools and through social media.

Parents submitted videos of nightly toothbrushing over 16 days, capturing both children’s persistence and parent talk. Parents were instructed to start recording the video before the toothbrush was in their child’s mouth and to stop recording when they took the toothbrush back from their child. Parents were asked to let their child brush their teeth by themselves for as long as they could before the parent stepped in to help. (If children did not brush their teeth for a night, resulting in no video, parents were instructed to let the researchers know). The videos also included parents talking to their child throughout the toothbrushing and “praise” used by parents throughout the nightly ritual. Praise was broken into categories including “process praise” (e.g., “good job”), “person praise” (e.g., “good girl”), and “other praise” (e.g., “very good” or “nice”). Other utterances from parents included “distraction” (e.g., singing, reading a book, invoking pretend play), and using expressions such as “brush the backs” and “keep brushing” as instruction.

Parents also completed daily surveys about the following:

• Parental nightly stress level: ranging from a scale of 0 (not stressed at all) to 10 (extremely stressed)
• Child’s mood: ranging from a scale of 0 (extremely bad) to 10 (extremely good)
• Sleep duration: daytime nap (if any) and length, nightly bedtime and morning wake up, periods of awake time during the night

The findings showed that children’s persistence fluctuates from day to day and is related to parent talk. Children brushed longer on days when their parents used more praise and less instruction. Parent praise during toothbrushing mostly consisted of generic praise and process (e.g., “nice” and “great job”), with few instances of person praise (e.g., “good girl”). Children varied in their sensitivity to mood, sleep, and parent stress.

“Our work provides a path towards identifying the specific factors that impact individual children’s persistence to design targeted interventions, some of which parents may not find obvious,” said Julia Leonard, assistant professor of psychology at Yale University. “Our work also demonstrates a new approach to studying children’s healthy development - instead of focusing on what factors make one group of children different from another, our study asked which factors make individual children more like the best version of themselves.”

The authors acknowledge several limitations of the study. The exact set of skills involved in toothbrushing are not yet known, the sample was skewed toward higher-income families within a Western, Educated, Industrialized, Rich, and Democratic (WEIRD) cultural context, potential bias in parental reporting and modifications in their behavior, lack of data on the quality of children’s sleep and morning toothbrushing. In addition, this study does not tell us whether parent praise causes positive changes in children’s behavior. To determine this, intervention studies are needed. Future research should consider a larger sample, whether results will differ beyond the pandemic and whether variables such as a good night sleep make an impact in the response to children’s social input. Toothbrushing was selected as the task in this study as it is an everyday, naturalistic task that is not particularly interesting or fun for children but is important for children’s health However, future work should test whether these findings could be used to translate children’s daily fluctuations on other tasks that require persistence including those with more immediate and delayed rewards.

USPSTF recommendation statement on screening, interventions to prevent cavities in children

 The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride and apply fluoride varnish to the primary teeth of all children starting at the age of primary tooth eruption. The USPSTF concludes that the current evidence is insufficient to make a recommendation on primary care clinicians performing routine screening exams for cavities in children younger than 5. Dental caries (cavities) is the most common chronic disease in children in the United States. The USPSTF routinely makes recommendations about the effectiveness of preventive care services and this statement is consistent with its 2014 recommendation.

Full report

Dental device for snoring may slow onset of Alzheimer’s disease

A multidisciplinary team of researchers discovered that an oral appliance not only improves breathing rate during sleep, but also appears to reverse cognitive impairment.

A good night’s sleep plays an essential role in regulating brain health by removing the waste material and toxins that accumulate. Although many things can disturb sleep, one of the most common causes is snoring or other breathing issues that cause obstructive sleep apnea. A team of researchers from Center for BrainHealth® at The University of Texas at Dallas and Texas A&M University sought to understand the relationship between breathing rate during sleep and cognitive function, and how a snoring intervention affects brain health.

 

The findings were published recently in Geriatrics by the team that included BrainHealth researchers Sandra Bond Chapman, PhD, chief director; Namrata Das, PhD, MD, MPH, a research neuroscientist in Alzheimer's disease; and Jeffrey Spence, PhD, director of biostatistics. Lead researcher Preetam Schramm, PhD, a Visiting Scholar at Texas A&M University, designed the interventional study and provided the sleep science expertise.

