Dentists and dental hygienists on early front lines of COVID-19 report symptoms of anxiety, depression

The first known U.S. study to evaluate the mental health of frontline dentists and dental hygienists during the pandemic found that dental health care workers report anxiety and depression symptoms during peaks of transmission among the public.

Published jointly in the August issues of The Journal of the American Dental Association and the Journal of Dental Hygiene and available online at JADA.ada.org, the study indicates between June 2020 and June 2021, 17.7% of dental health care workers reported anxiety symptoms, 10.7% reported depression symptoms, and 8.3% reported symptoms of both. The one-year study conducted from June 2020 to June 2021, included 8,902 dental health care workers participating monthly in an anonymous longitudinal, web-based survey.

According to the findings, between June 2020 and June 2021, dental hygienists reported higher rates of depression symptoms than dentists at each surveyed time point, with depression symptom rates peaking in December 2020. Dental hygienists’ depression rates declined in 2021 as dentists’ rates of depression symptoms remained steady. At the end of the study period, both groups had relatively similar rates — 11.8% for dentists and 12.4% for hygienists.

“Interestingly, dental health care workers reported lower rates of anxiety and depression symptoms than the general public, despite being on the front lines and providing oral health care during the pandemic,” says author Stacey Dershewitz, J.D., Psy.D., Adjunct Professor of Clinical Psychology and Director of the Center Clinic at the George Washington University Professional Psychology Program. “As the pandemic continues, it is critically important that dental health care workers continue to develop their ability to recognize and address signs and symptoms of mental health conditions within themselves and their colleagues, promote healthy work environments, reduce the impact of stress on the profession, and make supports accessible to those who are struggling emotionally.”

Some participants’ anxiety symptoms decreased after receiving the COVID-19 vaccine. The study — also the first to examine the association between the COVID-19 vaccine and mental health — found that unvaccinated dental health care workers who intended to be vaccinated suffered significantly more anxiety symptoms (20.6%) compared to fully-vaccinated dental health care workers (14.1%). 

“The hope is that this is just the first of many steps in monitoring mental wellness of the entire oral care team,” says JoAnn Gurenlian, R.D.H, M.S., Ph.D, A.F.A.A.O.M., Director of Education and Research, American Dental Hygienists’ Association. “There is much work to be done to dismantle barriers to treatment and prioritize wellbeing in the oral care setting, as well as look at future research around contributing factors to mental illness that may be unique to these professions.”

The study is part of ongoing collaborative research efforts between the American Dental Association (ADA) and the American Dental Hygienists’ Associations (ADHA) to understand COVID-19’s impact on dental health care workers.

“As members of the dental profession, we are committed to improving the oral health of our patients and communities. Furthermore, as healthcare professionals, we must be committed to our own health and wellness to optimally care for others,” says study author Maria L. Geisinger, D.D.S, M.S., Professor and Director of the Advanced Education Program in Periodontology at the University of Alabama at Birmingham School of Dentistry. “Creating professional environments that allow for open communication about mental health among members of the dental team can reduce the stigma around mental health diagnoses and treatment for dental health care workers.”

AI technology to automate the process of denture design and enhance treatment efficiency without compromising accuracy

 

Loss of permanent teeth is usually caused by dental diseases or trauma and is common in the global population, especially among the elderly due to aging and relatively poorer oral health.

Failure to replace a missing tooth not only affects facial aesthetic and chewing function, but it may also lead to jawbone loss and shifting to teeth, which may cause malocclusion and bite irregularities that could have a significant impact on the health of the remaining teeth, gums, jaw muscles and jaw points.

Artificial teeth, also known as bridges and dentures, are prosthetic devices used to replace missing teeth. It is essential for the false teeth to resemble the patient’s original tooth so that the patient can retain his or her original appearance, chewing function, oral and physical health.

Currently, the process of designing and creating dentures is highly time-consuming as the existing computerised design process requires tedious manual inputs, teeth occlusion information collection as well as multiple denture fitting procedures due to limited accuracy of exciting technologies.

