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Need to Reduce the Number of Antibiotic Prescriptions

Thedevelopmentofantibioticsmarked a dramatic advance in the management of infectious diseases, and one of the most important advances in modern medicine. Antibioticsgreatlyreducedthemorbidityand

mortalityratesassociatedwithbacterialinfec-

tions. Nevertheless, over the past 75 years, the extensive use of antibiotics has resulted in the emergence of microorganisms that

are resistant to most, if not all, of the major antibiotics. Further, the development of sec-

ondaryinfections,whichrepresentstheover-

growthofotherpathogenicmicroorganisms, can be life threatening. 1

Thissituationisdueinlargeparttoover-

prescribing of antibiotics in clinical practice as well as other uses of antibiotics, including increasing the growth of livestock. A recent report fromtheCenters forDiseaseControl and Prevention indicates that one third of the antibiotic prescriptions written by med- ical providers in outpatient settings were unnecessary. 2 Whileantibioticusagebyphysi- cians is declining, a disturbing trend is an apparentincreaseinantibioticprescriptions by dentists. 3,4 This practice must be evaluat- edandcorrectiveactiontaken.Dentistsmust have current knowledge on the appropriate use of antibiotics. 5,6

Antibiotic Prescribing by Dentists

In the United States, antibiotic pre-

scribingindentistryrepresentsaround10%

of the total prescribed annually, 7 10% of the total in Spain, and 9% of the total in Scotland. 8,9 In the Czech Republic, dentists were responsible for 8.5% of all antibiotics prescribed in 2012 compared with 6.5%in 2006. 4 Further,inBritishColumbiathepro- portion written by dentists represented 11.3% of the total in 2013 versus 6.7% in 1996; a 62.2% increase. 3 In contrast, physi- cians’ prescriptions in the same period decreased by 18.2%. 3

Of further concern, more broad-spec-

trumantibioticsarebeingprescribedbyden-

tists—predominantlytheamoxicillingroup—

andfewernarrow-spectrumdrugs(e.g.,peni-

cillin V). 10-15 Broad-spectrum antibiotics are

wellrecognizedforanincreasedriskofantimi-

crobial resistance. 5 In a 2009 survey in the United States (n = 845), amoxicillin was the

firstchoicefor37.6%ofrespondingdentists

in2009(intheabsenceofanallergy),upfrom

27.5%in1999.Inthesameperiod,penicillin

was the first choice for 43.3%in 2009, down

from61.5%in1999. 10 IntheCzechRepublic, amoxicillinwithclavulanicacid(Augmentin ® )

accountedfor31.4%ofantibioticsprescribed

by dentists in 2012 compared with 23.1% in

2006, and 19% of all antibiotics used in pri- mary care. 4 Similar trends are observed in othercountries 3,11-16 (seetableonnextpage).

Inadditiontotheincreaseduseofamox-

icillin, the number of unnecessary prescrip- tionswrittenbydentistsforclindamycinand

cephalosporinsisofconcern,giventheirasso-

ciationwithClostridiumdifficile-associateddis-

ease (i.e., pseudomembranous colitis). 1

Inappropriate Prescribing

Inappropriate antibiotic prescribing by dentists has been reported for dry sockets,

third molar extractions, localized swelling, andperiodontalandendodontictreatment. 3,5,17

Inoneretrospectivechartreview,70%ofantibi-

otic prescriptions were inappropriate, the majority given for acute pulpitis. 5 Antibiotics are not required for most properly managed endodonticinfections. 18 Routineuseofantibi- otics is not required for apical periodontitis (AP), chronic/acute apical abscesses (CAA/ AAA), 18 and clearly not indicated for irre- versible pulpitis (IP). Antibiotics should be prescribedwhenthereisdiffusefacialswelling or systemic involvement (fever, malaise, lym-

phadenopathy), 10,18 and when indicated by a patient’s medical status. 18

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Volume 26, Number 3, 2016

In This Issue NeedtoReducetheNumberof AntibioticPrescriptions 1 CLINICAL PRACTICE - Diagnosisof
In This Issue
NeedtoReducetheNumberof
AntibioticPrescriptions
1
CLINICAL PRACTICE - Diagnosisof
AcuteEndodonticLesions
4
TECHNOLOGY - Fixed Orthodontic
Appliances or Clear
Aligner Treatment
5
DENTISTRY AND HEALTH CARE -
Obesity and Periodontitis
7
PREVENTIVE DENTISTRY -
Dental Managementof
Patients with Autism
9
HEALTHCARE TRENDS -
MethamphetamineAbuseandthe
RolefortheDental Profession
11
Educational Objectives After reading this issue of the Colgate Oral Care Report and correctly answer-
Educational Objectives
After reading this issue of the Colgate
Oral Care Report and correctly answer-
ing the questions in the Continuing
EducationQuiz, youwill
1. understandtheproblemsassociated
withantibioticover-prescribingand
seethenecessityforpracticinggood
antibioticstewardship;
2. learnthelatesttechniquesdesigned
toassistdentalprofessionalsin
determiningthediagnosisofpainof
endodonticorigin;
3. becomefamiliarwiththerelative
benefitsofclearretainer-likeappli-
ancesvs.bracketsandarchwires
forcertainorthodontictreatments;
4. knowthelatestevidencesupporting
obesityasariskfactorforperiodon-
taldisease;and
5. recognizethechallengesassociated
withtreatingautisticpatientsand
thesuggestedmeanstoprovide
effectivecare.

Providing Continuing Education as a Service to Dentistry Worldwide

2

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Antibiotic Prescribing by Dentists 4,10-15

2004

Belgium

75.1%of prescriptions were amoxicillin or amoxicillin with clavulanic acid

2009

Spain

1st choice amoxicillin for 44.3%, amoxicillin with clavulanic acid for 41.8%

2009

USA

1st choice penicillin VK for 43.3%, amoxicillin for 41.2%

2010

Spain

1st choice amoxicillion with clavulanic acid for 61%, amoxicillin for 34%

2012

Czech Rep.

31.4%prescribedamoxicillinwithclavulanicacid(Augmentin)

2013

Jordan

62.9%most often prescribed amoxicillin, 33.4%amoxicillin combinations (with clavulanic acid and/or metronidazole)

2013

Turkey

61.8%often prescribed amoxicillin with clavulanic acid,

 

46.5%amoxicillin

2015

Saudi Arabia

45.2%prescribed amoxicillin with clavulanic acid, 33.7%amoxicillin and 15%amoxicillin with metronidazole

In one retrospective chart review, 70%of antibiotic prescriptions were inappropriate, the majority given for acute pulpitis.

Nonetheless, prescribing antibiotics for

endodontic conditions is a widespread prac- tice. Inappropriate prescribing is reported

forIP,acuteapicalperiodontitis(AAP),chron-

ic apical periodontitis, AAA, and other con- ditions. 3-5,8,10,11-15 AntibioticprescribingforAAP (with no swelling) was reported by 28.3%, 59%, and 71% of clinicians in surveys from the United States, Saudi Arabia, and Spain, respectively 10,12,15 (see figure).

Percentage of clinicians prescribing antibiotics for AAP (no swelling)

28%

59%

71%

n United States

n Saudi Arabia

n Spain

Antibiotics are also prescribed to man- ageendodonticflare-ups 10 andtorelievepain betweentreatments, 10 yetthereisnoevidence to support this practice. 3 Furthermore, they are given in lieu of proper treatment; 5,10,14 an antibiotic prescription without any definitive treatment was provided to 54% of patients receiving care in an after-hours dental clin- ic. 19 In other research, differences in the pat-

tern of antibiotic use have resulted in signifi-

cantdifferencesinthelevelofantibioticresist-

ance,withonestudyfindingincreasedantimi-

crobialresistanceforperiodontalpathogens. 20

The most important initial decision is not which antibiotic to prescribe, but whether to use one at all.

Other Factors

Additional reasons given for inappropri-

ateprescribingincludetheneedtodelaydefin-

itivetreatment,anuncertaindiagnosis,theneed to avoid problems if the patient/clinician will be on vacation, and lack of resources to pay

for care (no dental insurance). 10,11,21 Excessive antibiotic prescribing may also be associated

withtheincreaseinimplanttreatmentandasso-

ciatedcomplications,andwithroutineextrac-

tionof thirdmolars. 3 Patientexpectationsareadriver. 10,11,21 Insep- aratepatient anddentist surveys intheUK, 23% of patients (n=156) expectedanantibiotic and

8%ofdentistsreportedbeinginfluencedbysuch

expectations. 21 IntheUnitedStates, 19%of clin- icians gaveantibiotics if patients askedfor them, or out of fear of losing referrals if requested by thereferringdentist. 10

Patient expectations are a driver for over-prescribing of antibiotics by dentists.