 

The team discovered that maximum breathing rate can be used to distinguish healthy individuals from people with mild cognitive impairment and those with Alzheimer’s disease. The researchers also found that a dental device to reduce snoring improves cognitive function in individuals who suffer from mild cognitive impairment.

 

The team’s pilot study included 18 individuals aged 55-85 with a history of snoring. About one third of participants had mild cognitive impairment and another third had Alzheimer’s disease. To examine how breathing rate relates to an individual’s cognitive function, participants slept at home while portable recorders collected data on their breathing rate, heart rate and snoring. Clinicians from Center for BrainHealth assessed the participants’ memory, executive function, and attention. 

 

The team found that the maximum breathing rate during uninterrupted periods of sleep can differentiate healthy individuals from individuals with either Alzheimer’s disease or mild cognitive impairment. “We saw three distinct patterns amongst the groups of people, meaning we can look for a breathing pattern that might predispose individuals to having dementia,” said Emet Schneiderman, PhD, a co-author on the study and Professor in the Department of Biomedical Sciences at Texas A&M University College of Dentistry. Determining breathing rate is cheaper and faster than other existing assessments for measuring an individual’s cognitive function and could be an effective testing alternative.

 

The researchers also looked at whether the myTAP oral appliance, which snaps into the mouth at night to prevent snoring, affects breathing rate and cognitive function. For four weeks, participants wore the device at night and snoring decreased. After the intervention period, cognitive function – especially in the domain of memory – no longer differed between healthy individuals and individuals with mild cognitive impairment. This suggests better sleep improves cognition in individuals with mild cognitive impairment. “If we can make significant changes for individuals with mild cognitive impairment, we can slow the onset of Alzheimer’s disease,” said Das, now a postdoctoral fellow at McLean Hospital, Harvard Medical School.

 

Though the team did not notice an overall difference in the cognitive function of participants with Alzheimer’s disease, researchers are hopeful that the intervention could work. On the individual level, half of the participants with Alzheimer’s disease saw improvements in their cognitive function. “Brain neurogenesis is a slow process, so perhaps these individuals may need a longer time period with the intervention to see any significant cognitive changes,” noted Das.

 

Alternatives to medicine for treating snoring, like dental appliances, could help individuals sleep better and improve their cognitive function. Sleep medications give individuals the impression that they’ve slept well, when in reality the brain never enters a deep phase of the sleep essential for the housekeeping process to rid the body of toxins.

 

And it now appears that alternative treatments, like this dental appliance, might produce meaningful changes in cognition before mild cognitive impairment progresses to Alzheimer’s disease. “Oral appliances could have a wide range of applications since sleep is affected by many different things across many different age groups,” said Das. “Maybe appliances could help individuals sleep better, reducing mental health symptoms caused by poor sleep before they get serious decline in neurocognitive symptoms.”

 

Study: Obesity raises the risk of gum disease by inflating growth of bone-destroying cells

Findings may improve understanding of chronic inflammatory, bone-related diseases that develop alongside obesity, such as gum disease, arthritis and osteoporosis

Peer-Reviewed Publication

UNIVERSITY AT BUFFALO

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IMAGE: THE GRAPHIC DEMONSTRATES HOW MDSC EXPANSION DURING OBESITY TO BECOME BONE DESTROYING OSTEOCLASTS DURING GUM DISEASE IS TIED TO INCREASED BONE LOSS AROUND TEETH. view more 

CREDIT: PHOTO: KEITH KIRKWOOD.

BUFFALO, N.Y. – Chronic inflammation caused by obesity may trigger the development of cells that break down bone tissue, including the bone that holds teeth in place, according to new University at Buffalo research that sought to improve understanding of the connection between obesity and gum disease.

The study, completed in an animal model and published in October in the Journal of Dental Research, found that excessive inflammation resulting from obesity raises the number of myeloid-derived suppressor cells (MDSC), a group of immune cells that increase during illness to regulate immune function. MDSCs, which originate in the bone marrow, develop into a range of different cell types, including osteoclasts (a cell that breaks down bone tissue). 

