Salivary microbiome changes distinguish response to chemoradiotherapy in patients with oral cancer.

BACKGROUND: Oral squamous cell carcinoma (SCC) is associated with oral microbial dysbiosis. In this unique study, we compared pre- to post-treatment salivary microbiome in patients with SCC by 16S rRNA gene sequencing and examined how microbiome changes correlated with the expression of an anti-microbial protein. RESULTS: Treatment of SCC was associated with a reduction in overall bacterial richness and diversity. There were significant changes in the microbial community structure, including a decrease in the abundance of Porphyromonaceae and Prevotellaceae and an increase in Lactobacillaceae. There were also significant changes in the microbial community structure before and after treatment with chemoradiotherapy, but not with surgery alone. In patients treated with chemoradiotherapy alone, several bacterial populations were differentially abundant between responders and non-responders before and after therapy. Microbiome changes were associated with a change in the expression of DMBT1, an anti-microbial protein in human saliva. Additionally, we found that salivary DMBT1, which increases after treatment, could serve as a post-treatment salivary biomarker that links to microbial changes. Specifically, post-treatment increases in human salivary DMBT1 correlated with increased abundance of Gemella spp., Pasteurellaceae spp., Lactobacillus spp., and Oribacterium spp. This is the first longitudinal study to investigate treatment-associated changes (chemoradiotherapy and surgery) in the oral microbiome in patients with SCC along with changes in expression of an anti-microbial protein in saliva. CONCLUSIONS: The composition of the oral microbiota may predict treatment responses; salivary DMBT1 may have a role in modulating the oral microbiome in patients with SCC. After completion of treatment, 6 months after diagnosis, patients had a less diverse and less rich oral microbiome. Leptotrichia was a highly prevalent bacteria genus associated with disease. Expression of DMBT1 was higher after treatment and associated with microbiome changes, the most prominent genus being Gemella Video Abstract.

Survey of Michigan dentists and radiation oncologists on oral care of patients undergoing head and neck radiation therapy.

BACKGROUND: Oral complications of radiation therapy for head and neck cancer (HNC) are associated with a significant decline in oral health-related quality of life (OHQOL). The dentist, working with the radiation oncologist and the rest of the health care team, plays an important role in the prevention and management of these complications, but patients do not always receive care consistent with current guidelines. This study investigated barriers to recommended care. HYPOTHESES: There is variability in knowledge and practice among dentists and radiation oncologists regarding the dental management of patients treated with head and neck radiotherapy (HNRT), and inadequate communication and collaboration between members of the patient's health care team contribute to inconsistencies in application of clinical care guidelines. There is on interest and need for continuing dental (CDE) and medical education (CME) on this topic. MATERIALS/METHODS: A questionnaire was developed to assess dentists' knowledge and practice of dental management of HNC patients and their interest in CDE on this topic. All members of the Michigan Dental Association (MDA) with email addresses were asked to complete the survey online, and a random sample of MDA members without email addresses was invited to complete a paper version of the same survey. All Michigan members of the American Society for Radiation Oncology (ASTRO) were invited to complete an online version of the survey modified for radiation oncologists. RESULTS: The response rate for dentists was 47.9% and radiation oncologists was 22.3%. Of the dentists who responded, 81% reported that a major barrier to providing dental treatment before radiotherapy was a lack of time between initial dental consultation and the start of radiation; inadequate communication between health care providers was blamed most frequently for this. Ten percent of the dentists and 25% of the radiation oncologists reported that they did not treat HNC patients because they lacked adequate training, and 55% of dental respondents said that they did not feel adequately trained in dental school to treat patients who have had head and neck radiation therapy. Most respondents (radiation oncologists 67%; dentists 72%) were interested in CDE and CME on this topic. CONCLUSIONS: These results suggest a need for CDE and CME for Michigan dentists and radiation oncologists on the oral management of HNC patients. Improved training and communication between health professionals could improve patient outcomes and more consistent application of clinical care guidelines.