Researchers from the Faculty of Dentistry at the University of Hong Kong (HKU) and the Department of Computer Science of Chu Hai College of Higher Education, collaborated to develop a new approach using artificial intelligence to automate the design of individualised dentures, in order to enhance the treatment efficiency and improve patient experience.

The AI technology used in the process was based on 3D Generative Adversarial Network (3D-GAN) algorithm and tested on 175 participants recruited at HKU. The study shows that AI technology could reconstruct the shape of a natural healthy tooth and automate the process of false teeth design with high accuracy.

“The 3D GAN algorithm was selected due to its superior performance on 3D object reconstruction compared to other AI algorithms. In the preliminary study, 3D GAN was able to rebuild similar shapes to the original teeth for 60% of the cases. It is expected to mature with more AI training data,” co-Investigator, Dr Reinhard Chau explained.

The new approach only requires the digital model of a patient’s dentition to function. It can learn the features of an individual’s teeth from the rest of the dentition and generate a false tooth that looks like the missing tooth.

“This will facilitate the treatment workflow for dentists in replacing a missing tooth, as the preparation and fitting process will require minimal time, and a patient will not need to stay at the clinic for long hours,” said Principal Investigator Dr Walter Lam.

The study entitled “Artificial intelligence-designed single molar dental prostheses: A protocol of prospective experimental study” is published in the journal PLoS ONE. The preliminary results of the study were presented in the recent International Association of Dental Research (IADR) General Session. The study won the IADR Neal Garrett Clinical Research Prize and First runner-up in the 2022 IADR-SEA Hatton Award - Senior Category.

The research team members
HKU Faculty of Dentistry
Principal Investigator: Dr Walter Lam, Clinical Assistant Professor in Prosthodontics and Founding Member of HKU Musketeers Foundation Institute of Data Science
Co-investigators:
- Dr Reinhard Chau, Research Assistant in Restorative Dental Sciences and Applied Oral Sciences & Community Dental Care
- Professor Colman McGrath, Clinical Professor in Dental Public Health
- Dr Khaing Myat Thu, Senior Research Assistant in Restorative Dental Sciences

Chu Hai College of Higher Education
Co-investigator:
Professor Richard Hsung, Associate Professor in Department of Computer Science

The Journal “Artificial intelligence-designed single molar dental prostheses: A protocol of prospective experimental study”:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268535

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JOURNAL

PLoS ONE

DOI

10.1371/journal.pone.0268535 

Studying the link between gum disease and Alzheimer’s disease

 

Fusobacterium nucleatum (F. nucleatum) is a common type of bacteria that proliferates in periodontal disease. It affects the gums and jawbone, and if untreated results in unstable teeth and tooth loss. In recent years, F. nucleatum has been linked to conditions ranging from colorectal cancer to premature delivery of babies.

Now new research published in the journal Frontiers in Aging Neuroscience by Tufts University scientists and colleagues suggests a link between F. nucleatum and Alzheimer's disease.

"In this study, our lab is the first to find that Fusobacterium nucleatum can generate systemic inflammation and even infiltrate nervous system tissues and exacerbate the signs and symptoms of Alzheimer's disease," says Jake Jinkun Chen, professor of periodontology and director of the Division of Oral Biology at Tufts University School of Dental Medicine. The first author of the paper is Hongle Wu, who was a postdoctoral fellow in the Chen Lab at the time of the study.

F. nucleatum can also generate severe generalized inflammation, which is a symptom of many chronic diseases including Type 2 diabetes and Alzheimer's disease, notes Chen, who is also a trained pathologist and professor in the Department of Developmental, Molecular and Chemical Biology at the School of Medicine and Graduate School of Biomedical Sciences.

Chen and his colleagues believe that by targeting F. nucleatum, they can slow the spread and progression of at least two epidemics—periodontal disease, which affects 47% of U.S. adults over age 30, and Alzheimer's, which afflicts 6.5 million Americans currently, and is expected to increase to over 14 million by 2060.