Bone loss is a major symptom of gum disease and may ultimately lead to tooth loss. Also known as periodontal disease, gum disease affects more than 47% of adults 30 years and older, according to the Centers for Disease Control and Prevention.

“Although there is a clear relationship between the degree of obesity and periodontal disease, the mechanisms that underpin the links between these conditions were not completely understood,” says Keith Kirkwood, DDS, PhD, professor of oral biology in the UB School of Dental Medicine.

“This research promotes the concept that MDSC expansion during obesity to become osteoclasts during periodontitis is tied to increased alveolar bone destruction. Taken together, this data supports the view that obesity raises the risk of periodontal bone loss,” says Kyuhwan Kwack, PhD, postdoctoral associate in the UB Department of Oral Biology. 

The study examined two groups of mice fed vastly different diets over the course of 16 weeks: one group a low-fat diet that derived 10% of energy from fat, the other group a high-fat diet that drew 45% of energy from fat.

The investigation found that the high-fat diet group experienced obesity, more inflammation and a greater increase of MDSCs in the bone marrow and spleen compared to the low-fat diet group. The high-fat diet group also developed a significantly larger number of osteoclasts and lost more alveolar bone (the bone that holds teeth in place).

Also, the expression of 27 genes tied to osteoclast formation were significantly elevated in the group fed a high-fat diet. 

The findings may shed more light on the mechanisms behind other chronic inflammatory, bone-related diseases that develop concurrently with obesity, such as arthritis and osteoporosis, says Kirkwood.

Additional investigators include Lixia Zhang, PhD, research scientist in the UB Department of Oral Biology; Jiho Sohn, doctoral candidate in the Jacobs School of Medicine and Biomedical Sciences at UB; Victoria Maglaras, student in the UB School of Dental Medicine; and Ramkumar Thiyagarajan, research scientist in the Jacobs School.

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JOURNAL

Journal of Dental Research

DOI

10.1177/00220345211040729 

Local exhaust ventilation to control dental aerosols and droplets

Dental procedures produce aerosols which contain oral microbes, creating potential for infectious disease transmission. This study, “Local Exhaust Ventilation to Control Dental Aerosols and Droplets” published in the Journal of Dental Research (JDR), investigated the effect of a Local Exhaust Ventilation (LEV) device on aerosols and droplets produced during dental procedures. These devices are designed to be placed over the patient’s mouth to capture aerosols and droplets at the source. 

Researchers at Newcastle University, England, conducted experiments on dental mannequins. Ten-minute crown preparations were performed with an air-turbine handpiece in a large open plan clinic, and full mouth ultrasonic scaling was performed for ten minutes in a single dental surgery. Fluorescein was added to instrument irrigation reservoirs as a tracer. In both settings, Optical Particle Counters (OPCs) were used to measure aerosol particles between 0.3 – 10.0 μm and liquid cyclone air samplers were used to capture aerosolised fluorescein tracer. An LEV device with High Efficiency Particulate Air (HEPA) filtration and a flow rate of 5,000 L/min was tested during the experiments. 

 

The results show that using LEV reduced the dispersion of aerosols from the air turbine handpiece by 90% within 0.5 m, and this was 99% for the ultrasonic scaler. The settling of larger droplets was also measured for the air-turbine, and this was reduced by 95% within 0.5 m when LEV was used.

 

"This study shows that the effect of LEV was substantially greater than suction alone for the air-turbine and was similar to the effect of suction for the ultrasonic scaler,” said IADR President Eric Reynolds, The University of Melbourne, Australia. “While no mitigation measure alone will completely eliminate risk, LEV appears to be a useful approach, which in addition to other measures, substantially reduces dispersion of aerosols, and therefore risk of exposure to pathogens."

Baby teeth may one day help identify kids at risk for mental disorders later in life

Peer-Reviewed Publication

The thickness of growth marks in primary (or “baby”) teeth may help identify children at risk for depression and other mental health disorders later in life, according to a groundbreaking investigation led by researchers at Massachusetts General Hospital (MGH) and published in JAMA Network Open. The results of this study could one day lead to the development of a much-needed tool for identifying children who have been exposed to early-life adversity, which is a risk factor for psychological problems, allowing them to be monitored and guided towards preventive treatments, if necessary.