Salivary gland imaging.

Dry mouth, facial swelling, and pain are common signs of salivary gland disorders that may be encountered in the dental practice. Diagnostic imaging can facilitate assessment of patients with these problems. The purpose of this review paper is to discuss the imaging modalities available for assessment of the major salivary glands, their indications, and limitations to assist the dentist managing patients with salivary gland disorders.

Entrustable professional activities framework for assessment in predoctoral dental education, developed using a modified Delphi process.

PURPOSE/OBJECTIVES: The purpose of this study was to define and develop a set of Entrustable Professional Activities (EPAs) for dental education using a modified Delphi consensus approach. EPAs define the core tasks that a graduating dentist needs to perform independently in practice. The EPA framework facilitates assessment of competencies as they manifest in the tasks and independence needed to be ready for practice. METHODS: Feedback was obtained from participants about a list of EPAs, with modifications made after each of the 3 rounds, using a modified Delphi approach. Phase 1 included attendees at the ADEA Fall 2017 meeting (n = 35) who participated in an EPA workshop primarily composed of academic deans. The Phase 2 "reactor panel" consisted of 10 dental schools' academic deans and other individuals with expertise and interest in dental curriculum and assessment (n = 31). Phase 3 participants were attendees at the ADEA CCI 2019 meeting (n = 91) who also participated in a 2-day EPA workshop. RESULTS: In phase 1, overall ratings for acceptability of the EPAs were satisfactory. In phase 2, the next iteration of EPAs was judged as satisfactory for inclusion in curriculum, match well with clinical practice and clarity. In phase 3, the EPAs were judged as satisfactory for being an "entrustable, essential, and important task of the profession." Qualitative feedback suggested wording, measurability, and specific focus of EPA statements is important. CONCLUSIONS: A preliminary set of EPAs was designed for predoctoral dental education through a systematic, careful consensus building approach involving a diverse set of participants.

Contemporary appraisal of factors influencing pediatric dental program directors' selection of residents.

PURPOSE: With the increasing number of applicants and changes to information available in applications, pediatric dentistry program directors must adapt the resident selection process. The evaluation approach was significantly impacted when the National Board Dental Examination (NBDE) changed to a pass/fail grading system. The purposes of this are study to examine what criteria pediatric dentistry program directors now use to select residents, and to evaluate current criteria against those used in the past. METHODS: A 30-item survey was structured similar to a previous questionnaire used in 2005. An invitation to participate was sent via email to all pediatric dentistry program directors for the 82 Commission on Dental Accreditation (CODA)-accredited programs located in the United States and Canada. Anonymous responses were analyzed. RESULTS: There were 58 responses (70.7% response rate). The overall most important factors were clinical grades, dental school class rank, dental school grade point average (GPA), and applicant's essay. The least important factors were the applicant being a graduate of the program's dental school, Advanced Dental Admission Test (ADAT) score, and applicant's fluency in a second language. The factor that had the most significant increase in importance from 2005 is the applicant's essay, followed by dental school reputation and the dental school's pediatric program reputation. CONCLUSIONS: The most important factors to program directors are clinical grades, dental school class rank, dental school GPA, and applicant's essay. The applicant's essay has increased in importance since 2005.

Dose-effect relationships for the submandibular salivary glands and implications for their sparing by intensity modulated radiotherapy.