Lackofawarenessandknowledgeofcur-

rentguidelinesandanunwillingnesstochange are additional factors in antibiotic over-pre- scribingbydentalprofessionals.Furthermore, differences between past and current guide- lines (e.g., regarding antibiotic prophylaxis, lackofclarity,andminordifferencesbetween setsofguidelines)mayresultinconfusion. 18,21 As an example, revised guidelines were pro- videdbytheAmericanDentalAssociationon

antibiotic prophylaxis for patients with pros-

theticjointsandforprophylaxisagainstinfec-

tive endocarditis. 22 In contrast to prior rec- ommendations, there are now “relatively few patient subpopulations for whom antibiotic prophylaxismaybeindicatedpriortocertain dental procedures.” 22

Current Guidelines and Antibiotic Stewardship

Antimicrobialstewardshipprogramsare intended to optimize the use of antimicro- bials through appropriate use, dosing, dura- tion, and selection. 23 Guidelines include (1) prescribing the shortest effective dose; (2) only prescribing when necessary and provid- ing a delayed prescription that a patient can

fill later if needed; (3) discussing alternatives

withpatientsandeducatingthemaboutantibi-

otic use and risks; (4) avoiding repeat pre- scriptions whenever possible; and (5) audit- ing healthcare facilities for antibiotic pre- scribing patterns. 24

Improving Antibiotic Stewardship

Aconcertedeffortisrequiredtoimprove

antibiotic prescribing. In a review of interven- tions with providers, there was moderate evi- dence supporting communication skill train- ing. 23 Theevidenceforeffectivenessofprovider or patient education, guidelines, delayed pre- scribing, and computer-aided decision mak- ing was weak. However, the relative efficacy of individual interventions was not provided in most studies where several were used. 23 In a separate review, the most effective outcome

wasachievedusingacombinationofinterven-

tionsinvolvingproviders,patients,andthepub-

lic. 25 Interactive educational meetings were foundtobemoreeffectivethandidacticones, andpatienteducationwasalsoeffective.Printed educationalmaterialsoraudit/feedbackalone were of limitedvalue. 24 Intensive training has proven effective in changing prescribing behaviors, at least in

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the short term. In one prospective two-cycle audit of 60 patients, clinicians and students receivedintensivetrainingbetweentheaudits, whichwereheldtwomonthsapart.Significant improvements in prescribing were observed, with 80%of antibiotic prescriptions meeting

the guidelines versus 30% at the first audit. 5 Research-based audit and feedback mecha- nisms are now being investigated in a clus- tered, randomized, stratified trial. The con-

trolgroupistheauditgroup,whileeachden-

tist in the intervention group received individualized feedback regarding his/her

antibiotic prescribing rate for the prior 14 months. Some dentists also received feedback

at9months,text-basedinterventions,andacom-

parator. This trial will provide further informa-

tiononinterventions andtheir efficacy. 9

Computer-aided clinical decision mak- ingalsoshowspromiseasaguideforimproved

antibiotic prescribing. 26 In five of seven ran- domized or cluster randomized trials, a sta- tistically significant improvement in antibiot- ic prescribing was observed using this tool; greater improvements were observed when computer-aidedclinical decisionmakingwas used.Moreresearchisrequiredtodetermine

whichaspectsofcomputer-aidedclinicaldeci-

sion making would best drive appropriate antibiotic prescribing. 26

Conclusions

Over-prescribing of antibiotics by den- tists is observed globally, including both the clinical scenarioandselectionof aninappro- priate drug or dose. Recent studies are help- ingtodeterminerequiredchangesandwhich

interventions will be most effective. In order

tocombatantimicrobialresistance,itisessen-

tial that dental professionals understandand adheretotheguidelinesforantibioticuseand practice good antibiotic stewardship. OC

References

1. Beacher N, Sweeney MP, Bagg J. Dentists, antibiotics and Clostridium difficile-associat- ed disease. Br Dent J 2015;219:275-9.

2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, BartocesM,EnnsEA,FileTM,Jr.,Finkelstein JA, Gerber JS, Hyun DY, Linder JA, Lynfield R,MargolisDJ,MayLS,MerensteinD,Metlay JP, Newland JG, Piccirillo JF, Roberts RM, Sanchez GV, Suda KJ, Thomas A, Woo TM, Zetts RM, Hicks LA. Prevalence of inappro- priate antibiotic prescriptions among US ambulatory care visits, 2010-2011. J Am Med Assoc 2016;315:1864-73.

3. Marra F, George D, Chong M, Sutherland S, Patrick DM. Antibiotic prescribing by den- tists has increased: Why? J Am Dent Assoc

2016;147:320-7.

4. Pipalova R, Vlcek J, Slezak R. The trends in

antibiotic use by general dental practition- ers in the Czech Republic (2006-2012). Int Dent J 2014;64:138-43.

5. ChopraR,MeraliR,PaolinelisG,KwokJ.An auditofantimicrobialprescribinginanacute dental care department. Prim Dent J 2014;

3:24-9.

6. Johnson TM, Hawkes J. Awareness of antibi-

oticprescribingandresistanceinprimaryden-

tal care. Prim Dent J 2014;3:44-7.

7. CherryWR,LeeJY,ShugarsDA,WhiteJr.RP,

Vann Jr. WF. Antibiotic use for treating den- talinfectionsinchildren:asurveyofdentists’ prescribing practices. J Am Dent Assoc

2012;143:31-8.

8. Robles Raya P, de Frutos Echaniz E, Moreno Millán N, Mas Casals A, Sánchez Callejas A, Morató Agustí ML. I’m going to the dentist:

antibiotic as a prevention or as a treatment? Aten Primaria 2013;45:216-21.

9. Prior M, Elouafkaoui P, Elders A, Young L, Duncan EM, Newlands R, et al. Evaluating

anauditandfeedbackinterventionforreduc-

ing antibiotic prescribing behaviour in gen-

eral dental practice (the RAPiD trial): a par- tial factorial cluster randomised trial proto- col. Implement Sci 2014;9:50.

10. Pye K. Antibiotic Use by Members of the American Association of Endodontics: A National Survey for 2009. A follow up from

thereportin1999.Availableat:http://schol-

arscompass.vcu.edu.

11. Dar-OdehNS,Al-AbdallaM,Al-ShayyabMH, Obeidat H, Obeidat L, Abu Kar M, Abu-

HammadOA.Prescribingantibioticsforpedi-

atric dental patients in Jordan; knowledge andattitudesofdentists.IntArabicJAntimicrob Agents 2013;3(4):1-6.

12. Iqbal A. Theattitudesofdentiststowardsthe prescription of antibiotics during endodon- tictreatmentinNorthofSaudiArabia.JClin Diagn Res 2015;9:ZC82-4.

13. Mainjot A, D’Hoore W, Vanheusden A, Van Nieuwenhuysen JP. Antibiotic prescribing in dental practice in Belgium. Int Endod J

2009;42(12):1112-7.

14. Kaptan RF, Haznedaroglu F, Basturk FB, Kayahan MB. Treatment approaches and antibioticuseforemergencydentaltreatment in Turkey. Ther Clin Risk Manag 2013;9:

443-9.

15. Segura-Egea JJ, Velasco-Ortega E, Torres-

LagaresD,Velasco-PonferradaMC,Monsalve-

GuilL,Llamas-CarrerasJM.Patternofantibi-

otic prescription in the management of

endodontic infections amongst Spanishoral surgeons. Int Endod J 2010;43(4):342-50.

16. Rodriguez-Núñez A, Cisneros-Cabello R,

Velasco-OrtegaE,Llamas-CarrerasJM,Tórres-

Lagares D, Segura-Egea JJ. Antibiotic use by membersoftheSpanishEndodonticSociety.

J Endod 2009;35(9):1198-203.

17. JaunayT,SambrookP,GossA.Antibioticpre-

scribing practices by South Australian gen-

J

eral dental practitioners.

2000;45:(3):179-86.

Aust

Dent

18. American Association of Endodontists. Endodontics:Colleaguesforexcellence.Use and abuse of antibiotics. Winter 2012.

19. Tulip DE, Palmer NO. A retrospective inves- tigationoftheclinicalmanagementofpatients attending an out of hours dental clinic in Merseyside under the new NHS dental con- tract. Br Dent J 2008;205(12):659-64.

20. Ardila CM, Granada MI, Guzmán IC.

Antibiotic resistance of subgingival species inchronicperiodontitispatients.JPeriodontal Res 2010;45(4):557-63.

21. Cope AL, Chestnutt IG. Inappropriate pre- scribingofantibioticsinprimarydentalcare:

reasons and resolutions. Prim Dent J

2014;3(4):33-7.

22. American Dental Association. Antibiotic prophylaxis prior to dental procedures.

Availableat:http://www.ada.org/en/mem-

ber-center/oral-health-topics/antibiotic-pro-

phylaxis.

23. Drekonja DM, Filice GA, Greer N, Olson A,

MacDonaldR,RutksI,WiltTJ.Antimicrobial stewardship in outpatient settings: a system- atic review. Infect Control Hosp Epidemiol

2015;36:142-52.

Center for Biotechnology

24. National

Information, U.S. National Library of

Medicine. Guidelines set to tackle over-pre- scribing of antibiotics. 2015. Available from:

http://www.ncbi.nlm.nih.gov/pubmed-

health/behindtheheadlines/news/2015-08-

18-guidelines-set-to-tackle-over-prescribing-of-

antibiotics/.

25. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Evid Based Child Health

2006;623-690.

26. Holstiege J, Mathes T, Pieper D. Effects of

computer-aidedclinicaldecisionsupportsys-

tems in improving antibiotic prescribing by

primary care providers: a systematic review.

J Am Informatics Assoc 2015;22:236-42.