The origin of this study traces back several years, when senior author Erin C. Dunn, ScD, MPH, learned about work in the field of anthropology that could help solve a longstanding problem in her own research. Dunn is a social and psychiatric epidemiologist and an investigator in MGH’s Psychiatric and Neurodevelopmental Genetics Unit. She studies the effects of childhood adversity, which research suggests is responsible for up to one-third of all mental health disorders. Dunn is particularly interested in the timing of these adverse events and in uncovering whether there are sensitive periods during child development when exposure to adversity is particularly harmful. Yet Dunn notes that she and other scientists lack effective tools for measuring exposure to childhood adversity. Asking people (or their parents) about painful experiences in their early years is one method, but that’s vulnerable to poor recall or reluctance to share difficult memories. “That’s a hindrance for this field,” says Dunn.

However, Dunn was intrigued to learn that anthropologists have long studied the teeth of people from past eras to learn about their lives. “Teeth create a permanent record of different kinds of life experiences,” she says. Exposure to sources of physical stress, such as poor nutrition or disease, can affect the formation of dental enamel and result in pronounced growth lines within teeth, called stress lines, which are similar to the rings in a tree that mark its age. Just as the thickness of tree growth rings can vary based on the climate surrounding the tree as it forms, tooth growth lines can also vary based on the environment and experiences a child has in utero and shortly thereafter, the time when teeth are forming. Thicker stress lines are thought to indicate more stressful life conditions.

Dunn developed a hypothesis that the width of one variety in particular, called the neonatal line (NNL), might serve as an indicator of whether an infant’s mother experienced high levels of psychological stress during pregnancy (when teeth are already forming) and in the early period following birth.

To test this hypothesis, Dunn and two co-lead authors—postdoctoral research fellow Rebecca V. Mountain, PhD, and data analyst Yiwen Zhu, MS, who were both in the Psychiatric and Neurodevelopmental Genetics Unit at the time of the study—led a team that analyzed 70 primary teeth collected from 70 children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) in the United Kingdom. In ALSPAC (which is also called Children of the 90s), parents donated primary teeth (specifically, the pointed teeth on each side of the front of the mouth known as canines) that naturally fell out of the mouths of children aged 5 to 7. The width of the NNL was measured using microscopes. Mothers completed questionnaires during and shortly after pregnancy that asked about four factors that are known to affect child development: stressful events in the prenatal period, maternal history of psychological problems, neighborhood quality (whether the poverty level was high or it was unsafe, for instance), and level of social support.

Several clear patterns emerged. Children whose mothers had lifetime histories of severe depression or other psychiatric problems, as well as mothers who experienced depression or anxiety at 32 weeks of pregnancy, were more likely than other kids to have thicker NNLs. Meanwhile, children of mothers who received significant social support shortly after pregnancy tended to have thinner NNLs. These trends remained intact after the researchers controlled for other factors that are known to influence NNL width, including iron supplementation during pregnancy, gestational age (the time between conception and birth) and maternal obesity.

No one is certain what causes the NNL to form, says Dunn, but it’s possible that a mother experiencing anxiety or depression may produce more cortisol, the “stress hormone,” which interferes with the cells that create enamel. Systemic inflammation is another candidate, says Dunn, who hopes to study how the NNL forms. And if the findings of this research can be replicated in a larger study, she believes that the NNL and other tooth growth marks could be used in the future to identify children who have been exposed to early life adversity. “Then we can connect those kids to interventions,” says Dunn, “so we can prevent the onset of mental health disorders, and do that as early on in the lifespan as we possibly can.”

Root canal treatment work still favored for badly damaged teeth

 

Few patients regret having a severely damaged tooth saved by a root canal filling. A University of Gothenburg thesis shows that 87 percent would choose the same treatment again, if in need, although pain and discomfort around the tooth are common.