PURPOSE: Submandibular salivary glands (SMGs) dysfunction contributes to xerostomia after radiotherapy (RT) of head-and-neck (HN) cancer. We assessed SMG dose-response relationships and their implications for sparing these glands by intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: A total of 148 HN cancer patients underwent unstimulated and stimulated SMG salivary flow rate measurements selectively from Wharton's duct orifices, before RT and periodically through 24 months after RT. Correlations of flow rates and mean SMG doses were modeled throughout all time points. IMRT replanning in 8 patients whose contralateral level I was not a target incorporated the results in a new cost function aiming to spare contralateral SMGs. RESULTS: Stimulated SMG flow rates decreased exponentially by (1.2%)(Gy) as mean doses increased up to 39 Gy threshold, and then plateaued near zero. At mean doses < or =39 Gy, but not higher, flow rates recovered over time at 2.2%/month. Similarly, the unstimulated salivary flow rates decreased exponentially by (3%)(Gy) as mean dose increased and recovered over time if mean dose was <39 Gy. IMRT replanning reduced mean contralateral SMG dose by average 12 Gy, achieving < or =39 Gy in 5 of 8 patients, without target underdosing, increasing the mean doses to the parotid glands and swallowing structures by average 2-3 Gy. CONCLUSIONS: SMG salivary flow rates depended on mean dose with recovery over time up to a threshold of 39 Gy. Substantial SMG dose reduction to below this threshold and without target underdosing is feasible in some patients, at the expense of modestly higher doses to some other organs.

Dental Students' Evaluations of Practice Management Education and Interest in Business-Related Training: Exploring Attitudes Towards DDS/DMD-MBA Programs.

Being well prepared for a competitive business environment is crucial for future dentists. The aims of this study were to assess dental students' satisfaction with their practice management education, their current and future interest in business-related education and attending a DDS/DMD-MBA program, and the relationship between their demographic and other characteristics and their business education-related responses. The study, conducted in 2016 and 2017, surveyed students in all four years at the authors' home school and at other schools that did not have a DDS/DMD-MBA program. At the home school, 273 students responded (response rate 63%); and 341 students from 11 of the 51 U.S. dental schools without a DDS/DMD-MBA program responded (respondents were from 21% of schools invited; the response rate of those students could not be calculated). The responding students disagreed that their school adequately prepared them for the business aspects of dentistry (mean=2.42 on a scale from 1=disagree strongly to 5=agree strongly). Large majorities agreed/strongly agreed that dentistry is a career that requires a certain amount of business acumen (95%) and that they were very interested in learning about business (85%). A total of 68% agreed/strongly agreed that their school should offer a dual DDS/DMD-MBA degree and 63% that they would consider enrolling in such a program. The more advanced the respondents were, the less satisfied they were with their practice management education (r=-0.20; p<0.001). Female respondents were less interested in business-related education (r=-0.20; p<0.001) and less likely to consider a DDS/DMD-MBA program than the males. Respondents planning to own a dental practice were more interested in additional current business education (r=0.22; p<0.001) and in future business education (r=0.15; p<0.001) than those without that plan. These results showed that a significant percentage of these dental students were interested in a DDS/DMD-MBA program. The male students and students who planned to own a practice were more interested in business education than the female students and students who did not plan to own their own practice.

General Dentists' Perceptions of Dental Hygienists' Professional Role: A Survey.

Purpose: Changes in dental hygienists' scope of practice in the United States (U.S.) are not independent of general dentists' attitudes and behavior related to dental hygienists' professional roles. The purpose of this study was to assess perceptions and knowledge of general dentists concerning the legally allowable duties of dental hygienists in their state versus the services they provide in their individual practices; the importance of dental hygienists' contributions to the practice; and how well dental hygienists interact with dentists and patients. The relationships between dentists' attitudes, and dental hygienists' actual behavior, the age of the dentist and the number of dental hygienists and dental assistants employed in the practice were also explored.Methods: Survey data were collected from 292 general dentists in the state of Michigan concerning their attitudes and behavior related to dental hygienists' scope of practice.Results: The average number of services dental hygienists provided in the practices surveyed were lower than the average number of services that dental hygienists are legally permitted to provide in the state of Michigan. The higher the importance dentists placed on dental hygienists' clinical and overall contributions to their practice and their patient management skills, the more diagnostic services and therapies the dental hygienists performed. The older the dentists were, the higher they rated the importance of dental hygienists' clinical contributions, their contributions for the provision of patient care, and the more often dental hygienists performed diagnostic and additional procedures.Conclusions: While dentists did not indicate delegating all of the legally allowable dental hygiene duties in their practices, they did indicate having a very high appreciation of the contributions of dental hygienists to their practice. The perceived value of dental hygienists' contributions correlated positively with the number of diagnostic and adjunctive services dentists delegated dental hygienists to perform in their practices.

