Effective school-based cavity prevention program

School-based prevention programs can substantially reduce children's cavities - but what type of treatment should be delivered in schools to best prevent tooth decay?
A new study by researchers at NYU College of Dentistry, published in the journal BMC Oral Health, suggests that cavity prevention programs with a combination of prevention strategies may be more effective than one alone for reducing tooth decay.
Dental cavities are the world's most prevalent childhood disease, affecting nearly 30 percent of school-age children and 50 percent of rural, minority, or Medicaid-receiving children in the United States.
School-based cavity prevention programs have emerged as an important way to improve access to dental services. In medically underserved areas, these programs often serve as the sole source of dental care for children. While the American Dental Association supports the use of school-based cavity prevention programs, questions remain on the optimal mix of treatment services, intensity, and frequency of care.
"Given the high variability in school-based programs to prevent cavities, comparing the effectiveness of different prevention agents, frequency of care, or intensity of treatment can lead to optimal program design," said Ryan Richard Ruff, MPH, PhD, assistant professor of Epidemiology & Health Promotion at NYU Dentistry and the study's lead author.
In this study, NYU Dentistry researchers compared two cavity prevention programs in elementary schools serving more than 8,200 students over 10 years (2004-2014). Both programs provided school-based care twice a year to children ages 5 to 12.
One program provided sealants on molars (primary prevention) while the other provided sealants on all teeth and interim therapeutic restorations (primary and secondary prevention). Interim therapeutic restorations are a minimally-invasive method for controlling tooth decay by filling a cavity with a fluoride?releasing agent. Interim therapeutic restorations are intended to bridge the gap between identifying a cavity, particularly in a nontraditional setting or in a very young child, and having the cavity filled or crowned in a more permanent procedure.
Both school-based cavity prevention programs reduced the risk of untreated decay over time. While the total number of all decayed or filled teeth observed over the course of the study increased across both programs, the comprehensive program that provided primary and secondary prevention significantly lowered the rate of new and untreated cavities when compared to only sealants on molars.
"A comprehensive cavity prevention program, particularly for children without regular access to dental care, can be significantly better than the traditional molar sealant programs," said Richard Niederman, DMD, professor and chair of the Department Epidemiology & Health Promotion at NYU Dentistry and the study's coauthor.
Ruff and Niederman are continuing to study how to optimize school-based cavity prevention. They are currently leading two large studies - a PCORI-funded study in the Bronx and an NIH-funded study in New Hampshire - to compare two cavity prevention techniques in school-based dental programs. One technique is a more complex treatment similar to the combined primary and secondary prevention, but the Bronx and New Hampshire studies will also introduce the use of silver diamine fluoride, a non-invasive, cavity-fighting liquid that is painted onto teeth to halt the progression of tooth decay. The cavity prevention programs will begin in schools in the fall of 2018.

People with diabetes visit the dentist less frequently despite link between diabetes, oral health

Adults with diabetes are less likely to visit the dentist than people with prediabetes or without diabetes, finds a new study led by researchers at NYU Rory Meyers College of Nursing and East Carolina University's Brody School of Medicine.

The study, published in The Journal of the American Dental Association, showed an overall decline in dental visits among adults with and without diabetes, but people with diabetes were consistently the least likely to obtain oral healthcare.

Research has shown a two-way relationship between diabetes and oral health. People with diabetes are at an increased risk for periodontal disease, a chronic inflammation of the gums and surrounding tissue and bone, while periodontal disease has an adverse effect on blood glucose control - which can contribute to the progression of diabetes. In fact, periodontal disease has been called the "sixth complication" of diabetes after issues like kidney disease, damage to the retina, and heart disease.

"For people living with diabetes, regular dental check-ups - paired with proactive dental and diabetes self-care - are important for maintaining good oral health. Regular dental visits provide opportunities for prevention, early detection, and treatment of periodontal disease, which can potentially help with blood glucose control and preventing complications from diabetes," said Bei Wu, PhD, Dean's Professor in Global Health and director of Global Health & Aging Research at NYU Meyers and the study's senior author.

Older studies have shown that individuals with diabetes had fewer dental visits than those without diabetes. In order to have an updated understanding of dental visits among people with diabetes, this study assessed the trends of annual dental visits from 2004 to 2014 in adults with diabetes, prediabetes, and without diabetes, and assessed racial and ethnic disparities in dental visits.

The researchers used data from the Behavioral Risk Factor Surveillance System, an annual telephone survey of U.S. adults during which respondents are asked whether or not they had a dental visit in the past 12 months and whether they were ever diagnosed with diabetes or prediabetes. The study sample included 2.5 million adults age 21 years and older, including 248,203 people with diabetes, 30,520 with prediabetes, and 2,221,534 without diabetes.

The researchers found that people with diabetes were the least likely to visit the dentist, followed by people with prediabetes. From 2004 to 2014, the proportion of annual dental visits declined from 66.1 percent to 61.4 percent among people with diabetes, 66 percent to 64.9 percent among people with prediabetes, and 71.9 percent to 66.5 percent among people without diabetes.

"This pattern is concerning, given that timely dental care is essential for good oral health, especially in individuals with diabetes. Those who need dental care the most seem to be the least likely to have it," said study author Huabin Luo, PhD, of East Carolina University.

Several factors may account for the underutilization of dental services by people with diabetes, according to the researchers. People may not be aware of the impact of diabetes on their oral health and vice versa. In addition, in a previous study, individuals with diabetes more frequently reported the cost of dental care as a reason for avoiding routine visits.

The researchers also observed racial and ethnic disparities in dental care. Black and Hispanic individuals were less likely to visit the dentist than were white people, and these disparities persisted over the decade studied. Males and single people were also less likely to regularly visit the dentist than females and married people.

