Joana Cunha-Cruz

Risk Factors for Osteonecrosis of the Jaws a Case-Control Study from the CONDOR Dental PBRN

Case reports and cohort studies have linked bisphosphonate therapy and osteonecrosis of the jaws (ONJ), but neither causality nor specific risks for lesion development have been clearly established. We conducted a 1:3 case-control study with three dental Practice-based Research Networks, using dentist questionnaires and patient interviews for collection of data on bisphosphonate therapy, demographics, co-morbidities, and dental and medical treatments. Multivariable logistic regression analyses tested associations between bisphosphonate use and other risk factors with ONJ. We enrolled 191 ONJ cases and 573 controls in 119 dental practices. Bisphosphonate use was strongly associated with ONJ (odds ratios [OR] 299.5 {95%CI 70.0-1282.7} for intravenous [IV] use and OR = 12.2 {4.3-35.0} for oral use). Risk markers included local suppuration (OR = 7.8 {1.8-34.1}), dental extraction (OR = 7.6 {2.4-24.7}), and radiation therapy (OR = 24.1 {4.9-118.4}). When cancer patients (n = 143) were excluded, bisphosphonate use (OR = 7.2 {2.1-24.7}), suppuration (OR = 11.9 {2.0-69.5}), and extractions (OR = 6.6 {1.6-26.6}) remained associated with ONJ. Higher risk of ONJ began within 2 years of bisphosphonate initiation and increased four-fold after 2 years. Both IV and oral bisphosphonate use were strongly associated with ONJ. Duration of treatment > 2 years; suppuration and dental extractions were independent risk factors for ONJ.

The relative contribution of income inequality and imprisonment to the variation in homicide rates among Developed (OECD), South and Central American countries

Homicide rates vary widely across and within different continents. In order to address the problem of violence in the world, it seems important to clarify the sources of this variability. Despite the fact that income inequality and imprisonment seem to be two of the most important determinants of the variation in homicide rates over space and time, the concomitant effect of income inequality and imprisonment on homicide has not been examined. The objective of this cross-sectional ecological study was to investigate the association of income inequality and imprisonment with homicide rates among Developed (OECD), South and Central American countries. A novel index was developed to indicate imprisonment: the Impunity Index (the total number of homicides in the preceding decade divided by the number of persons in prison at a single slice in time). Negative binomial models were used to estimate rate ratios of homicides for young males and for the total population in relation to Gini Index and Impunity Index, controlling for infant mortality (as a proxy for poverty levels), Gross Domestic Product per-capita, education, percentage of young males in the population and urbanization. Both low income inequality and low impunity (high imprisonment of criminals) were related to low homicide rates. In addition, we found that countries with lower income inequality, lower infant mortality (less poverty), higher average income (GDP per-capita) and higher levels of education had low impunity. Our results are compatible with the hypothesis that both low income inequality and imprisonment of criminals, independent of each other and of other social-structural circumstances, may greatly contribute to the reduction in homicide rates in South and Central American countries, and to the maintenance of low levels of homicides in OECD countries. The Impunity Index reveals that countries that show greater commitment to education and to distribution of income also show greater commitment to punish serious criminal behavior.

Thyroid shields and neck exposures in cephalometric radiography

BackgroundThe thyroid is among the more radiosensitive organs in the body. The goal of this study was twofold: (1) to evaluate age-related changes in what is exposed to ionizing radiation in the neck area, and (2) to assess thyroid shield presence in cephalometric radiographsMethodsCephalometric radiographs at one academic setting were sampled and neck exposure was related to calendar year and patients gender and age.ResultsIn the absence of shields, children have more vertebrae exposed than adults (p < 0.0001) and females have more neck tissue exposed inferior to the hyoid bone than males (p < 0.0001). The hyoid bone-porion distance increased with age (p <0.01). Thyroid shields were visible in 19% of the radiographs and depended strongly on the calendar year during which patient was seen (p-value <0.0001). Compared to adults, children were less likely to wear thyroid shields, particularly between 1973 and 1990 (1.8% versus 7.3% – p-value < 0.05) and between 2001 and 2003 (7.1% versus 42.9% – p-value < 0.05).ConclusionIn the absence of a thyroid shield, children have more neck structure exposed to radiation than adults. In agreement with other reports, thyroid shield utilization in this study was low, particularly in children.