The reason for getting a root filling is often that the soft tissue inside the tooth, the dental pulp, is inflamed or infected. The root canal treatment is carried out in stages, on several occasions. Soft parts are removed and the root canals are finally filled with a combination of a natural, rubberlike material (gutta-percha) and a kind of cement.

Despite generally good oral health, root canal treatment is still a common and necessary measure. In Sweden, as in most countries, most root canal treatments are performed by general dental practitioners in the public or private sector.

For her PhD thesis, dentist Emma Wigsten of the Institute of Odontology at Sahlgrenska Academy, University of Gothenburg, studied various aspects of root canal treatments performed in Swedish general dental practice, with the Public Dental Service in Region Västra Götaland as a base.

Molars difficult to treat

In several of the component studies in Wigsten’s compilation thesis, data on a patient group initially numbering 243 were analyzed. They had all started root canal treatment at one of the 20 public dental clinics in the region. The patients were then followed up for one to three years.

Most of the root canal treatments studied were prompted by toothache in teeth with caries and large restorations, which culminated in root fillings within a year. Molars were an exception: only just over half of the root fillings met their purpose and, as a result, many molars had to be removed (i.e. extracted).

“It seems harder to get a good result in treating the molars, despite time and resources invested. Root canal treatment is complicated: You’re working inside the tooth where you can’t see anything, and the further back you go in the mouth, the more difficult it becomes,” Wigsten says.

“Root canal treatments of molars involve significantly bigger challenges than other tooth groups. So it may be important to investigate whether root canal treatments of molars should be performed to a greater extent by dentists specializing in root canal treatment.”

Satisfaction and quality of life

Half of the patients stated that they had mild pain or discomfort from their root-filled tooth during the follow-up period of up to three years. Nevertheless, the great majority (87 percent) were satisfied. They did not regret their choice to get root canal treatment instead of a tooth extraction.

Another component study, at six public dental clinics in Region Västra Götaland, covered 85 patients in whom either root canal treatment was started or a tooth was removed. An improved health-related quality of life was observed in the patients who started root canal treatment, but not in those who underwent a tooth extraction.

“The studies show that the patients' quality of life benefited from root canal treatment. On the other hand, it’s unclear whether the treatment is cost-effective compared with tooth removal, especially where molars are concerned,” Wigsten concludes.

Title: Root Canal Treatment in a Swedish Public Dental Service: Studies of indications and results, http://hdl.handle.net/2077/68698

Oral health can be an additional, modifiable risk factor for high risk COVID-19 patients

 The correlation between poor oral health and COVID-19 severity, as well as the correlation between oral health and delayed recovery, demonstrates a potential need to consider oral health an additional risk factor for cardiac patients who may contract COVID-19. The new sub-study, examining Egyptian cardiac patients, will be presented at ACC Middle East 2021, a hybrid meeting held in partnership by the American College of Cardiology, Egyptian Society of Cardiology and the ACC Egypt Chapter on Oct. 14-15, 2021.

The oral cavity is a potential reservoir for respiratory pathogens. Previous trials have linked poor oral hygiene with increased inflammation and cardiovascular disease. According to the researchers, COVID-19 severity has also been linked to an inflammatory response.

The researchers hypothesized that increased COVID-19 severity may be linked to poor oral health status, especially in patients with cardiovascular diseases. According to the study authors, the study assessed oral health status, severity of COVID-19 symptoms, C-reactive protein (CRP) levels and duration of recovery.

“Oral tissues could act as a reservoir for SARS-CoV-2, developing a high viral load in the oral cavity. Therefore, we recommended maintenance of oral health and improving oral hygiene measures, especially during COVID-19 infection,” said Ahmed Mustafa Basuoni, MD, cardiology consultant at Cairo University and lead author of the study. “Simple measures like practicing proper oral hygiene, raising awareness of oral health importance either in relation to COVID-19 infection or systemic diseases by using media and community medicine, regular dental visits, especially in patients with CVD, and using [antimicrobial] mouthwashes [could help in] preventing or decreasing the severity of COVID-19 disease.” 

