Mary Tavares

Dental Composite Restorations and Psychosocial Function in Children

BACKGROUND AND OBJECTIVE: Resin-based dental materials may intraorally release their chemical components and bisphenol A. The New England Children’s Amalgam Trial found that children randomized to amalgam had better psychosocial outcomes than those assigned to composites for posterior tooth restorations. The objective of this study was to examine whether greater exposure to dental composites is associated with psychosocial problems in children. METHODS: Analysis of treatment-level data from the New England Children’s Amalgam Trial, a 2-group randomized safety trial comparing amalgam with the treatment plan of bisphenol A-glycidyl methacrylate (bisGMA)-based composite and urethane dimethacrylate–based polyacid-modified composite (compomer), among 534 children aged 6 to 10 years at baseline. Psychosocial function at follow-up (n = 434) was measured by using the self-reported Behavior Assessment System for Children (BASC-SR) and parent-reported Child Behavior Checklist (CBCL). RESULTS: Children with higher cumulative exposure to bisGMA-based composite had poorer follow-up scores on 3 of 4 BASC-SR global scales: Emotional Symptoms (β = 0.8, SE = 0.3, P = .003), Clinical Maladjustment (β = 0.7, SE = 0.3, P = .02), and Personal Adjustment (β = –0.8, SE = 0.2, P = .002). Associations were stronger with posterior-occlusal (chewing) surfaces, where degradation of composite was more likely. For CBCL change, associations were not statistically significant. At-risk or clinically significant scores were more common among children with greater exposure for CBCL Total Problem Behaviors (16.3% vs 11.2%, P-trend = .01) and numerous BASC-SR syndromes (eg, ≥13 vs 0 surface-years, Interpersonal Relations 13.7% vs 4.8%, P-trend = .01). No associations were found with compomer, nor with amalgam exposure levels among children randomized to amalgam. CONCLUSIONS: Greater exposure to bisGMA-based dental composite restorations was associated with impaired psychosocial function in children, whereas no adverse psychosocial outcomes were observed with greater urethane dimethacrylate–based compomer or amalgam treatment levels.

Dental Amalgam Restorations and Children’s Neuropsychological Function: The New England Children’s Amalgam Trial

Background A concern persists that children’s exposure to mercury vapor from dental amalgams produces neurotoxicity. Objective Our goal was to compare the neuropsychological function of children, without prior exposure to dental amalgam, whose caries were repaired using either dental amalgam or mercury-free composite materials. Methods We conducted a randomized controlled trial involving 534 6- to 10-year-old urban and rural children who were assessed yearly for 5 years using a battery of tests of intelligence, achievement, language, memory, learning, visual–spatial skills, verbal fluency, fine motor function, problem solving, attention, and executive function. Results Although the mean urinary mercury concentration was greater among children in the amalgam group than the composite group (0.9 vs. 0.6 μg/g creatinine), few significant differences were found between the test scores of children in the two groups. The differences found were inconsistent in direction. Analyses using two cumulative exposure indices—surface years of amalgam and urinary mercury concentration—produced similar results. Conclusions Exposure to elemental mercury in amalgam at the levels experienced by the children who participated in the trial did not result in significant effects on neuropsychological function within the 5-year follow-up period.

Dental Amalgam and Psychosocial Status: The New England Children’s Amalgam Trial

High-dose exposures to elemental mercury vapor cause emotional dysfunction, but it is uncertain whether the levels of exposure that result from having dental amalgam restorations do so. As part of the New England Children’s Amalgam Trial, a randomized trial involving 6- to 10-year-old children, we evaluated the hypothesis that restoration of caries using dental amalgam resulted in worse psychosocial outcomes than restoration using mercury-free composite resin. The primary outcome was the parent-completed Child Behavior Checklist. The secondary outcome was children’s self-reports using the Behavior Assessment System for Children. Children’s psychosocial status was evaluated in relation to three indices of mercury exposure: treatment assignment, surface-years of amalgam, and urinary mercury excretion. All significant associations favored the amalgam group. No evidence was found that exposure to mercury from dental amalgams was associated with adverse psychosocial outcomes over the five-year period following initial placement of amalgams.