Laser therapy for dentine hypersensitivity

Data sourcesMedline, Embase, the Cochrane Central database as well as the Cochrane Oral Health Groups Trials Register and the National Research Register. In addition relevant journals were hand searched from 2000 to 2010 (Lasers in Medical Sciences, Lasers in Surgery and Medicine, Photomedicine and Laser Surgery, Photodiagnosis and Photodynamic Therapy, Journal of Oral Rehabilitation, Journal of Periodontology, Journal of Clinical Periodontology, Journal of Endodontics, Clinical Oral Investigations, Journal of Dental Research, Journal of Oral Laser Applications, Journal of Periodontal Research and Periodontology 2000) together with the reference lists of relevant trials.Study selectionRandomised controlled trials (RCT) that included patients with two or more hypersensitive teeth confirmed by evaporative stimulus or tactile hypersensitivity assessment, comparing laser therapy versus other topical desensitising agents, such as fluoride varnish, dentine bonding agents etc, that were published in English.Data extraction and synthesisStudies were assessed for quality by two reviewers independently and data were extracted using a standardised form. Because of heterogeneity of the studies meta-analysis was not performed, so a qualitative synthesis is presented.ResultsEight trials (234 participants) met the inclusion criteria. Half of the included studies compared GaALAS laser with topical desensitising agents, but the findings were conflicting. The remaining studies involved Nd:YAG laser, Er:YAG laser and CO2 laser, and all showed that the three types of lasers were superior to topical desensitising agents, but the superiority was slight.ConclusionsThe review suggests that laser therapy has a slight clinical advantage over topical medicaments in the treatment of dentine hypersensitivity. However more large sample-sized, long-term, high-quality randomised controlled clinical trials are needed before definitive conclusions can be made.

Disparity between Dental Needs and Dental Treatment Provided

We hypothesized that more teeth would be treated by fee-for-service dentists than predicted by salaried dentists. In a cohort of 3818 participants, the number of teeth treated was related to the number of teeth with treatment needs by means of a zero-inflated negative binomial model. Among those obtaining dental care within 6 months (study population, n = 1239), the adjusted predicted number of teeth treated was 2 (95%CI = 1.7;2.3) for patients with no treatment needs. The sum of teeth treated by fee-for-service dentists (4374 when considering the whole cohort and 3550 when considering the study population) was much higher than that predicted by salaried dentists (4220 when considering the whole cohort and 1770 when considering the study population). Our findings demonstrate a disparity between dental needs assessment and the dental treatment actually provided.

Historical perspectives on theories of periodontal disease etiology

Our understanding of the causes of periodontal disease have two major competing paradigms: one that focuses on ‘local’ etiologic factors and one that focuses on remote ‘host-level’ factors. We provide a historical overview of local and remote cause hypotheses and discuss some key reasons why the local cause hypothesis has become dominant.

A Prospective Study of Clinical Outcomes Related to Third Molar Removal or Retention

OBJECTIVES We investigated outcomes of third molar removal or retention in adolescents and young adults. METHODS We recruited patients aged 16 to 22 years from a dental practice-based research network in the Pacific Northwest from May 2009 through September 2010 who had at least 1 third molar present and had never undergone third molar removal. Data were acquired via questionnaire and clinical examination at baseline, periodic online questionnaires, and clinical examination at 24 months. RESULTS A total of 801 patients participated. Among patients undergoing third molar removal, rates of paresthesia and jaw joint symptoms lasting more than 1 month were 6.3 and 34.3 per 100 person-years, respectively. Among patients not undergoing removal, corresponding rates were 0.7 and 8.8. Periodontal attachment loss at distal sites of second molars did not significantly differ by third molar removal status. Incident caries at the distal surfaces of second molars occurred in fewer than 1% of all sites. CONCLUSIONS Rates of paresthesia and temporomandibular joint disorder were higher after third molar removal. Periodontal attachment loss and incident caries at the distal sites of second molars were not affected by extraction status.