The study included 86 Egyptian heart disease patients with a confirmed COVID-19 PCR test. Using a questionnaire, researchers from Cairo University assessed oral health and COVID-19 severity. An oral health score was used to determine the effect of oral health on COVID-19. Data on CRP levels and COVID-19 PCR tests were collected via the questionnaire and confirmed via medical records. CRP levels are used to determine when there is inflammation in the body.

According to the researchers, the correlation between oral health and COVID-19 severity showed a significant inverse relationship, as did the correlation between oral health with recovery period and CRP values. Poor oral health was correlated to increased values of CRP and delayed recovery, especially in patients with cardiac diseases.

“Oral health should be a part of routine history taking and examination in cardiac patients,” Basuoni said. “Lifestyle measures should be instructed to all cardiac patients regarding good oral hygiene with regular dental visits. We need to give more space in research for these risk factors which can be easily modified.”

Survey of US dentists shows high rate of opioid prescriptions despite knowledge of effective alternatives

 

- A survey of dentists in the United States finds that an overwhelming majority of those who responded believe nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are as effective or more effective in managing dental pain as opioids; however, almost half say they still prescribe opioids.

The results of the survey, conducted by PharmedOut at Georgetown University Medical Center with  undergraduate students at Georgetown University School of Nursing & Health Studies, were published October 21 in The Journal of the American Dental Association.

“These results suggest that dentists are familiar with the evidence about the effectiveness of NSAID-acetaminophen medications, but their self-reported prescribing patterns demonstrate a disconnect,” says Matthew Heron, the first author who conducted the research as an undergraduate at Georgetown’s School of Nursing & Health Studies.

Previous studies find that dentists comprise 15.8% of opioid prescribers and prescribe 8.6% of opioid medications in the United States. Dentists are the highest prescribers of opioids to patients 18 years and younger.

“We know that the first exposure to opioids for many people occurs in their teens and early 20s following  common dental procedures like third molar extractions,” says Nkechi Nwokorie, who also conducted the work as an undergraduate at Georgetown. “This is a particularly vulnerable population for misuse.”

The Georgetown researchers received 291 survey responses and analyzed 269 completed surveys. Although 84% of respondents reported believing that NSAID-acetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications.

“This underscores the need for more education about the harms of opioids and the need for national guidelines to align clinical practice with current evidence,” concludes Adriane Fugh-Berman, MD, a professor in the departments of pharmacology & physiology, and family medicine at Georgetown University Medical Center. Fugh-Berman is also the director of PharmedOut.

Study: Heartburn drugs may have unexpected benefits on gum disease

 

The use of heartburn medication is associated with decreased severity of gum disease, according to a recent University at Buffalo study.

The research found that patients who used proton pump inhibitors (PPIs) – a class of drugs commonly prescribed to treat heartburn, acid reflux and ulcers – were more likely to have smaller probing depths in the gums (the gap between teeth and gums). When gums are healthy, they fit snuggly against the teeth. However, in the presence of harmful bacteria, the gap deepens, leading to inflammation, bone loss and periodontitis, also known as gum disease.

The findings, published last month in Clinical and Experimental Dental Research, may be linked to the side effects of PPIs, which include changes in bone metabolism and in the gut microbiome, says lead investigator Lisa M. Yerke, DDS, clinical assistant professor in the Department of Periodontics and Endodontics at the UB School of Dental Medicine.

“PPIs could potentially be used in combination with other periodontal treatments; however, additional studies are first needed to understand the underlying mechanisms behind the role PPIs play in reducing the severity of periodontitis,” says Yerke.

Additional investigators include first author and UB alumnus Bhavneet Chawla, and Robert E. Cohen, DDS, PhD, professor of periodontics and endodontics in the UB School of Dental Medicine.

The study sought to determine whether a relationship exists between PPI use and gum disease. The researchers analyzed clinical data from more than 1,000 periodontitis patients either using or not using PPIs. Probing depths were used as an indicator of periodontitis severity.

Only 14% of teeth from patients who used PPIs had probing depths of 6 millimeters or more, compared to 24% of teeth from patients who did not use the medication. And 27% of teeth from patients using PPIs had probing depths of 5 millimeters or more, compared to 40% of teeth from non-PPI users, according to the study.