While the study did not measure whether individuals had dental insurance, the researchers found substantial financial barriers to dental services for people with diabetes based comparing dental visits and income levels. The researchers assert that reducing these barriers and improving access to dental providers is needed, especially among people with diabetes and prediabetes.

"Healthcare providers and public health professionals should promote oral health in diabetes management and encourage people with diabetes to visit a dentist at least annually. Increasing access to dental services is vital to achieving this goal," said Wu, who is also co-director of the NYU Aging Incubator.

Associations between longitudinal beverage intakes and adolescent caries

At the 47th Annual Meeting of the American Association for Dental Research (AADR), held in conjunction with the 42nd Annual Meeting of the Canadian Association for Dental Research (CADR), Teresa A. Marshall, University of Iowa College of Dentistry, Iowa City, presented an oral session titled "Associations Between Longitudinal Beverage Intakes and Adolescent Caries." The AADR/CADR Annual Meeting is in Fort Lauderdale, Fla., USA from March 21-24, 2018. "Sugar-sweetened beverages (SSB) are the most relevant dietary risk factor for caries in young children, but there has not been as much research done on adolescent caries. Our objective was to assess associations between longitudinal beverage intakes and adolescent caries experience, adjusting for known caries-preventive factors," said Marshall.
Area-under-the-curve daily beverage and fluoride intakes of Iowa Fluoride Study participants were calculated for ages 0.5-17 years from questionnaire-reported intakes of milk, 100% juice, sugar-sweetened beverages (SSB) and water-based sugar-free beverages. Dental exams were completed when the participant reached 17 years old.
The results show that higher SSB intake and lower brushing frequency were significant predictors of the caries. In multivariable models including all beverages, higher SSB and lower juice intakes were also significant predictors of caries.
"The observed associations of sugar-sweetened beverages and juice with caries are consistent with previous studies. The relationship between SSB and caries was reduced by tooth brushing and fluoride intake, and suggests an association between beverage intakes and oral health behaviors. To accurately estimate the effect of SSB on caries, future studies should adjust for preventive factors including brushing frequency and fluoride intake," said Marshall.

Middle-aged tooth loss linked to increased coronary heart disease risk Amer

Losing two or more teeth in middle age is associated with increased cardiovascular disease risk, according to preliminary research presented at the American Heart Association's Epidemiology and Prevention | Lifestyle and Cardiometabolic Health Scientific Sessions 2018, a premier global exchange of the latest advances in population based cardiovascular science for researchers and clinicians.

Studies have shown that dental health problems, such as periodontal disease and tooth loss, are related to inflammation, diabetes, smoking and consuming less healthy diets, according to study author Lu Qi, M.D., Ph.D., professor of epidemiology at Tulane University in New Orleans.

"Previous research has also found that dental health issues are associated with elevated risk of cardiovascular disease," Qi said. "However, most of that research looked at cumulative tooth loss over a lifetime, which often includes teeth lost in childhood due to cavities, trauma and orthodontics. Tooth loss in middle age is more likely related to inflammation, but it hasn't been clear how this later-in-life tooth loss might influence cardiovascular disease risk."

In a collaborative research effort between Tulane University School of Public Health and Tropical Medicine and Harvard T.H. Chan School of Public Health, Qi and colleagues analyzed the impact of tooth loss in large studies of adults, aged 45 to 69 years, in which participants had reported on the numbers of natural teeth they had, then in a follow-up questionnaire, reported recent tooth loss.

Adults in this analysis didn't have cardiovascular disease when the studies began. The researchers prospectively studied the occurrence of tooth loss during an eight-year period and followed an incidence of cardiovascular disease among people with no tooth loss, one tooth lost and two or more teeth lost over 12-18 years.

They found:

• Among the adults with 25 to 32 natural teeth at the study's start, those who lost two or more teeth had a 23 percent increased risk of cardiovascular disease, compared to those with no tooth loss.
• The increased risk occurred regardless of reported diet quality, physical activity, body weight and other cardiovascular risk factors, such as high blood pressure, high cholesterol and diabetes.
• There wasn't a notable increase in cardiovascular disease risk among those who reported losing one tooth during the study period.
• Cardiovascular disease risk among all the participants (regardless of the number of natural teeth at the study's start) increased 16 percent among those losing two or more teeth during the study period, compared to those who didn't lose any teeth.
• Adults with less than 17 natural teeth, versus 25 to 32, at the study's start, were 25 percent more likely to have cardiovascular disease.

"In addition to other established associations between dental health and risk of disease, our findings suggest that middle-aged adults who have lost two or more teeth in recent past could be at increased risk for cardiovascular disease," Qi said. "That's regardless of the number of natural teeth a person has as a middle-aged adult, or whether they have traditional risk factors for cardiovascular disease, such as poor diet or high blood pressure."

Armed with the knowledge that tooth loss in middle age can signal elevated cardiovascular disease risk, adults can take steps to reduce the increased risk early on, he said.

A limitation of the study was that participants self-reported tooth loss, which could lead to misclassification in the study, according to Qi.

Tooth health may indicate diabetes risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Toothpaste alone does not prevent dental erosion or hypersensitivity

An analysis of nine toothpastes found that none of them protects enamel or prevents erosive wear. Specialists stress that diet and treatment by a dentist are key to avoid the problems originated by dentin exposure.

 

The rising prevalence of dental erosion and dentin hypersensitivity has led to the emergence of more and more toothpastes on the market that claim to treat these problems. While no such toothpaste existed 20 years ago, today, many brands with different attributes are being offered.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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