Are Tooth Decay Prevention Visits in Primary Care Before Age 2 Years Effective

In this issue of JAMA Pediatrics, Blackburn and colleagues1 address whether preventive dental care for children younger than 2 years by primary care professionals, including pediatricians and dentists, reduces subsequent need for fillings and other treatments for tooth decay. They use data for children enrolled in Alabama Medicaid from 2008 to 2012. The American Academy of Pediatrics2 and the American Academy of Pediatric Dentistry recommend that risk assessment and preventive care should begin with the eruption of the first baby tooth. The main preventive service recommended is the topical application of fluoride varnish every 3 to 6 months.3,4 The rationale is that anticipatory guidance plus topical fluoride treatments prevent the onset of tooth decay when children are at the greatest risk. This is important because tooth decay negatively affects overall health, particularly for the poor and minority children who have a greater burden of disease and less access to dentists.5 The evidence of this is scarce. Seminal work by Savage and colleagues6 that found that children with early dental visits had subsequently lower treatment costs was retrospective, and only 3% of the children had a preventive service before age 2 years. Moreover, fluoride toothpaste was not often recommended at this age because of fluorosis concerns, and fluoride varnish was not yet available. Since then, fluoride varnish has been cleared in the United States as a medical device for adult tooth sensitivity and is prescribed off-label. The varnish is simple to apply and well-tolerated and quickly became widely used by primary care providers and dentists for preschool children. Manufacturers skirted Federal Drug Administration requirements that tooth decay treatments be reviewed as drugs, and dozens of minimally-regulated varnishes were released to the market. None now sold in the United States were tested in the studies cited by the US Preventive Services Task Force.7 A recent study documented the extensive variation in fluoride release and other characteristics.8 Many contain supposedly inactive ingredients that have not been properly vetted. Against this background, Blackburn and colleagues1 conducted another retrospective cohort study using more recent claims data and a larger cohort exposed to early visits. The investigators attempted to mitigate the problems of previous research by using propensity scores to reduce confounding. They reported higher tooth decay–related visits and expenditures when children received early preventive dental care. The results are consistent with a previous finding from this group in which children aged 0 to 4 years enrolled in the Alabama Children’s Health Insurance Program did not have better longterm outcomes after a preventive visit to the dentist prior to age 4 years.9 In neither case, however, did they observe higher decay-related visits or expenditures from primary care practitioner–delivered preventive dental care. Propensity scores matched individuals exposed to preventive services to those not exposed on factors such as medical services received. However, only a randomized clinical trial would address key factors such as the indication for the preventive service and perceived risk. Thus, 2 main types of bias may be present: prognostic and protopathic. In first case, the health care professional perception that the child has a poor prognosis, rather than the severity of disease, acts as a confounder. In the second case, preventive services may be provided preferentially to children who have early signs of tooth decay; thus, their higher decay-related treatments at follow-up result from higher chances to develop decay initially. When compared with lower–risk children, the treatment needs of those children would be higher and the higher costs justifiable. If this is the case, it is amazing that children who received preventive treatments did not have higher decayrelated treatment, not higher costs. The American Academy of Pediatrics recommends that children be risk assessed and if the risk is positive, then appropriate action should follow. The only validated measure of tooth decay risk is early signs of tooth decay itself. Thus, the children receiving preventive services could have been receiving it as an early-age treatment. This is especially true because many do not have access to a dentist. The study misses the opportunity to assess this important issue by not reporting or adjusting for decay-related treatments before age 2 years. Finally, we cannot rule out the possibility that there is a true effect in which preventive visits lead to higher cariesrelated treatment as a result of ineffective anticipatory guidance and fluoride varnish applications. Fluoride varnish may not be effective if applied infrequently or if the varnish prescribed is ineffective. Even if effective, those who receive enough of it may be those least at risk. Fluorides are most beneficial when given on a periodic schedule, while children at the greatest risk often miss well-child visits. Within these major limitations, the research was well executed. Nevertheless, the most reasonable conclusion is that children with early tooth decay are identified early and subsequently are more likely to be referred for treatment at an earlier stage. This interpretation is consistent with the work by Savage and colleagues.6 The number of tooth decay–related Related article Opinion

“Everybody Brush!”: Protocol for a Parallel-Group Randomized Controlled Trial of a Family-Focused Primary Prevention Program With Distribution of Oral Hygiene Products and Education to Increase Frequency of Toothbrushing

Background Twice daily toothbrushing with fluoridated toothpaste is the most widely advocated preventive strategy for dental caries (tooth decay) and is recommended by professional dental associations. Not all parents, children, or adolescents follow this recommendation. This protocol describes the methods for the implementation and evaluation of a quality improvement health promotion program. Objective The objective of the study is to show a theory-informed, evidence-based program to improve twice daily toothbrushing and oral health-related quality of life that may reduce dental caries, dental treatment need, and costs. Methods The design is a parallel-group, pragmatic randomized controlled trial. Families of Medicaid-insured children and adolescents within a large dental care organization in central Oregon will participate in the trial (n=21,743). Families will be assigned to one of three groups: a test intervention, an active control, or a passive control condition. The intervention aims to address barriers and support for twice-daily toothbrushing. Families in the test condition will receive toothpaste and toothbrushes by mail for all family members every three months. In addition, they will receive education and social support to encourage toothbrushing via postcards, recorded telephone messages, and an optional participant-initiated telephone helpline. Families in the active control condition will receive the kit of supplies by mail, but no additional instructional information or telephone support. Families assigned to the passive control will be on a waiting list. The primary outcomes are restorative dental care received and, only for children younger than 36 months old at baseline, the frequency of twice-daily toothbrushing. Data will be collected through dental claims records and, for children younger than 36 months old at baseline, parent interviews and clinical exams. Results Enrollment of participants and baseline interviews have been completed. Final results are expected in early summer, 2017. Conclusions If proven effective, this simple intervention can be sustained by the dental care organization and replicated by other organizations and government. Trial Registration Trial Registration: ClinicalTrials.gov NCT02327507; http://clinicaltrials.gov/ct2/show/NCT02327507 (Archived by WebCite at http://www.webcitation.org/6YCIxJSor).

The burden of dentine hypersensitivity

Dentine hypersensitivity is a significant burden for patients and practitioners. Knowing its prevalence and methods for accurate diagnosis is imperative to guide treatment decisions and develop new treatments. In this chapter, we describe the methods commonly used to diagnose dentine hypersensitivity including self-reports, clinical tests to elicit pain, and clinical examination to exclude other causes of tooth pain. The prevalence of dentine hypersensitivity is presented through a systematic review of the studies published since 1964. A wide range of estimates of prevalence of dentine hypersensitivity was observed in 56 studies, from as low as 1.8% to as high as 84%, and this heterogeneity could not be completely explained by study characteristics. The meta-analysis revealed that the average prevalence of all studies was 33% and the best estimate was approximately 10%.