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CLINICALPRACTICE

Diagnosis of Acute Endodontic Lesions

One of the most challenging aspects of

clinical dentistry is the accurate diagnosis of acute pain, often due to endodontic involve- ment. Typically, the diagnosis of pain of endodonticoriginreliesonclinicalsymptoms, some simple physical tests, and radiographic

findings.Thesealonemaynot;however,accu-

ratelyprovideadiagnosis.Acuteapicalabscess-

es(AAA)areusuallyobvious,howeveradefin-

itive diagnosis of symptomatic apical peri- odontitis (SAP) and/or of symptomatic irre- versible pulpitis (SIP) for a tooth can be dif- ficultwhenrelyingonclinicalsymptoms,basic physical tests, and radiography. New approaches have also been intro- duced to improve the accuracy of diagnosis of endodontic lesions. These include ultra- soundimagingandcolorDoppler(USCD), 1,2 as well as cone beam computed tomography (CBCT) 3 . These too have their limitations, 1,4 including the static nature of the informa- tion obtained. As acute, emergent situations are often stressful for both the provider and patient, a decision tree has been introduced to help guide the clinician to the proper endodontic diagnosis. 5 Use of the decision tree is a dynamic approach to diagnosis.

Radiographs

Peri-apical radiographs (PAs) are stan- dardpracticewhenassessingacutedentalpain, andtreatmentisoftenbasedontheobserved findings. Digital radiography permits rapid acquisition and manipulation of images, including magnification and digital subtrac- tionapplications. 6 However,sincePAsaretwo- dimensional, not all details are visible. PAs may not detect early periapical changes asso- ciated with SAP, appearing normal or only showing a thickening of the periodontal lig- ament. 7 In one study, PAs detected periapi-

calradiolucenciesinjust15%ofrootsinteeth

withSAP. 8 Inaddition,PAsusuallydetectperi- apical lesions only after the cortical plate has been perforated. 9

PAs may not detect early periapical changes associated with SAP, appearing normal or only showing a thickening of the periodontal ligament.

USCD

Ultrasound technology allows three- dimensional (3D) visualization of structures deepwithinthetissues. 2 Thediagnosticcapa-

bilities of ultrasound are enhanced by color

Dopplertechnology,whichdetectsandmeas-

ures blood flow in the tissues. 10 Studies have

comparedthesensitivity,specificity,andaccu-

racyofUSCDandPAsinthedifferentialdiag-

nosisofperiapicalgranulomatous,cystic,and

mixedlesions,andtotrackpost-surgicalheal-

ing. Results from these studies have been promising, with one (n = 30) finding 100% concurrence in a diagnosis of anterior gran- ulomatous lesions (n = 16) with USCD and the histology gold standard. 2 Nonetheless, there is currently a paucity of USCD data for SAP. In addition, in com- paringUSCDwithPAsandhistologysamples

from periapical lesions in anterior, bicuspid, and molar teeth (n = 30), 1 USCD was found

tobeaccurateonlywhenthemeanbonethick-

ness was < 1.6 mm(p = 0.03). 1 This limits the

potentialuseofthistechniquetoareaswhere cortical bone is thinner, such as the anterior maxilla.

CBCT

CBCTprovidesimagesfreeofdistortion

and without the possibility of superimposi- tionthatisinherentforPAs. 4 Inarecentstudy

(n = 130) comparing the diagnosed preva-

lence of SAP and asymptomatic AP in 307 paired roots representing 138 teeth, 11 AP lesions were observed in 3.3% and 13.7% of roots when using PAs and CBCT, respective-

ly(p<0.05).Agreaternumberoflesionswas

observed for SAP vs. asymptomatic AP using CBCT, and 22 affected roots were identified that were not detected on PAs. 11 In another studyinvolving340pairedroots of 161teeth,

15previouslyunidentifiedaffectedrootswere

found using CBCT. 8 IncomparingtheaccuracyofCBCTand PAsindetectingrootanatomyandanomalies

in250roots,asreferencedtothebenchmark

(transverse sections of teeth; TS), significant- lymorerootcanalswereidentifiedwithCBCT

(294of295vs.230of295withPAs;seeFigure

1). 4 Additionally,CBCTdetected10of16acces- sory canals (with no false positives) and 4 of 5 transverse fractures. 4 The quality of CBCT is,however,impactedbymetallicrestorations, pins, and root fillings. 4

230 294 295 n PAs n CBCT n Transverse Sections

230

230 294 295 n PAs n CBCT n Transverse Sections
230 294 295 n PAs n CBCT n Transverse Sections

294

295

n PAs

n CBCT

n Transverse Sections

Figure 1. Number of root canals identified by different diagnostic techniques. 4

Diagnosis Using a Decision Tree

In a recent study involving patients with

a chief complaint of acute severe dental pain

(n = 221), a decision tree was developed as

an aid to diagnosis. 5 The study included 103

patientsdiagnosedwithSAPand70diagnosed

withSIP.Duringdevelopmentofthedecision tree, the clinical signs and findings and a

checklistwith11questionsonsymptomswere

used to identify differentiators for SIP and SAP.Anumericassessmentofthelevelofpain in the prior 24 hours (with 0 being no pain and 10 being the worst pain imaginable) was included. 5 ClinicalfindingsusedtodifferentiateSIP

andSAPincludedsensitivitytocoldusingcar-

bon dioxide ice, and the identification of a widened periodontal ligament on PAs. However, since PAs may or may not show a widenedperiodontalligamentspacewithSAP, this is not definitive, and early radiolucen- cies may also not be apparent. Of teeth with a pain response to cold, duration of pain < 1 week and that felt high, 72% were correctly determined to have SAP (Figure 2). Non-differentiators included the level, constancy, and reduction of pain spon- taneously or upon application of cold, response to heat, the presence of a sharp or radiating pain, pain on chewing, and sleep disturbance. It was determined that the deci-

75.7% 69.9% n SIP n SAP 48.5% 45.7% 35.9% 28.6% Pain < 1 Week Pain
75.7%
69.9%
n SIP
n SAP
48.5%
45.7%
35.9%
28.6%
Pain
< 1 Week
Pain
Tooth
on Cold
Felt High
Figure2. Frequency of apositive response to differentiators
for SIPandSAP. 5

siontreehadapositivepredictivevalueof67%,

thoughspecificitywasonly31%. 5 Thismeans that therewas a 67%chancethat theindivid- ual had the condition, but also a high risk of false negative findings.

Conclusions

The ability to differentiate endodontic lesions is necessary for an accurate diagnosis andsubsequenttreatment.NotonlycanAAA developrapidly,theemergencytreatmentfor SIP and SAP differ (pulpotomy vs. pulpecto- my). Therefore, an accurate definitive diag- nosis for SIP and SAP is clinically important. Currently, there is a paucity of data for USCD with respect to SIP and SAP. Data on CBCT is promising, although now limited. The decision tree described in this article is an innovation in clinical care. While not a perfect tool, it provides a logical approach to arriving at the diagnosis of pain of endodontic origin. OC

References

1. Tikku AP, Bharti R, Sharma N, Chandra A, Kumar A, Kumar S. Role of ultrasound and colordopplerindiagnosisofperiapicallesions of endodontic origin at varying bone thick- ness. J Cons Dent 2016;19(2):147-51.

2. Sandhu SS, Singh S, Arora S, Sandhu AK, Dhingra R. Comparative evaluation of advanced and conventional diagnostic aids for endodontic management of periapical lesions, an in vivo study. J Clin Diagn Res

2015;9(1):ZC01-4.

3. Leonardi Dutra K, Haas L, Porporatti AL, Flores-Mir C, Nascimento Santos Mezzomo LA, Correa M, De Luca Canto G. Diagnostic accuracy of cone-beam comput- ed tomography and conventional radiogra- phyonapicalperiodontitis:asystematicreview and meta-analysis. J Endod 2016;42(3):

356-64.

4. Weber MT, Stratz N, Fleiner J, Schulze D,

Hannig C. Possibilities and limits of imaging endodontic structures with CBCT. Swiss Dent J

2015;125(3):293-311.

5. Rechenberg DK, Held U, Burgstaller JM,

BoschG,AttinT.Painlevelsandtypicalsymp-

toms of acute endodontic infections: a prospective, observational study. BMC Oral Health 2016;16(1):61.

6. Carvalho FB, Gonçalves M, Tanomaro-Filho M. Evaluation of chronic periapical lesions by digital subtraction radiography by using Adobe Photoshop CS: a technical report. J Endod 2007;33:493-7.

7. Gutmann JL, Baumgartner JC, Gluskin AH, HartwellGR,WaltonRE.Identifyanddefine

alldiagnostictermsforperiapical/periradic-

ular health and disease states. J Endod

2009;35(12):1658-74.

8. Abella F, Patel S, Durán-Sindreu F, Mercadé M, Bueno R, Roig M. An evaluation of the periapical status of teeth with necrotic pulps usingperiapicalradiographyandcone-beam computed tomography. Int Endod J

2014;47(4):387-96.

9. BenderIB,SeltzerS.Roentgenographicand direct observation of experimental lesions in bone. J Am Dent Assoc 1961;62:708.