F. nucleatum and Immune Cells in the Brain

The latest research, done in mice, shows that F. nucleatum results in an abnormal proliferation of microglial cells, which are immune cells in the brain that normally remove damaged neurons and infections and help maintain the overall health of the central nervous system. This over-supply of microglial cells also created an increased inflammatory response, the researchers found. Chronic inflammation or infection is believed to be a key determinant in the cognitive decline that occurs as Alzheimer's disease progresses.

"Our studies show that F. nucleatum can reduce the memory and thinking skills in mice through certain signal pathways. This is a warning sign to researchers and clinicians alike," Chen says.

Possible links between periodontal disease and Alzheimer’s have been posited by scientists in the past. While the new research does not show that F. nucleatum-related periodontal disease leads directly to Alzheimer’s disease, the new study suggests that periodontal disease caused by F. nucleatum and left untreated or poorly treated could exacerbate symptoms of Alzheimer's disease, Chen believes. Conversely, treating periodontal disease effectively in those who have early-stage Alzheimer's could potentially slow Alzheimer's progression.

"Testing for bacterial load and degree of symptoms could one day become a way to measure the effects of F. nucleatum and manage treatment to slow progression of both periodontal disease and Alzheimer's," Chen says.

Their research also suggests potential drug targets that could specifically quench the local as well as systemic inflammation caused by F. nucleatum in a periodontal environment.

Oral Infections and Systemic Diseases

More broadly, Chen and colleagues are targeting their translational research at blocking the pathways between periodontal disease and not only Alzheimer’s, but other diseases linked to inflammation, including Type 2 diabetes.

Only 2% of mRNA is translated into proteins. Ninety-eight percent of RNA is "noncoding" and traditionally has been considered as no more than "junk genes." But increasingly scientists, including Chen, are uncovering important functions they possess.

In particular, his lab is focused on two noncoding RNAs. One—microRNA—regulates the production of proteins in cells. Another—lncRNA—performs other functions to regulate gene expression and could ultimately be used to treat atherosclerosis (hardening of the arteries) as well as periodontal disease, diabetes, cancer, and diabetic bone disease.

Studies by Chen's lab have shown that a molecule called microRNA-335-5P can inhibit damage done by periodontal pathogens. The molecule could also have a robust effect in targeting the pathological molecules produced in the brain that lead to Alzheimer's.

"MicroRNA in general suppresses gene expression and could stop the production of certain proteins. MicroRNA-335-5P in particular could target three 'bad' genes—DKK1, TLR-4, and PSEN-1—all believed to be related to Alzheimer's disease," he says.

His lab has also designed a small molecule called adipoAI, which has strong anti-inflammatory properties. Chen hopes to begin a clinical trial soon to study whether it is effective in treating a range of inflammatory diseases including Type 2 diabetes, Alzheimer's disease, and periodontal disease.

"Your mouth truly is the gateway to your body," he says

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Gender inequities in dental research publications: Findings from 20 years

This study described trends in gender disparities in first and last authorship in the most cited dental publications and general dental literature over a 20- year period. Articles and bibliometric data were retrieved from the Scopus database for the period 1996 to 2015. Two groups of 1,000 articles each were retrieved: a random sample and another sample of top-cited articles for each year. The gender of the first and last author of each publication was manually identified. When this was not possible, an online software platform was used (https://genderize.io). Descriptive analyses identified the proportion of female first and last authors in both samples, stratifying by dental discipline and geographic region. Trends were ascertained by frequency metrics across years.

Gender disparity was observed in both first and last authorship, with a larger gap being observed in the top cited sample. Women led 28.4% and 20.3% of articles in the random and top cited samples, respectively. A similar pattern was observed for the last authorship group (22.1% and 16.1%, respectively). An increasing trend in the proportion of articles led by women over time was observed in both samples. This increase was larger in the top cited sample (from 15.0% in 1996-2000 to 25.1% in 2015) than in the random sample (from 26.3% in 1996-2000 to 33.2% in 2011). Clear gender disparities in dental research publications in the last 20 years were identified in both general and top cited manuscripts, across dental disciplines, across countries, across first and last authorship, and over time. The authors call for actions to be taken to attract, retain and promote women in science, as well as to monitor and ensure progress towards gender equity.