The Prevalence of Root Caries in a Diabetic Population

The objective of this study was to assess the level of root caries in a population of diabetic adults. Diabetics are of special interest because they are alleged to be periodontally compromised and have atypical patterns of refined carbohydrate ingestion. Diabetic subjects were patients of the Joslin Diabetic Center in Boston and had significantly elevated blood glucose and glycosylated hemoglobin levels over at least a ten-year period. Eligible subjects had to be between the ages of 45 and 65 and have a minimum of ten teeth and three sites with recession. Data were collected on coronal caries, oral hygiene, gingivitis, pocket depth, recession, and root caries and were compared with data from control subjects from a larger nondiabetic study group. There were 88 diabetics and 185 controls with mean ages of 55.7 and 56.3 years, respectively. The groups were found to be similar with respect to the numbers of buccal surface sites with gingival recession and the numbers of carious root lesions. There was a distinct difference, however, with respect to restored root surfaces: 1.76 mean filled surfaces were observed in the controls, as compared with 0.49 in the diabetics. A Katz Root Caries Index (for which lesions are calculated as a percentage of the numbers of exposed root surfaces) was determined to be 15.2 for the controls and 7.1 for the diabetics. A reasonable inference is that these differences are the result of a restricted ingestion of refined carbohydrates by the diabetic group. This was confirmed by a dietary survey of subsamples from the diabetic and nondiabetic groups.

Underutilization of Dental Care When It Is Freely Available: A Prospective Study of the New England Children's Amalgam Trial

OBJECTIVE This study aims to prospectively examine the trends and reasons for the underutilization of free semiannual preventive dental care provided to children with unmet dental needs who participated in the 5-year New England Childrens Amalgam Trial. METHODS Children aged 6 to 10 at baseline (1997-99) with > or = 2 posterior carious teeth were recruited from rural Maine (n = 232) and urban Boston (n = 266). Interviewer-administered questionnaires assessed demographic and personal characteristics. Reasons for missed appointments were recorded during follow-up and are descriptively presented. We used an ordinal logistic regression to analyze the utilization of semiannual dental visits. RESULTS On average, urban children utilized 69 percent of the visits and rural children utilized 82 percent of the visits. For both sites, utilization steadily decreased until the end of the 5-year trial. Significant predictors of underutilization in the multivariate model for urban children were non-White race, household welfare use, deep debt, and distance to dental clinic. Among the relatively less-diverse rural children, caregiver education level and a greater number of decayed tooth surfaces at baseline (i.e., need for care) were significantly associated with underutilization. Among all children, the common reasons for missed visits included guardian scheduling and transportation difficulties; reasons among urban participants also indicated a low priority for dental care. CONCLUSIONS Among these children with unmet dental needs, the provision of free preventive dental care was insufficient to remove the disparities in utilization and did not consistently result in high utilization through follow-up. Differences between educational levels, ethnicities, and rural/urban location suggest that public health programs need to target the social settings in which financial burdens exist.

Effect of Acculturation on Objective Measures of Oral Health in Haitian Immigrants in New York City

Acculturation is a complex phenomenon that can serve as a proxy for cultural norms and behaviors affecting care-seeking, prevention behaviors, and, ultimately, health outcomes. The purpose of this study was to assess the effect of acculturation on the oral health of Haitian immigrants in New York City. We hypothesized that acculturation would be a predictor of the oral health status of the participating individuals. An acculturation scale was specifically developed and validated for this study. A sample of 425 adult Haitian immigrants living in NYC was obtained through outreach activities. Oral health examinations were conducted, and a questionnaire was administered to the participants. After adjustment for age, sex, education, income, and marital status, acculturation was negatively associated with measures of decayed teeth, periodontal attachment loss of ≥ 4 mm, and the number of missing teeth. Results suggest a positive impact of acculturation on the oral health status of these individuals.