10. Patel S, Dawood A, Whaites E, Pitt Ford T. Newdimensionsinendodonticimaging:Part 1. Conventional and alternative radiograph- ic systems. Int Endod J 2009;42:447-62.

11. Abella F, Patel S, Duran-Sindreu F, Mercadé M, Bueno R, Roig M. Evaluating the periapi- cal status of teeth with irreversible pulpitis by using cone-beam computed tomography scanningandperiapicalradiographs.JEndod

2012;38(12):1588-91.

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TECHNOLOGY

5

Fixed Orthodontic Appliances or Clear Aligner Treatment

Clear Aligner Treatment (CAT) was introduced commercially approximately 15

yearsago,andrepresentsanalternativetotra-

ditional orthodontic tooth movement with a fixedorthodonticappliance(FOA). 1 Utilizing

a series of clear retainer-like appliances that move the teeth in a sequential fashion, CAT representsamajorchangeinorthodonticcare,

withmorethan3millionpatientshavingbeen

treated across the globe. 2 CAT involves the

applicationofthree-dimensionaldigitaltech-

nology to dentistry, and represents another

aspect in the evolution of clinical practice. Many types of malocclusion have now been treated using CAT, including, but not limit-

edto,maxillaryandmandibularincisorcrowd-

ing,toothrotations,andclassI,II,andIIImal-

occlusions. 1,3-7 CATofferssomedistinctadvan- tages, as well as some limitations. 8

Advantages of CAT

TheadvantagesofCATcomparedtoFOA

includebetterestheticsduringtreatment,the

ability to more easily perform oral hygiene since the aligners are removable, and an absenceof “plaquetraps”(bracketsandarch

wires).Theresultisimprovedoralhealthdur-

ing orthodontic treatment. 9-12

Oral Health-Related Quality of Life (OHRQoL)

OHRQoL is a subjective assessment by the patient of his/her perceived well-being related to the oral cavity. 13 In a study of 100 patients receiving CAT or FOA for a mean durationofslightlyoveroneyear, 9 6%ofCAT and36%of FOApatients perceivedadecline in well-being. Statistically significant differences were observed for “willingness to laugh” (p = 0.012), “impact on eating habits”

(p=0.066),and“gingivalirritation”(p=0.001).

Just 2% of patients receiving CAT said they wouldbeunwillingtohavethesametreatment again vs. 22% of patients receiving
Just 2% of patients receiving CAT said they
wouldbeunwillingtohavethesametreatment
again vs. 22% of patients receiving FOA
(p = 0.004; see Figure 1). 9
Would have
78%
treatment again
98%
Impact on
70%
eating habits
50%
Gingival
56%
irritation
14%
Reluctant
26%
to laugh
6%
Decline in
36%
well-being
n FOA
n CAT
6%

Figure 1. Subjective assessment of factors affecting OHRQoL. 9

In a systematic review of 11 studies, the first few weeks of wearing an FOA negatively impacted OHRQoL, which then partially

rebounded. The most significant influence onOHRQoLwaspain. 13 Ultimately,OHRQoL was higher post- than pre-treatment. In one FOA study, 91% of patients reported pain, some citing it as a reason for wanting to end treatment. 14

98%of patients receiving CAT said they would be willing to have the same treatment again versus 78%of patients receiving FOA.

Inaseparatestudy,lessintenseandshort-

erdurationofpainwasexperiencedbypatients receiving CAT (n = 38) than FOA for edge- wise treatment (n = 55), or a combination of an FOA and then CAT (n = 52). For patients

receivingCATwhocomplainedofpain,itwas usually due to tray deformation. 15

Efficacy of FOA and CAT

The objective of orthodontic treatment is to have esthetically pleasing and function- al outcomes, usually with an ideal occlusion. FOAs are effective in correcting malocclu- sions,andofferhighsuccessrates. 16 However, results vary depending on the malocclusion and its severity, treatment provided, and

patientcompliance. 1,5,16 Openbites 17 andmolar distalization, with movement of the upper

to create space, 18 present

treatment challenges. Relatively minor treat- mentdifferencesmayalsoinfluenceoutcomes; forinstance,FOAarchwire,sequencing,and twisting of arch wire within the slots in the brackets. 5,19 Studies have compared actual and pre- dicted tooth movement to measure ortho- donticoutcomesforCATandFOA.Forlower anterior crowding, in one study a mean dif- ference of 0.01 mm was observed for actual andpredictedtoothmovementwithCAT.The only observed statistically significant differ- encewasforoverbite,withameandifference of0.7mm. 20 Buccalexpansionalongwithinter- proximal reduction (IPR) was determined to be effective for mandibular crowding of < 6 mm in a chart review of CAT (n = 61), although more severe crowding resulted in proclined and protruded lower incisors. 3 Using superimposed digital images, no statisticallysignificantdifferenceswerefound for the same teeth for upper and lower arch- es in another study comparing actual vs. pre- dicted tooth movements (n=37). 21 However, theaccuracyofmovementsfordifferentteeth varied, e.g., derotation for canines was signif- icantly less predictablethanfor lower central incisors (Figure 2). 21

molars posteriorly

59.3% 54.8% 54.2% 32.2% Rotation Rotation Lingual Lingual upper upper constriction constriction central lower
59.3%
54.8%
54.2%
32.2%
Rotation
Rotation
Lingual
Lingual
upper
upper
constriction
constriction
central
lower
lower
canines
incisors
laterals
canines
Figure 2. Mean accuracy of actual vs. predicted tooth
movements using CAT. 21

Therehavebeena number of small het- erogeneous studies that assessed the efficacy ofCAT. 1 Asystematicreviewof11studiesfrom 2000 to June 2014 has been published. 1 CAT was found to be as effective as FOA for the control of vertical buccal occlusionandante- riorintrusion,andtoeffectivelylevelandalign arches. 1 In addition, CAT was observed to be predictableforuppermolardistalization,with an overall accuracy of 88% when 1.5 mm movement was planned. However, results for buccolingual tippingvaried, theaccuracy for extrusion was 30%. 1 CAT was not recom- mended for treatment of an open bite. 1 Plannedderotations <15°androtations with a planned staging < 1.5°/aligner, were signif- icantly more accurate than the outcome for larger derotations. 5

Results and Patient Satisfaction

Predicted and actual tooth movement and occlusion were compared for 27 cases for CAT using the American Board of Orthodontics Objective Grading System (OGS). 22 It was concluded that tooth move- ment was not accurately predicted for CAT. Nonetheless, the results were not dissimilar to those found for FOA therapy. It was also concluded that the OGS score for patients treated with CAT would be clinically accept- able. 22 Further,nomatterhowidealtheocclu- sion and alignment immediately following treatment withFOAor CAT, settling/relapse occurred post-retention. 23,24

Auxiliary

Components/Attachments

Auxiliary components are now incorpo-

ratedintoCAT,withthegoalofachievingbet-

tercontrolofintendedtoothmovement,par-

ticularlyforrotationandtipping. 4 Inonecase,

severe lower incisor rotations were success-

fullycorrectedabout2°/aligner,andthecross-

biteandcrowdingtreatedusingattachments

with a series of 23 aligners over 12 months. 4

Incomparingactualvs.predictedtoothmove-

ment, an overall mean accuracy of 59% was found in a split-mouth study (n = 30). 5

6

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Thedifficultyoftreatingextractioncases

with CAT was demonstrated in a 2006 case. 25 A multicenter randomized controlled trial compared the results of FOA (n = 80) and CAT with attachments (n = 72) for Class I crowding extraction cases. 7 There were no differencesintheoverallOGSscoresforCAT

andFOA,althoughthereweresignificantdif-

ferences for two of the eight OGS categories (buccolingual inclination and occlusal con-

tacts; p = 0.002 and p = 0.000, respectively). ItwasconcludedthatCATandFOAwereboth

successfulintreatingClassIcrowdingextrac-

tion cases. 7

Recent Developments

Mini-screws or temporary anchorage devices (TAD) may be used for supplemen- tal anchorage with FOA, serving to prevent unwantedtoothmovement.Forthetreatment of openbites, adjunctive use of TADor tradi- tional edgewise FOA treatment were both foundtobeeffective. 17 Anidealocclusionwas obtained with both techniques. It was also

found that esthetics might be superior after using TAD, with changes in facial morpholo- gy that resulted in lip competency. 17 The adjunctiveuseofTADforCAT,togetherwith IPR and button attachments, is reported to improvepredictabilityforcomplexcasesand to help prevent tipping. 26 TAD provided anchorageandallowedforintended,butnot unintended, tooth movement. 26

Photobiomodulation(PBM)usinglight-

emitting diodes (LEDs) promotes bone

remodeling and can accelerate tooth move- ment.Inaproof-of-principlecasereport,IPR wasperformed,attachmentswereplacedafter

thepatienthadusedthefirstandsecondalign-

ers, and PBM was applied daily for five min-

utes to each arch. It was thereby possible to

changealignerseverythreedays,andtocom-

plete treatment in six months rather than 92 weeks without any reported discomfort. 27

Conclusions

CAThasincreasedthedemandforortho-

dontic treatment, especially among adults,

by offering an esthetic solution during treat- ment. Other advantages include both improved oral hygiene and OHRQoL. The accuracy of tooth movements has, however, been variable with CAT, depending on the type of tooth movement and the severity of themalocclusion.However,noonetreatment guarantees a perfect result, and settling/ relapsecanoccurpost-retention;thismayalso make minor differences inoutcomes less rel- evant over time. Auxiliary CAT components

canprovideadditionalcontroloftoothmove-

ment, and the adjunctive use of new tech- nologies for FOA and CAT is promising. Recently, a systematic review was conducted examiningtheefficacyandoutcomesofCAT.