View this Interactive Talk in the IADR General Session Virtual Experience Platform.

Study examines the influence of dietary free sugar intake on dental caries

Free sugar consumption was measured in children enrolled in the Barwon Infant Study at age 18-months and 4-years. The exposure, free sugar intake was quantified as continuous and binary variables indicating less than 5% of total energy intake (TEI) at 18-months and 4-years of age. The prevalence of dental caries was obtained from dental records. Multiple logistic regression estimated the effect of the exposure variables on the presence of dental caries at 4-6 years of age, adjusting for potential confounders.

Of the original birth cohort, dietary data (N=863) and dental caries data (N=368) were available. 70.4% and 36.7% participants consumed less than 5% TEI from free sugars at 18-months and 4-years, respectively. Dental caries affected 46.7% of children. In fully adjusted models, free sugar at 18-months (OR 1.74; 95% CI 1.06, 2.86 per 5% of TEI) and at 4-years of age (OR 1.43; 95% CI 0.90, 2.28, per 5% of TEI) increased dental caries risk at 4-6 years. The estimated effect of consuming less than 5% free sugars of TEI at 18-months and 4-years of age on dental caries prevalence at 4-6 years was an OR 0.71, 95% CI 0.42, 1.19 and OR: 0.61; 95% CI 0.38, 0.97 respectively. The estimated effect of lowering free sugars to less than 5% of TEI at both timepoints compared to exceeding 5% TEI at one or both timepoints, on dental caries risk at 4-6 years was an OR 0.55; 95% CI 0.33, 0.93.

The authors concluded that between 18-months and 4-years, free sugar consumption increased markedly with two thirds of children exceeding 5% of TEI at 4-years of age. Early free sugar intake increases the risk of dental caries at 4-6-years of age.

View this Interactive Talk in the IADR General Session Virtual Experience Platform.

Acids in sugar-free beverages could erode tooth enamel,

  New research finds acids in sugar-free beverages could erode tooth enamel, as a recipe mixing flavored sparkling water with balsamic vinegar to create a so-called “healthier” alternative to soda takes TikTok by storm.

The research, published online in the open access journal JADA Foundational Science, adds to our understanding about the importance of limiting consumption of acidic beverages. The TikTok video of adding balsamic vinegar (an acid) to flavored sparkling water (an acidic beverage) recently received more than 6.3 million views. 

“I love balsamic vinegar, but I enjoy it more on my salad than in my drinking glass. It’s much kinder to the teeth than bathing them in a beverage blend of two acids,” says Dr. Edmond Hewlett, a spokesperson for the American Dental Association. “The more acidic the drink, the greater the risk of tooth erosion with frequent consumption.”

Acidic foods and beverages can wear away the enamel that protects teeth, a process known as tooth erosion. Tooth erosion is permanent and may open the door for bacteria to cause cavities or infection. It can also make teeth appear discolored, as white enamel is worn away to expose the yellow layer below called dentin.

Research and results

In the study, researchers wanted to see whether non-carbonated bottled water, flavored sparkling water and plain sparkling water might cause dental erosion. Recently extracted human teeth were soaked in 7 different sugar-free beverages (and one soda with sugar for comparison) to see which, if any, beverages caused erosion. Teeth were exposed for twenty-four hours, which the researchers considered to replicate a year’s worth of exposure to these beverages.

When measuring the results of soda with sugar versus sugar-free soda, they found acids in both caused dental enamel to erode. Sweetener type was less of a factor, as it was the acid in the beverage that eroded the enamel.

Researchers also observed erosion in flavored sparkling waters, though it was less than that observed for sugar containing and sugar-free soda. The only beverages in the study that did not erode enamel were non-carbonated, non-flavored bottled waters.