Dental Composites and Amalgam and Physical Development in Children

Resin-based composite dental restoration materials may release bisphenol-A, an endocrine-disrupting chemical. Using secondary analysis of a randomized clinical safety trial of amalgam vs. composites, we tested the hypothesis that dental restoration materials affect children’s growth. Children (N = 218 boys, N = 256 girls) aged 6 to 10 yrs at baseline with ≥ 2 decayed posterior teeth were randomized to amalgam or composites (bisphenol-A-diglycidyl-dimethacrylate composite for permanent teeth, urethane-dimethacrylate compomer for primary teeth) for treatment of posterior caries throughout follow-up. Primary outcomes for this analysis were 5-year changes in BMI-for-age z-scores, body fat percentage (BF%), and height velocity; exploratory analyses (n = 113) examined age at menarche. Results showed no significant differences between treatment assignment and changes in physical development in boys [(composites vs. amalgam) BF%, 4.9 vs. 5.7, p = 0.49; (BMI-z-score) 0.13 vs. 0.25, p = 0.36] or girls (8.8 vs. 7.7, p = 0.95; 0.36 vs. 0.21, p = 0.49). Children with more treatment on primary teeth had greater increases in BF% regardless of material type. Girls assigned to composites had lower risk of menarche during follow-up (hazard ratio = 0.57, 95% CI 0.35-0.95). Overall, there were no significant differences in physical development over 5 years in children treated with composites or amalgam. Additional studies examining these restoration materials in relation to age at menarche are warranted (clinicaltrials.gov number NCT00065988).

Systemic diseases and oral health.

The US population is at the beginning of a significant demographic shift; the American geriatric population is burgeoning, and average longevity is projected to increase in the coming years. Elder adults are affected by numerous chronic conditions, such as diabetes, hypertension, osteoarthritis, osteoporosis, cardiovascular diseases, and cerebrovascular diseases. These older adults need special dental care and an improved understanding of the complex interactions of oral disease and systemic chronic diseases that can complicate their treatment. Oral diseases have strong associations with systemic diseases, and poor oral health can worsen the impact of systemic diseases.

Violence and abuse: core competencies for identification and access to care.

Violence and abuse (V/A) is recognized as a significant public health problem, especially in females. Injuries to the head, neck, and/or mouth are clearly visible to the dental team during examination. This article provides compelling evidence that supports the pivotal position occupied by oral health care professionals within the arena of detection, intervention, and prevention of V/A. This article reviews the epidemiology of orofacial risk factors for V/A, diagnostic tools and surveys for identifying victims of all ages, and suggests interdisciplinary educational curricula/specific algorithms to provide the necessary core competencies for identifying victims in the oral health care environment.

Rural and Urban Disparities in Caries Prevalence in Children with Unmet Dental Needs: The New England Children's Amalgam Trial

OBJECTIVES To compare the prevalence of caries between rural and urban children with unmet dental health needs who participated in the New England Childrens Amalgam Trial. METHODS Baseline tooth and surface caries were clinically assessed in children from rural Maine (n = 243) and urban Boston (n = 291), who were aged 6 to 10 years, with two or more posterior carious teeth and no previous amalgam restorations. Statistical analyses used negative binomial models for primary dentition caries and zero-inflated models for permanent dentition caries. RESULTS Urban children had a higher mean number of carious primary surfaces (8.5 versus 7.4) and teeth (4.5 versus 3.9) than rural children. The difference remained statistically significant after adjusting for sociodemographic factors and toothbrushing frequency. In permanent dentition, urban children were approximately three times as likely to have any carious surfaces or teeth. However, rural/urban dwelling was not statistically significant in the linear analysis of caries prevalence among children with any permanent dentition caries. Covariates that were statistically significant in all models were age and number of teeth. Toothbrushing frequency was also important for permanent teeth. CONCLUSIONS Within this population of New England children with unmet oral health needs, significant differences were apparent between rural and urban children in the extent of untreated dental decay. Results indicate that families who agree to participate in programs offering reduced cost or free dental care may present with varying amounts of dental need based on geographic location.