In the future, additional and large-scale ran- domized clinical trials of CAT would provide evidence supporting clinical decision mak- ing, treatment planning, and outcomes.

References

1. RossiniG,ParriniS,CastroflorioT,Deregibus

A, Debernardi CL. Efficacy of clear aligners incontrollingorthodontictoothmovement:

a systematic review. Angle Orthod

2015;85(5):881-9.

2. Align Technology, Inc. Invisalign ® . 2016. Available from: www.aligntech.com/solu- tions/invisalign. Accessed 18 May 2016.

3. DuncanLO, PiedadeL, LekicM, CunhaRS, Wiltshire WA. Changes in mandibular inci-

sor position and arch form resulting from

Invisalign correction of the crowded denti- tion treated nonextraction. Angle Orthod

2015;86(4):577-83.

4. FrongiaG,CastroflorioT.Correctionofsevere tooth rotations using clear aligners: a case report. Aust Orthod J 2012;28(2):245-9.

5. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C. Treatment outcome and effica- cy of an aligner technique—regarding inci-

sor torque, premolar derotation and molar

distalization. BMC Oral Health 2014;14:68.

6. NeedhamR,WaringDT,MalikOH.Invisalign

treatmentofClassIIImalocclusionwithlower-

incisor extraction. J Clin Orthod 2015;49(7):

429-41.

7. Li W, Wang S, Zhang Y. The effectiveness of

the Invisalign appliance in extraction cases

usingtheABOmodelgradingsystem:amul-

ticenter randomized controlled trial. Int J Clin Exp Med 2015;8(5):8276-82.

8. Turpin DL. Clinical trials needed to answer questions about Invisalign. Am J Orthod Dentofacial Orthop 2005;127(2):157-8.

9. Azaripour A, Weusmann J, Mahmoodi B, Peppas D, Gerhold-Ay A, Van Noorden CJ, Willershausen B. Braces versus Invisalign®:

gingivalparametersandpatients’satisfaction

duringtreatment:across-sectionalstudy.BMC Oral Health 2015;15:69.

10. HennessyJ,Al-AwadhiEA.Clearalignersgen- erations and orthodontic tooth movement. J Orthod 2016;43(1):68-76.

11. Karkhanechi M, Chow D, Sipkin J, Sherman

D,BoylanRJ,NormanRG,CraigRG,Cisneros GJ. Periodontal status of adult patients treat- ed with fixed buccal appliances and remov- ablealignersoveroneyearofactiveorthodontic therapy. Angle Orthod 2013;83(1):146-51.

12. Juliena KC, Buschang PH, Campbell PM.

Prevalenceofwhitespotlesionformationdur-

ing orthodontic treatment. Angle Orthod

2013;83(4):641-7.

13. Zhou ZY, Wang Y, Wang XY, Volière G, Hu

RD, et al. The impact of orthodontic treat-

mentonthequalityoflife.asystematicreview.

BMC Oral Health 2014;14:66.

14. Pringle AM, Petrie A, Cunningham SJ,

McKnight M. Prospective randomized clini- caltrialtocomparepainlevelsassociatedwith 2 orthodontic fixed bracket systems. Am J

Orthod Dentofacial Orthop 2009;136(2):160-7.

15. Fujiyama K, HonjoT, Suzuki M, Matsuoka S,

DeguchiT.Analysisofpainlevelincasestreat-

ed with Invisalign aligner: comparison with fixededgewiseappliancetherapy.ProgOrthod

2014;15:64.

16. Birkeland K, Furevik J, Bøe OE, Wisth PJ. Evaluation of treatment and post-treatment changes by the PAR Index. Eur J Orthod

1997;19(3):279-88.

17. Deguchi T, Kurosaka H, Oikawa H, Kuroda S,TakahasiI,YamashiroY,Takano-Yamamoto T. Comparisonof orthodontic treatment out- comesinadultswithskeletalopenbitebetween

conventionaledgewisetreatmentandimplant-

anchoredorthodontics.AmJOrthodDentofacial Orthop 2011;139(4 Suppl):60-8.

18. Jambi S, Thiruvenkatachari B, O’Brien KD, Walsh T. Orthodontic treatment for distalis- ing upper first molars in children and ado- lescents. Cochrane Database Syst Rev

2013;(10):CD008375.

19. Flores-Mir C. Little evidence to guide initial arch wire choice for fixed appliance thera- py. Evid Based Dent 2014;15(4):112-3.

20. Krieger E, Seiferth J, Marinello I, Jung BA, Wriedt S, Jacobs C, Wehrbein H. Invisalign ® treatment in the anterior region: were the predictedtoothmovementsachieved?JOrofac Orthop 2012;73(5):365-76.

21. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agrane B. How well does Invisalign work? A prospective clinical study evaluating the effi- cacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop 2009;135:27-35.

22. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM. Predicted and actual end-of- treatment occlusion produced with aligner therapy. Angle Orthod 2015;85:723-7.

23. Bondemark L, Holmb A-K, Hansenc K, AxelssondS,MohlineB,BrattstromV,Pauling G, Pietila T. Long-termstability of orthodon- tic treatment and patient satisfaction. A sys- tematic review. Angle Orthod 2007;77(1):

181-91.

24. NettBC,HuangGJ.Long-termposttreatment changes measured by the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2005;127(4):

444-50.

25. GiancottiA,GrecoM,MampieriG.Extraction treatment using Invisalign ® technique. Prog Orthod 2006;7(1):32-43.

26. LinJC,TsaiSJ,LiouEJ,BowmanSJ.Treatment of challenging malocclusions with Invisalign and miniscrew anchorage. J Clin Orthod

2014;48(1):23-36.

27. Ojima K, Dan C, Kumagai Y, Schupp W. Invisalign treatment accelerated by photo- biomodulation. The Cutting Edge 2016;L5:

309-17.

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7

DENTISTRYANDHEALTHCARE

The relationship between systemic dis- easeandoraldiseasehasfocusedprimarilyon

cardiovascular disease (CVD), diabetes melli-

tus(DM),andpregnancyoutcomes.Onecon-

dition that is important in the development of chronicdiseases suchas CVDandDM, and

has a role in complications of pregnancy, is

obesity.Recentlypublishedstudieshaveexam-

inedtherelationshipofobesityandperiodon-

titis in the general population, patients with DM, and on birth outcomes in pregnant women. 1-5 Asystematicreviewhasalsosuggest- ed that there is a bi-directional relationship between obesity and tooth loss, 6 a conclusion basedprimarily oncross-sectional studies. Worldwide, an estimated 38% of female adults and 36.9% of male adults were over- weight or obese in 2013. 7 In total, 2.1 billion childrenandadultswereoverweightorobese. 7 In the United States, an estimated 33.9% of women and 31.6% of men are obese. 7 It is important for oral healthcare providers (OHCPs) to understand the health implica- tions of obesity, and the relationship of oral diseasetoexcessweightgain.OHCPsmaybe abletoreferpatientsorassistthemwithweight lossmanagementprograms,ascaloricintake and dietary choices are part of dental prac- tice. This common risk factor approach can help improve outcomes of care. 8

It is important for oral healthcare providers to understand the health implications of obesity, and the relationship of oral disease to excess weight gain.

Measures of Obesity

Body mass index (BMI, which is calcu- latedasweightdividedbysquareoftheheight) isusedmost frequentlytomeasureobesity; 9,10 other measures used include waist circum- ference (WC) and waist hip ratio (WHP; see table). 9 Neck circumference (NC) is now being considered an alternative measure for obesi- ty. 11 In the Framingham Heart Study (n = 3,307),ameanBMIof 27.8kg/m 2 wasequiv- alent to a mean NC of 34.2 cm for females and 40.5 cm for males. 12 In a second study,

Obesity and Periodontitis

Definitions Using BMI, WC, and WHP 9

 

Female

Male

BMI: Obese

30kg/m 2

30kg/m 2

BMI: Overweight

25kg/m 2

25kg/m 2

BMI: Normal weight

18.5kg/m 2

18.5kg/m 2

WC: Obese

>35inches (88cm)

>40inches (102cm)

WHP: Obese

>0.85

>0.90

NC correlated more closely than WC with metabolic parameters and hypertension; an NC of 35 cm for females and 38 cm for

menwassuggestedasaclinicallyrelevantobe-

sity benchmark. 11

Obesity and Clinical Attachment Loss

A recent five-year prospective study (n = 582) is supportive of obesity as a risk factor forprogressiveclinicalattachmentloss(CAL)

in females, but not in males. 1 All participants reportednohistoryofDM,had 6teethand

a BMI 18.5kg/m 2 ; CAL progression was

definedasproximalCAL 3mm,in 4teeth overthefive-yearperiod.Amongthesubjects, 30% and 19% were overweight and obese, respectively, and 38% experienced CAL pro-

gression. 1 Afteradjustingforotherfactors(e.g., demographics, medical and dental history), obesity increased the risk of CAL by 64% in females (p=0.01). No significant increased risk was observed for overweight females (p