Lack of osteoradionecrosis of the mandible after intensity-modulated radiotherapy for head and neck cancer: likely contributions of both dental care and improved dose distributions.

PURPOSE: To assess the prevalence and dosimetric and clinical predictors of mandibular osteoradionecrosis (ORN) in patients with head and neck cancer who underwent a pretherapy dental evaluation and prophylactic treatment according to a uniform policy and were treated with intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: Between 1996 and 2005, all patients with head-and-neck cancer treated with parotid gland-sparing IMRT in prospective studies underwent a dental examination and prophylactic treatment according to a uniform policy that included extractions of high-risk, periodontally involved, and nonrestorable teeth in parts of the mandible expected to receive high radiation doses, fluoride supplements, and the placement of guards aiming to reduce electron backscatter off metal teeth restorations. The IMRT plans included dose constraints for the maximal mandibular doses and reduced mean parotid gland and noninvolved oral cavity doses. A retrospective analysis of Grade 2 or worse (clinical) ORN was performed. RESULTS: A total of 176 patients had a minimal follow-up of 6 months. Of these, 31 (17%) had undergone teeth extractions before RT and 13 (7%) after RT. Of the 176 patients, 75% and 50% had received >or=65 Gy and >or=70 Gy to >or=1% of the mandibular volume, respectively. Falloff across the mandible characterized the dose distributions: the average gradient (in the axial plane containing the maximal mandibular dose) was 11 Gy (range, 1-27 Gy; median, 8 Gy). At a median follow-up of 34 months, no cases of ORN had developed (95% confidence interval, 0-2%). CONCLUSION: The use of a strict prophylactic dental care policy and IMRT resulted in no case of clinical ORN. In addition to the dosimetric advantages offered by IMRT, meticulous dental prophylactic care is likely an essential factor in reducing ORN risk.

Factors influencing candidates' choice of a pediatric dental residency program.

The goal of this study was to identify the factors and program characteristics that influenced the program ranking decisions of applicants to pediatric dentistry residency programs. A questionnaire was sent to the first-year resident class in 2005 with a response rate of 69.2 percent (n=260). Approximately 55 percent were female (104/180) and 61 percent were non-His-panic white (110/180). The respondents reported that they applied to an average of nine programs, of which five were ranked. Most applicants were interested in a program that had a hospital component with a duration of two years. A program's ability to prepare the resident for an academic career was a minimal influence for 48.6 percent (87/179), and 57.5 percent (103/179) were not interested in a master's or Ph.D. degree. Factors associated with program ranking included modern clinical facilities, high ratio of dental assistants and faculty to residents, availability of assistants for sedation and general anesthesia cases, availability of a salary or stipend, and amount of clinical experience. Important non-clinical factors included hospitality during the interview, geographic location, and perceived reputation of the program. Opportunity to speak with the current residents in private, observing the interaction between residents and faculty, and touring the facilities were also highly considered. These findings may help program directors tailor their interviews and programs to suit the needs of applicants.

Severe gingival recession and early loss of teeth in a child with chronic graft versus host disease: a case report.

Graft versus host disease (GVHD) occurs after a hematopoietic stem cell transplantation (HSCT) when the donor's immune system rejects the recipient's body, leading to significant morbidity and mortality. Increased numbers of chronic GVHD (c-GVHD) patients are likely to be seen by dental professionals because of the advances made in transplantation. The oral cavity may be the primary or the only site of c-GVHD and may have persistent lesions after resolution has occurred in other areas. Approximately 80% of patients with extensive c-GVHD present some type of oral involvement, including xerostomia, oral pain and lesions. Dental and oral care can be challenging for these patients. This paper discusses the manifestations and treatment of oral c-GVHD and presents the case history of a 15-month-old girl who developed severe oral GVHD with an unusual periodontal presentation and early loss of primary teeth.