The researchers theorized that PPIs’ ability to alter bone metabolism or the gut microbiome, as well as potentially impact periodontal microorganisms, may help lessen the severity of gum disease.

Additional studies are under development to determine if this relationship can be found in other populations of patients with gum disease, and to learn to what extent the relationship can be directly attributed to PPIs, says Yerke.

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JOURNAL

Clinical and Experimental Dental Research

DOI

https://doi.org/10.1002/cre2.495 

ARTICLE TITLE

Association between proton pump inhibitors and periodontal disease severity

Multiple bacteria types found to contribute to bone loss in gum disease

 

IMAGE: THE DATA EXPRESSED AS THE MEAN ± SEM OF 6 MICE. A SIGNIFICANT DIFFERENCE BETWEEN THE TWO GROUPS WAS INDICATED; *P<0.05 AND **P<0.01 VS PBS, BY STUDENT’S T-TEST. SCALE BAR INDICATED 1 MM. view more 

CREDIT: MASAKI INADA / TUAT

Mouths are filthy, harboring the second largest microbiome of the human body. Some bacteria can help break down food, among other responsibilities; other bacteria can travel into the mouth on food, fingers, pen caps and more to contribute to gum disease and other oral infections. More than good or bad bacteria, researchers have now unveiled that positive and negative bacterium are responsible for periodontitis symptoms — Gram-positive and Gram-negative, that is.

Gram-positive bacteria have thicker cell walls that retain the purple color from Gram stain, which can quickly differentiate cell types based on the width of their cell walls. For the first time, researchers found that Gram-positive bacteria can also induce the resorption of the bone that holds teeth in place, called the alveolar bone. The results were published on June 25 in Scientific Reports.

“This finding is a new concept: both Gram-positive and -negative bacteria are involved in the progression of periodontal bone loss,” said lead author Masaki Inada, associate professor in the Department of Biotechnology and Life Science at the Tokyo University of Agriculture and Technology (TUAT). “In a healthy condition, the tooth root is embedded into a socket in the alveolar bone in periodontal tissue. Infection of mixed multiple Gram-negative bacteria resulted in alveolar bone resorption and tooth loss induced by severe inflammation in periodontal tissues. It is well-known that the major pathogens of periodontitis are dominantly gram-negative bacteria. It was unclear whether gram-positive bacteria are associated with or contribute to the progression of periodontal bone loss.”

In a previous study, the researchers injected lipopolysaccharide (LPS) from Gram-negative bacteria into mice engineered without the gene that produces molecules that gather at sites of damaged tissue. Without these molecules, called prostaglandin E2 (PGE2), the LPS failed to induce bone loss. This suggested, Inada said, that PGE2 is required for periodontitis to progress.

“LPS is considered to be a dominant pathogen causing inflammatory bone resorption in periodontitis,” Inada said. “On the other hand, Gram-positive bacteria have been known to contribute to the inflammation of the periodontal gums in the initial phases of periodontitis; however, there was little evidence to show that these pathogens contribute to the induction of inflammatory bone resorption in the late phase of periodontitis.”

It comes down to bone remodeling, according to Inada. At what point does cell death from the infection outpace the body’s effort to create new bone cells?

“Several reasons could be counting and explaining on these phenomena, “ Inada said.

In the case of LPS in the PGE2-deficient mice, the balance stayed in favor of bone formation. But when the researchers introduced lipoteichoic acid (LTA), a major component of the cell wall in Gram-positive bacteria, the balance tipped to bone resorption. The researchers injected mice with periodontitis with LTA and found that it increased the amount of PGE2, resulting in bone resorption. They also saw that Gram-positive bacteria proliferated at a higher rate than Gram-negative bacteria and they preferred to occupy the depths of the teeth pockets — suggesting a more potent dose of LTA closer to the site of bone lose, according to Inada.

“Our goal is to clarify the crosstalk of Gram-positive and -negative bacteria for the pathogenesis and progression of periodontal bone loss,” Inada said. “The understanding of the mechanisms will contribute to developing novel drugs for the treatment of periodontal bone loss.”