= 0.34) or for overweight or obese males (p

= 0.70 and p = 0.56, respectively). 1 This was

hypothesized to be the result of the inability

ofBMImeasurementstodifferentiatebetween

a lean body mass (muscle) and adipose tis- sue (see Figure 1). 1 64% 13%
a lean body mass (muscle) and adipose tis-
sue (see Figure 1). 1
64%
13%
21%
6%
Overweight
Obese
n Females
n Males
*p = 0.01

Figure 1. Increased risk of CAL based on BMI. 1

An increased risk of CAL progression has been observed in other studies. In one prospective study (n = 3,590), statistically

significant increases in periodontitis risk of

30%,70%,and324%wereobserved,respec-

tively,forobesemales(p<0.001),overweight

females (p < 0.01), and obese females (p < 0.05). 2 A statistically significant association was also observed for obesity and periodon- titis (defined as pocket probing depths 4 mmandCAL 3mmin 4 teeth)inasep- araterandomizedstudy (n=340). 3 Subjects defined as obese using the BMI, WC, and

highfatpercentage(HFP)were2.9,2.1,and

1.8 times more likely, respectively, to have periodontitis. 3 Ina systematic reviewof five studies (n= 42,198), obesity was also found to increase the likelihood of developing periodontitis. 4 Three studies used BMI to measure obesity, andtwousedBMI,WC,andWHR.Compared to normal weight subjects, overweight and

obesesubjectswere1.13and1.33timesmore

likely, respectively, to develop periodontitis. 4

Compared to normal weight subjects, overweight and obese subjects were 1.13 and 1.33 times more likely, respectively, to develop periodontitis.

Basedonlimiteddata,findingsonarela-

tionshipbetweenobesityandperiodontaltreat-

ment outcomes are conflicting. One study found an increased risk of poor treatment outcomes in obese patients compared to normal weight patients (p = 0.012). 13 In con- trast, conclusions from a systematic review were that obesity does not negatively affect

8

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theresultsofperiodontaltherapy. 14 Thisques- tion requires further investigation.

Obesity and Tooth Loss

Obesesubjectswere1.49timesmorelike-

lytohavetoothlossand1.25timesmorelike-

ly to be edentate based on a meta-analysis of 16studies(p<0.05). 6 Conversely,subjectswith

toothlossandedentulismwere1.41and1.60

timesmorelikelytobeobese(p<0.05).While

this might suggest a bi-directional relation- ship, these were cross-sectional studies, limit- ing interpretation of the data. In addition, only 4 studies were included for tooth loss, with criteria ranging from 1 tooth missing to 6 teeth missing. 6

Maternal Obesity and Adverse Birth Outcome

Focusing on periodontitis and obesi- ty/excessweightaspotentiallysynergisticrisk factors for adverse pregnancy outcomes, one

study (n = 328) assessed the risk of pre-term birth (PTB) in women with pre-eclampsia (PE). 5 PEaccountsforupto20%ofallPTBs. 15 Previous studies reported that periodontitis may be associated with PTB and PE. 16 In the

currentstudy,PTB(<37weeks)was5.56times

morelikelyinwomenwithPEiftheyhadperi-

odontitis (p < 0.027), and if they were also obese/overweight that risk increased almost three-fold (p < 0.001; see Figure 2). 5

15.94**

2.08 5.56*

2.08

2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*

5.56*

2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*
2.08 5.56*

Obese/

overweight

Periodontitis

Periodontitis and

obese/overweight

*p < 0.027

**p < 0.001

Figure 2. Increased risk level for PE-associated PTB based on maternal weight. 5

Implications for Dental Care

Theimportanceof patient obesitywhen providingoralhealthcareservicescanbeseen in many ways. Obesity has been observed to impactCALandoralhealth,andmayincrease the risk of PE-associated PTB. Further, obesi- ty is associated with DM, while DM has a bi- directional relationship with periodontitis.

A study in the dental setting examining

risk factors for undiagnosed diabetes melli- tusincludedtheuseofWCinthealgorithm. 17 Oneconcernthathasbeenraisedwithregard

totheapplicationofthisalgorithmisthecom-

fortOHCPshaveinmeasuringWC.However,

arecentreportsuggeststhatNCmaybeabet-

ter indicator of metabolic health than WC forseverelyobeseindividuals. 11 Thisprovides OHCPswithaviableapproachtoassessweight asariskfactor. Inaddition, OHCPsfrequent- ly see patients who believe they are healthy and may have undiagnosed DM, which may first manifest with intraoral signs and symp- toms. This provides an opportunity for early intervention.

Conclusions

Strongevidenceprovidessupportforthe

importance of obesity as a risk factor for sys- temic disease. OHCPs are in a unique posi-

tiontoconsiderobesityasacommonriskfac-

torfororalandsystemicdisease,andtoadvise,

counsel,and/orreferpatientsforlifestylemod-

ifications. 8 Indoingso,OHCPshaveanoppor- tunity to intervene, collaborate with medical professionals, and to help improve oral and general health outcomes for patients.OC

References

1. Gaio EJ, Haas AN, Rosing CK, Oppermann RV, Albandar JM, Susin C. Effect of obesity

onperiodontal attachment loss progression:

a 5-year population-based prospective study. J Clin Periodontol 2016;43(7):557-65.

2. Morita I, Okamoto Y, Yoshii S, Nakagaki H, Mizuno K, Sheiham A, Sabbah W. Five-year incidence of periodontal disease is related to body mass index. J Dent Res 2011;90(2):

199-202.

3. KhaderYS, Bawadi HA, HarounTF, Alomari

M,TayyemRF.Theassociationbetweenperi-

odontal disease and obesity among adults in

Jordan. J Clin Periodontol 2009;36(1):18-24.

4. NascimentoGG,LeiteFR,DoLG,PeresKG, CorreaMB,DemarcoFF,PeresMA.Isweight gain associated with the incidence of peri-

odontitis?Asystematicreviewandmeta-analy-

sis. J Clin Periodontol 2015;42(6):495-505.

5. Lee HJ, Ha JE, Bae KH. Synergistic effect of maternalobesityandperiodontitisonpreterm

birthinwomenwithpreeclampsia:aprospec-

tive study. J Clin Periodontol 43(8):646-51.

6. Nascimento GG, Leite FR, Conceicao DA, Ferrua CP, Singh A, Demarco FF. Is there a

relationship between obesity and tooth loss

andedentulism?Asystematicreviewandmeta-

analysis. Obes Rev 2016;17(7):587-98.

7. TheGBD2013ObesityCollaboration,NgM,

FlemingT, et al. Global, regional andnation- al prevalence of overweight and obesity in children and adults 1980-2013: A systematic analysis. Lancet 2014;384(9945):766-81.

8. CullinanM.Theroleofthedentistintheman- agement of systemic conditions. Ann R Australas Coll Dent Surg 2012;21:85-7.

9. World Health Organization. Waist Circumference and Waist-Hip Ratio Report of a WHO Expert Consultation. Geneva, 8- 11 December, 2008. Available at:

http://www.who.int/nutrition/publica-

tions/obesity/WHO_report_waistcircumfer-

ence_and_waisthip_ratio/en/.

10. KopelmanPG.Obesityasamedicalproblem. Nature 2000;404(6778):635-43.

11. Assyov Y, Gateva A, Tsakova A, Kamenov Z. A comparisonoftheclinicalusefulnessofneck circumference and waist circumference in individuals with severe obesity. Endocr Res

2016;6:1-9.

12. Preis SR, Massaro JM, Hoffmann U, D’Agostino RB Sr, Levy D, Robins SJ, Meigs JB, Vasan RS, O’Donnell CJ, Fox CS. Neck circumference as a novel measure of car- diometabolic risk: the Framingham Heart study. J Clin Endocrinol Metab 2010;95(8):

3701-10.

13. Suvan J, Petrie A, Moles DR, Nibali L, Patel K, Darbar U, Donos N, Tonetti M, D’Aiuto F. Body mass index as a predictive factor of periodontal therapy outcomes. J Dent Res

2014;93(1):49-54.

14. NascimentoGG,LeiteFR,CorreaMB,Peres MA,DemarcoFF.Doesperiodontaltreatment have an effect on clinical and immunologi- calparametersofperiodontaldiseaseinobese

subjects?Asystematicreviewandmeta-analy-

sis. Clin Oral Investig 2016;20(4):639-47.

15. Jeyabalan A. Epidemiology of preeclampsia:

impact of obesity. Nutr Rev 2013;71(Suppl

1):S18-25.

16. KumarA, BasraM, BegumN, Rani V, Prasad S, Lamba AK, Verma M, Agarwal S, Sharma S.Associationofmaternalperiodontalhealth with adverse pregnancy outcome. J Obstet Gynaecol Res 2013;39(1):40-5.

17. LiS,WilliamsPL,DouglassCW.Development ofaclinicalguidelinetopredictundiagnosed diabetes in dental patients. J Am Dent Assoc

2011;142(1):28-37.