Consuming acidic foods and beverages

While the TikTok recipe was not included in the study, it is similar to the other sugar-free, acidic beverages tested.

“People find carbonated beverages refreshing, especially this time of year. Enjoy them in moderation and preferably with meals,” Dr. Hewlett says. “But if you’re looking for a glass of something that is actually good for your dental health, regular water, including fluoridated tap water, or milk are always good options.”

The American Dental Association offers these tips to reduce tooth erosion from acidic food and beverages:

• Use a straw, sip and swallow – do not swish or hold it in your mouth longer than you need to.

• Wait an hour before brushing to give saliva a chance to naturally wash away acids and re-harden enamel.
• Rinse with water, drink milk or enjoy a snack of cheese right afterward. Dairy and other calcium-rich foods can help neutralize acids.
• Keep saliva flowing to keep acids under control and protect your teeth. You can do so by chewing sugarless gum. 
• Look for dental health products like enamel erosion control toothpaste and sugarless gum with the ADA Seal of Acceptance, which indicates the product has been rigorously and independently evaluated by dental experts.  
• Practice good oral health every day: Brush twice a day with fluoride toothpaste, clean between your teeth daily with floss or another interdental cleaner, eat a healthy diet that limits sugary foods and beverages, and visit a dentist regularly.

Visit MouthHealthy.org for more information on how food and beverage choices can impact teeth.
 

Linking medical and dental records in health information exchanges could improve dental patient safety, preventive care, and treatment outcomes

 

– Dental professionals require access to each patient’s complete electronic health record – including laboratory test results and current prescriptions – so they can provide the best care possible; care that is safe for the patient, promotes preventive management and improves dental treatment outcomes.

This unprecedented access would aid all types of dental professionals, including general dentists, oral surgeons, periodontists, prosthodontists, endodontists, hygienists and others. A new multi-study project from the Regenstrief Institute and Indiana University School of Dentistry has determined that information from patients’ medical records is generally not available to oral health practitioners in either an easy-to-use or timely manner.

The dental informatics researchers confirmed that requested medical information typically is faxed from a medical facility to the dental office. Faxes, sometimes unreadable when received, often are scanned into the patient’s dental record. The researchers found that, typically, the faxed information arrived in 7 to 10 days, although in the study, 30 percent took even longer.

“Oral health practitioners may need to confirm a list of medical considerations; for example, that there is no contraindication to a patient sitting in a chair for a lengthy procedure or whether a patient is taking any medication that could put them at risk for excessive bleeding during a tooth extraction or other procedure,” said senior author and study leader Thankam P. Thyvalikakath, DMD, MDS, PhD, director of the Regenstrief and IU School of Dentistry Dental Informatics program. “In this day and age of electronic data transmissions in banking, shopping and other commercial fields, should health professionals still be relying on inefficient, paper-based methods for sharing patient information?”

Demand for advanced dental care is increasing due to people living longer with chronic diseases like HIV and the growing number of older adults with natural teeth. For these patients, information from their medical file may be especially critical to appropriate dental treatment.

The researcher-clinicians found that the medical information most frequently requested by a dental office to finalize treatment decisions and procedure timing were patient diabetes status and history of blood sugar levels. Knowing this information helps oral health professionals rule out any contraindication to undergo dental treatments, determine outcomes of a surgical procedure or assess options for implant placement and calculate risk for gum disease. For example, if blood sugar numbers are high, there is a greater probability that an implant may fail.

“Retrospective Study of the Reasons and Time Involved for Dental Providers’ Medical Consults” is published in the peer-reviewed journal Frontiers in Digital Health. Authors, in addition to Dr. Thyvalikakath, who is the senior and the corresponding author, are Shuning Li, PhD, IU School of Dentistry; Karmen S. Williams, MBA, DrPH, Regenstrief Institute and IU Richard M. Fairbanks School of Public Health, IU School of Dentistry and City University of New York; Jayanth Kuman Medam, BDS, M.S., IU School of Dentistry and ELLKAY LLC; Jay S. Patel, BDS, MS, PhD, IU School of Dentistry and Temple University and Theresa Gonzalez, DDS, IU School of Dentistry.