Educating Dental Students About Eating Disorders: Perceptions and Practice of Interprofessional Care.

Providing care for patients with eating disorders (EDs) requires an interprofessional care (IPC) approach. The aims of this study were to assess dental students' ED- and IPC-related educational experiences, perceptions of preparedness for ED-related communication with patients and providers, and attitudes related to an IPC approach to ED. Relationships among perceptions of education, preparedness, attitudes, and characteristics (e.g., year in program and family members in other health care fields) were also explored. Of the 440 University of Michigan students invited to participate, 339 completed the survey (77% response rate). A total of 257 students from another 21 dental schools completed the web-based survey, but their response rates could not be computed because it is unknown how many academic deans at the other 65 schools forwarded the recruitment email to their students. In the combined results, the students did not evaluate their ED- and IPC-related clinical education positively (mean=1.33 on scale from 1=least to 3=most education), with first-year students (D1) reporting the least and fourth-year students (D4) the most educational experiences (D1: 1.08, D2: 1.16, D3: 1.42, D4: 1.59; p<0.001). While the students did not perceive themselves well prepared to talk with patients about mental health/ED, they reported feeling better prepared for IPC-related communication: on scale from 1=least to 5=most prepared, mean (patient)=2.94 vs. mean (IPC/provider)=3.61; p<0.001. All the students had mean positive attitudes towards dental professionals' ED-related responsibilities and related IPC considerations. The more education these students reported, the more prepared they perceived being and the more positive their attitudes. The more family members in health professions the students had, the better prepared they reported feeling to communicate with patients and providers from other disciplines about EDs. However, the finding that even the fourth-year students did not evaluate their ED- and IPC-related clinical education positively deserves attention. Educating students about EDs with an IPC approach could ensure better professional preparedness in this context.

Grading xerostomia by physicians or by patients after intensity-modulated radiotherapy of head-and-neck cancer.

PURPOSE: To assess observer-based vs. patient self-reported scoring of xerostomia after intensity-modulated radiotherapy (IMRT) of head-and-neck (HN) cancer. METHODS: A total of 38 patients who had received IMRT for HN cancer underwent xerostomia evaluations 6 to 24 months after completion of therapy using three methods each time: (1) Grading by 3 observers according to the Radiotherapy Oncology Group/European Organization for Research and Therapy of Cancer (RTOG/EORTC) system; (2) patient self-reported validated xerostomia questionnaire (XQ); and (3) major salivary gland flow measurements. RESULTS: The interobserver agreement regarding the RTOG/EORTC grades was moderate: kappa-coefficient 0.54 (95% CI=0.31-0.76). The correlations between the average RTOG/EORTC grades and the salivary flow rates were not statistically significant. A trend for significant correlation was observed between these grades and the percent (relative to the pretherapy) nonstimulated salivary flow rates (p=0.07), but not with the percent stimulated flow rates. Better correlations were found between grading made more than the median time (15 min) after the last liquid sipping and the nonstimulated (but not the stimulated) flows compared with grading made shortly after sipping. In contrast, significant correlations were found between the XQ scores and the nonstimulated (p<0.005) and the stimulated (p<0.005) salivary flow rates, as well as with the percentages of the corresponding pretherapy values (p=0.002 and 0.038, respectively). No significant correlation was found between the RTOG/EORTC grades and the XQ scores. The observer-based grades underestimated the severity of xerostomia compared with the patient self-reported scores. CONCLUSIONS: Patient self-reported, rather than physician-assessed scores, should be the main end points in evaluating xerostomia.