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PREVENTIVEDENTISTRY

Dental Management of Patients with Autism

Autism represents a spectrum of neu- rodevelopmental disorders. It is character- ized by altered social interaction, affecting communication and interaction with others, and repetitive behavior. 1,2 The 1994 clinical diagnosticcriteriaforautismintheDiagnostic and Statistical Manual of Mental Disorders, 4 th Edition included five subtypes of autism. 1,2

However,since2013autismhasbeendefined

as one disorder. 1 The prevalence of autism has beenthe subject of debate, andhas been reportedgloballytorangefrom0.1%to2%. 1,3 In the United States, it appears that the diag- nosisisnowmademoreoften,butitisunclear iftheprevalencehasactuallyincreasedormay be at least partly attributable to more thor- ough assessments. More males are affected than females, with a 4.5:1 ratio. 1

Caring for Dental Patients with Autism

Dental care for persons with autism can

bechallengingduetoalackofeffectivecom-

munication and, for patients, the unfamiliar

setting and unfamiliar tasks and activities. 2 Patientswithautismmayexhibitunusualand uncooperative behavior, such as head bang- ing, tantrums, hyperactivity, and agitation. Signs of self-injurious behavior may be evi- dent; these include biting, grinding, cheek

biting,headbanging,andpinching.Self-inju-

rious behavior is reported to occur in up to 70%of children with autism. 4

Dental care for persons with autism can be challenging due to a lack of effective communication, the unfamiliar setting, and unfamiliar tasks and activities.

Due to altered sensory processing, patients with autism do not interpret sensa- tions inthe same manner as patients without autism, which may also lead to exaggerated responses to sounds, smells, lights, or touch,

all of which can occur during treatment. 5-7 In

onestudy,morethanhalfofchildrenandado-

lescentswithautismwereuncooperativewith

dentalcare,comparedwith25.4%oftheunaf-

fected group, and just 9.2% exhibited posi-

tive behavior (p < 0.0001). 8 As a result of the challenges in providing comprehensive care to individuals with autism, there is the possi- bility of long-termneglect of oral health. 2 Behavioral management techniques should be emphasized when providing den- tal care topersons withautism. 3 Preventionis key, especially when caring for children, but even simple preventive procedures may not beeasilyaccomplished.Techniquesthatteach skills and improve communication help to overcomedifficultiesintreatingpatientswith

autism.“Tell-show-do”andpositivereinforce-

ment may be effective depending on the

patient’slevelofimpairment.Briefclearcom-

mands are required. 6 Another approach, which does not rely heavily on interpersonal

communication,hasbeenreferredtoas“den-

tal stories.” 5

Behavioral Approaches

Suggestedbehavioralapproachesinclude

applied behavior analysis (ABA). 9 This tech- nique requires participation of the dental provider, and also parents and teachers. 9

Patientswithautismfailtodevelop“jointatten-

tion,” and therefore may be unable to share informationandhavenocuriosityabouttheir surroundings. 9 ABAinvolvesanalyzingbehav-

ior,thenimplementingactionsthatwillmod-

ify this behavior. Observing, gathering infor- mationusingquestionnairesorinterviewswith

patients/parent/caregivers,andunderstand-

ing what the patient achieves with a given behavior (for example, whether it means the patient avoids treatment) are important in determining what is required to modify such functional behavior. 9 Apre-visitsessionwithparents/caregivers is recommended to determine how they can help with home preparation prior to the

patientsvisittothedentaloffice. 10 Parents/care- givers can help prepare the patient at home

bygettinghim/herfamiliarwithdentalinstru-

mentssuchasmirrors,showingpicturesofthe dental office and chair, and coaching them onactivitiesandphrasesthatwillbeused(e.g.,

“open your mouth” or “close your mouth”). 10

Inthismanner,itispossibletoteachthebehav-

ior that will be needed for a successful dental visit. 10 Dentaltreatmentandthepatient’scoop- erationare a teameffort. 9 Desensitization is a process by which the patient is gradually introduced to the dental setting with progressively longer vis- itsthatmaystartwithjustafewsecondsand then build up. Distracting the patient with avideoormusic,orhavingthepatienthold on to objects, may also be helpful during appointments. 11 Ideally, the patient with

autism will see the same dental team mem- bers on each visit, as this makes the patient more comfortable. 12

Ideally, the patient with autism will see the same dental team members on each visit, as this makes the patient more comfortable.

Dental Stories

Dental stories are social stories that use

basiclanguageandimagestodescribetheden-

tal operatory environment to patients with autismandwhat will happenduringthevisit. Dental stories are read/viewed repeatedly beforethefirstdentalappointment.Bothprint and video versions have been utilized to pre-

pare a child with autism for a dental visit. 4 Dentalstoriesarealsoavailableascomicbooks, drawings, and photographs. The choice of medium depends on language comprehen- sion and preference in the home (p = 0.038 and p = 0.002, respectively). 13 Standard den-

talstoriesarealsoavailablethatcanbeadapt-

ed for an individual office. 11 More informa- tion on dental stories and books about visit- ing the dentist such as Show Me Your Smile! A Visit to the Dentist, and Dora the Explorer can be found on the AutismSpeaks website. 11

Communicating with Pictures and Icons

Patients with autism who have difficulty with language may communicate using pic- tures, photos, a tablet with images, a simple word processor, or a formal communication tool with simple words/images/icons. 11 Examples include a picture vocabulary chart (Figure 1) and the Neo from AlphaSmart (Figure 2).

vocabulary chart (Figure 1) and the Neo from AlphaSmart (Figure 2). Figure 1. Picture vocabulary chart

Figure 1. Picture vocabulary chart for dental visits.

10

10 O O r r a a l l C C a a r r e

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10 O O r r a a l l C C a a r r e

Figure 2. The Neo from AlphaSmart.

Medication Use

In one study of patients with autism

(n = 187), 47% took medications associated

withtheircondition,mostcommonlyantipsy-

chotics which reduce irritability, self-injuri- ous behavior, distress, and other disorders. Of the patients taking medications, almost half were taking more than one. Forty-one

percent,20%,16%,and11%ofpatientswere

receiving antipsychotics, central nervous sys- tem stimulants and other drugs, anticonvul- sants,andantidepressants,respectively(Figure 3). 8 Some of the signs and symptoms associ- ated with these medications include dry mouth, difficulty swallowing, gingivitis, stom- atitis, gingival enlargement, sialadenitis, and tonguediscoloration. 8 Nonetheless,children andadolescentswithautismhavebeenfound to experience no more, or less, caries than unaffected children. In one study, 68% of patients with autism experienced caries vs. 86%of unaffectedsubjects(n=269and332, respectively; p < 0.0001). 8

Antidepressants 11% Anticonvulsants 16% CNS Stimulants, 20% Other Drugs Anti-Psychotics 41% Figure2. Percentage
Antidepressants
11%
Anticonvulsants
16%
CNS Stimulants,
20%
Other Drugs
Anti-Psychotics
41%
Figure2. Percentage of patients withautismusingmedications. 8

Other Considerations and Implications

It is essential that patients with autism

haveadentalhomeandthattheyreceivereg-

ularpreventivecaretomaintainoralhealth. 14 However, barriers to care include the child’s attitude toward dental procedures and limit- edresources. 15 Itis,therefore,importantthat a positive relationship is developed with the patientandthatcareismanagedtogetherwith parents/caregivers.

Forsomepatients,behavioralissuesmake treatment without additional approaches

impossible. In certain cases, protective stabi-

lizationmaybeconsideredappropriate,how-

ever this is controversial. 11 Nitrous oxide may be helpful, provided the patient can inhale through the nose during treatment. If con- scious sedation is being considered, the patient’s physician should be consulted and a physical exam performed. General anes- thesia may also be a necessary option, sub-

ject to

health considerations. 11

It is important that a positive relationship is developed with the patient and that care is managed in coordination with parents/ caregivers.

Anotherrealchallengeisthelackofexpo-

sure to patients with autism and other devel- opmental disorders during dental and den- tal hygiene school training. The necessity of including these experiences in the curricu- lum was underscored by the Commission on Dental Accreditation, which stated in 2006 that all schools considered for accreditation must offer such didactic and clinical educa- tion to students. 16

Conclusions

Knowledge concerning autism and an understandingofitsbehavioralprinciplesare

essential when treating these patients. Using ABA procedures can help with the effective

managementofproblembehaviorswhenpro-

viding dental care. In addition, the involve- ment of parents/caregivers is an important

partofasuccessfulapproachtoprovidingden- tal care to patients with autism. OC

References

1. Christensen DL, Baio J, Braun KV, Bilder D, Charles J, Constantino JN, Daniels J, Durkin MS, Fitzgerald RT, Kurzius-Spencer M, Lee L-C,PettygroveS,RobinsonC,SchulzE,Wells C,WingateMS,ZahorodnyW,Yeargin-Allsopp M. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. MMWR Surveill Summ 2016;65(No. SS-3)(No. SS-3):1–23.

2. Gandhi RP, Klein U. Autism spectrum disor- ders:anupdateonoralhealthmanagement. J Evid Based Dent Pract 2014;14(Suppl):

115-26.

3. CentersforDiseaseControlandPrevention.

Available

at: http://www.cdc.gov/ncbddd/autism/ data.html.