The study was funded by IU School of Dentistry and the National Library of Medicine.

Related study reports few dental-medical record integrations exist

In a related study, published earlier this year, Dr. Thyvalikakath and colleagues report that, with the exception of large healthcare organizations that provide both dental and medical care to patients, for example safety net health systems, few integrated medical-dental records exist. In “How Do Dental Clinicians Obtain Up-To-Date Patient Medical Histories? Modeling Strengths, Drawbacks, and Proposals for Improvements,” also published in Frontiers in Digital Health, the researcher-clinicians present a health information exchange (HIE) approach they designed to address the need of dental professionals to access a patient’s medical record expeditiously. They note this approach can be adopted by electronic health record (EHR) and electronic dental record (EDR) vendors to develop a connection between dental systems and HIEs.

Authors of this study, in addition to Dr. Thyvalikakath, who is the senior author, are Shuning Li, PhD, IU School of Dentistry; Anushri Singh Rajapuri, BDS, M.S., Regenstrief Institute; Grace Gomez Felix Gomez, BDS, PhD, MPH, IU School of Dentistry; and Titus Schleyer, DMD, PhD, and Eneida Mendonca, M.D., PhD, Regenstrief Institute and IU School of Medicine. 

“Oral health practitioners shouldn’t have to wait, as our work shows they often currently must, for medical information to make treatment decisions. Delays in receiving medical information can require dental treatment to be postponed, sometimes to the detriment of the patient’s health and convenience,” said Dr. Thyvalikakath. “And the exchange of information process should be two-way – in addition to the medical record informing dental care, dental records can inform medical care. For example, an oral health professional’s identification of new oral ulcers or dry mouth may alert the physician to a previously unreported medical issue or present another symptom, helping in the identification of a medical syndrome. Incorporating the patient’s electronic dental record as part of the information that can be shared through an HIE makes this possible and practical.”

NIH 5-year grant to investigate HIEs and medical-dental records coordination

Dr. Thyvalikakath recently received a grant, 1RO1DE031259-01, “Development and evaluation of patient medical summary from health information exchange to improve dental care,” expected to total $2.4 million over five years, from the National Institutes of Health’s National Institute of Dental and Craniofacial Research (NIDCR) to build upon the knowledge gained in the two studies and to investigate how an HIE can improve communication and referrals between dental and medical clinicians.

“The advantage of accessing the patient’s medical history through an HIE is that not only will the data be readily and promptly available, but dental professionals will also have access to extensive information coming from multiple providers – the primary care physician, specialists, emergency departments, and from multiple healthcare systems,” said Dr. Thyvalikakath. “Incomplete patient medical history can compromise dental care and increase the risk of potential adverse events, a concern that has intensified during the pandemic with oral health professionals having to rely on the patient for many issues related to COVID-19, such as immuno-compromised status and vaccine history, to prevent disease transmission.”

With the NIDCR funding, the researchers hope to demonstrate that the electronically transmitted patient medical summaries from an HIE, in addition to being timelier, will contain a higher percentage of complete, up-to-date and legible medical information than what oral health providers now receive via fax.

The goal of the study, which will commence in the coming months, is to lay a strong foundation for interprofessional dental-medical care delivery that supports patient care and reduces dental care costs. The research team plans to design, develop and test new technological solutions that are practical for the connection of even solo- and small- group dental practices with community HIEs to access their patients’ medical data. They anticipate that their work will facilitate bidirectional communication among providers to promote patient safety and enhance both dental and medical health.

Thankam Thyvalikakath, DMD, MDS, PhD  

In addition to her role as a Regenstrief research scientist and director of the Regenstrief and IU School of Dentistry Dental Informatics program, Thankam Thyvalikakath, DMD, MDS, PhD, is the director of the dental informatics core, a professor at IU School of Dentistry and an adjunct associate professor in the IUPUI School of Informatics and Computing.