4. MurshidEZ.Oralhealthstatus,dentalneeds habits and behavioral attitude towards den- tal treatment of a group of autistic children in Riyadh, Saudi Arabia. Saudi Dent J

Autism

spectrum

disorder.

2005;17:132-9.

5. National Institute of Dental andCraniofacial Research. Practical oral care for people with autism.Availableat:http://www.nidcr.nih.gov/ OralHealth/Topics/DevelopmentalDisabilities /PracticalOralCarePeopleAutism_mobile.htm.

6. GuptaM.Oralhealthstatusanddentalman- agement considerations in autism. Int J Contemp Dent Med Rev 2014; Article ID

011114:1-6.

7. SteinLI,PolidoJC,MaillouxZ,ColemanGG, Cermak SA. Oral care and sensory sensitivi- ties in children with autism spectrum disor- ders. Spec Care Dentist 2011;31:102-10.

8. LooCY,GrahamRM,HughesCV.Thecaries experience and behavior of dental patients withautismspectrumdisorder.JAmDentAssoc

2008;139(11):1518-24.

9. Hernandez P, Ikkanda Z. Applied behavior analysis: behavior management of children

withautismspectrumdisordersindentalenvi-

ronments. J Am Dent Assoc 2011;142(3):

281-7.

10. Delli K, Reichart PA, BornsteinMM, Livas C. Management of children with autism spec- trumdisorderinthedentalsetting:Concerns, behavioural approaches and recommenda- tions. Med Oral Patol Oral Cir Bucal

2013;18(6):e862-8.

11. AutismSpeaks.Treatingchildrenwithautism

spectrumdisorders.Atoolkitfordentalpro-

fessionals. Available at: https://www.autism-

speaks.org/docs/sciencedocs/atn/dental-

toolkit.pdf

12. Marshall J, Sheller B, Manci L, Williams BJ. Parental attitudes regarding behavior guid- ance of dental patients with autism. Pediatr Dent 2008;30(5):400-07.

13. MarionIW,NelsonTM,ShellerB,McKinney CM,ScottJM.Dentalstoriesforchildrenwith autism. Spec Care Dentist 2016;36(4):181-6.

14. CharlesJM.Dentalcareinchildrenwithdevel- opmental disabilities: attention deficit disor- der,intellectualdisabilities,andautism.JDent Child (Chic) 2010;77(2):84-91.

15. Lai B, Milano M, Roberts MW, Hooper SR. Unmet dental needs and barriers to dental care among children with autism spectrum disorders. J Autism Dev Disord 2012;42:

1294-303.

16. CommissiononDentalAccreditation–2006.

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11

HEALTHCARE TRENDS

a r r e e r r e e p p O O r r t

Editor-in-Chief

Ira B. Lamster, DDS, MMSc Professor of HealthPolicy & Management, MailmanSchool of Public Health DeanEmeritus, Columbia University College of Dental Medicine

International Editorial Board

P. Mark Bartold, BDS, BScDent (Hons), PhD, DDSc, FRACDS (Perio); Australia

John J. Clarkson, BDS, PhD; Ireland

Kevin Roach, BSc, DDS, FACD; Canada

Prof. Cassiano K. Rösing; Brazil

Mariano Sanz, DDS, MD; Spain

Ann Spolarich, RDH, PhD; USA

Xing Wang, MD, PhD; China

Rebecca S. Wilder, RDH, MS; USA

DavidT.W. Wong, DMD, DMSc; USA

© 2016 Colgate-Palmolive Company. All rights reserved.

The Oral Care Report (ISSN 1520-0167) is supported by the Colgate-Palmolive Company for oral care professionals.

Editorial Quality Control by Teri S. Siegel.

Layout and graphic design by Horizons Advertising and Graphic Design, Morrisville, PA (USA).

Published by Professional Audience Communications, Inc., Charlotte, NC (USA).

E-mail comments and queries to the Editor, Oral Care Report ColgateOralCareReport@gmail.com

Earn3 CEcredits for this issue of the Oral Care Report online at www.colgateprofessional.com.

Methamphetamine Abuse and the Role for the Dental Profession

A recent essay in the ADA News discussed the effects of recreational use of methamphetamine

(“meth”) on the oral cavity. 1 This is a condition that was identified 15 years ago, seen in individuals who abuse methamphetamine. 2,3 Methamphetamine is a stimulant, very addictive, and induces wakefulness and excessive physical activity. The adverse side effects include elevated blood pressure, cardiac arrhyth- mias, hallucinations, and bizarre and often violent behavior. A severe form of oral disease – characterized by extensive dental caries, worn teeth, and peri- odontal disease – was first described by two emergency department physicians in 2000. 3 Since that time, there have been a number of published case reports or case series, often appearing in local den- tal journals, 4-6 suggesting a clustering of cases in certain areas of the United States. However “meth mouth,” as this has come to be known, is an international problem, reported in Europe, 7 Taiwan, 8 and South Africa. 9 The oral findings in persons with meth mouth are believed to be due to xerostomia, excessive tooth clenching, a lack of concern about oral hygiene, and increased consumption of sugar- sweetened beverages. Early reports were limited by the number of cases that were reported, not allowing conclusions regarding prevalence or distribution by age, sex, or drug use. Shetty and colleagues, 3 however, have pub- lished the findings of a study of methamphetamine users in the Los Angeles, California, area. This study used a stratified sampling approach to assess the oral status of a large sample of metham- phetamine users. A total of 571 individuals were examined and divided into light, moderate, and heavy users. The majority were male, and either Hispanic or African-American. Nearly 70% were currently using cigarettes. The oral findings revealed extensive severe oral disease. Being older and a moderate or heavy user were associated with more extensive caries, periodontal disease, and tooth loss. Women were affected to a greater degree than men. Molars were the teeth that demonstrated the greatest extent and

severityoforaldisease,andmaxillaryanteriorteethdemonstratedgreatercariesexperiencethanmandibu-

lar anterior teeth. Of all users, 96%had evidence of caries and nearly 60%had untreated caries. Periodontitis was also common in these individuals, with nearly 60% of moderate/heavy metham- phetamine users demonstrating moderate periodontitis and nearly one-third demonstrating severe periodontitis. Further, a majority of the methamphetamine users reported embarrassment as a result of their oral condition. The onset of this relatively new oral “syndrome” highlights the pressing need for oral healthcare providers (OHCPs) to take a broader viewof their role inpatient care. First, patients presenting withthe conditions seen in these reports require more than dental care alone. If seeing a patient with oral find- ings suggestive of methamphetamine abuse, OHCPs must treat the whole patient, while considering the need for medical/psychiatric consultation, appropriate management of pain that does not add to the addictive problems often faced by these patients, and avoidance of drugs used during dental treatment that may be affected by methamphetamine use (i.e., the cardiac effects of vasoconstrictors such as epi- nephrine in local anesthetics). This epidemic further emphasizes the importance of interprofessional practice, and the need for multiple healthcare providers to participate in patient care.

Dental offices can be points of surveillance for newly emerging diseases and disorders, and also provide opportunities for OHCPs to have a positive impact on the overall health of persons in their care.

Second, the appearance of meth mouth also stresses that OHCPs must be vigilant for the next new oral disorder or manifestation of a systemic condition. In recent years bisphosphonate-related osteonecro- sis of the jaws (BRONJ), as well as peri-implant mucositis and perimplantitis, have been identified. Thirty years ago it was a variety of newly identified oral manifestations of HIV infection, including hairy leuko- plakia andHIV-associatedperiodontitis. Dental offices can be points of surveillance for newly emerging diseases and disorders, and also pro- vide opportunities for OHCPs tohave a positive impact onthe overall healthof persons intheir care.OC

References

1. American Dental Association. ADA News. MyView: Meth: the loss of America’s smile. Available from:

http://www.ada.org/en/publications/ada-news/viewpoint/my-view/2016/may/meth-the-loss-of-americas-smile.

Accessed 16 May 2016.

2. RichardsJR,BrofeldtBT.Patternsoftoothwearassociatedwithmethamphetamineuse.JPeriodontol2000;71(8):

1371-4.

3. Shetty V, Harrell L, Murphy DA, Vitero S, Gutierrez A, Belin TR, Dye BA, Spolsky VW. Dental disease patterns in methamphetamine users: Findings in a large urban sample. J Am Dent Assoc 2015;146(12):875-85.

4. Jones K. “Meth mouth”: one dentist’s personal experience. J Mich Dent Assoc 2011;93(2):60-1.

5. Settle SL. “Meth mouth” for the general practitioner. J Okla Dent Assoc 2010;101(8):31-42.

6. Brown RE, Morisky DE, Silverstein SJ. Meth mouth severity in response to drug-use patterns and dental access in methamphetamine users. J Calif Dent Assoc 2013;41(6):421-8.

7. De-Carolis C, Boyd GA, Mancinelli L, Pagano S, Eramo S. Methamphetamine abuse and “meth mouth” in Europe. Med Oral Patol Oral Cir Bucal 2015;20(2):e205-10.

8. Wang P, Chen X, Zheng L, Guo L, Li X, Shen S. Comprehensive dental treatment for “meth mouth”: a case report and literature review. J Formos Med Assoc 2014;113(11):867-71.

9. Naidoo S, Smit D. Methamphetamine abuse: a review of the literature and case report in a young male. SADJ

2011;66(3):124-7.