Poor Oral Health in Trauma Intensive Care Unit Patients: Application of a Novel Oral Health Score.

Background: Although oral hygiene in patients in the intensive care unit (ICU) has been shown to reduce hospital-associated infections, baseline and progressive oral health are often not reported because of lack of a standardized tool. The Oral Health Risk Assessment Value Index (OHRAVI) is a comprehensive oral assessment validated by dental providers. This study hypothesizes that non-dental providers can use OHRAVI in trauma ICU patients with minimal training and acceptable inter-rater reliability (IRR). Patients and Methods: Dentulous adult patients in the ICU at a level 1 trauma center were scored, excluding those with severe orofacial trauma. The eight categories of the OHRAVI were scored 0 to 3 (best to worst) with summed total and index (average) score. Index scores 1 or less need routine oral care; greater than 1-2 require moderate care; and greater than 2-3 require extensive oromaxillofacial care. Inter-rater reliability was assessed by two to three raters with Krippendorff's α (≥0.80 for good and ≥0.667 for acceptable). Results: Eighty-four ratings were completed across 34 patients, with 16 patients (47%) scored by all three raters. Ten patients (29%) had an index score <1. The average index score for patients was 1.28 (median, 1.34; range, 0.63-2). Krippendorff's α for index score was 0.86. For individual categories, α ranged from 0.44 to 1, with six of the eight categories achieving an α ≥ 0.667. Conclusions: With minimal training, non-dental providers were able to use OHRAVI with a good IRR for index score and an acceptable/good IRR for most individual categories. This novel, simple, comprehensive oral health score could help standardize oral assessment and facilitate future studies of peri-operative oral hygiene interventions.

Assessment of oral and overall health parameters using the SillHa Oral Wellness System.

OBJECTIVE: The study evaluated use of a multipoint saliva analyzer to assess patient wellness in a contemporary dental practice setting. STUDY DESIGN: Unstimulated saliva from a diverse 104 patient cohort was analyzed using the SillHa Oral Wellness System. The device measures the following 7 analytes present in the patient's oral rinse: cariogenic bacteria, acidity, buffer capacity, blood, leukocytes, protein, and ammonia. Data obtained were compared with validated clinical assessment data independently provided by credentialed dental professionals. RESULTS: Measured leukocyte and protein levels were higher in patients with periodontal disease and/or deep gingival pockets. Patients with a history of cancer and/or diabetes presented with higher ammonia and lower leukocyte levels. Acidity levels were higher in patients using multiple xerogenic medications and lower in patients with a history of sleep apnea. Sex differences showed female patients exhibiting higher acidity, lower buffer capacity, and lower ammonia than male patients. Increasing age is associated with elevated buffer capacity. CONCLUSIONS: Multipoint saliva analyzers such as the one used in this study, along with clinical practice examination and medical history, can provide rapid salivary component analysis that augments treatment planning. A follow-up multisite study would provide the opportunity to test this analyzer in clinical sites with different practice workflows.

Surfactant Protein A and Microbiome Composition in Patients With Atraumatic Intraoral Lesions.

Oral ulcers are lesions that occur due to disruption of epithelial integrity of the mucosa of the oral cavity. Intraoral ulcers are often associated with pain, redness, symptoms of discomfort, and blood hemorrhage. The etiology for many oral ulcers is local trauma, systemic health conditions, or medication; for other ulcers the cause is less clear. This pilot study aims to evaluate the salivary components and microbiome in patients with atraumatic pre-ulcerous and ulcerous oral lesions compared to control individuals, while considering three common risk factors for atraumatic ulcers, smoking, stress, and gender. This study uses matched age, sex, and ethnicity samples from healthy otherwise and oral lesion patients to investigate the changes in salivary surfactant protein A (SP-A) and examines the prevalence and diversity of the salivary oral microflora. The goal is to determine if there are factors in saliva that have the potential to be used as biomarkers for risk of developing atraumatic oral ulcers. Our data show that the average level of SP-A is significantly reduced in female smokers compared to non-smoker healthy females. The average level of SP-A in female oral lesion patients is reduced compared to controls. The microbiome composition is significantly affected by smoking and the level of SP-A. Comparing the control participants and oral lesion patients, there are 16 species of bacteria that are significantly different, and all of these bacteria are significantly affected by smoking and SP-A. LEfSe analysis identified five bacteria that may represent potential biomarkers. This preliminary study demonstrates the potential of the oral microbiome to act as a biomarker for oral ulcer risk and infers potential mechanistic links between risk factors and alterations in innate immune mechanisms such as SP-A levels.

When should sleep bruxism be considered in the diagnosis of temporomandibular disorders?

OBJECTIVE: Both temporomandibular disorders (TMDs) and sleep bruxism (SB) are known to be destructive to the masticatory system. However, the association between the 2 conditions is poorly understood. The aim of our study was to assess the relationship between TMD and SB through the signs and symptoms in 2 patient groups: TMD only and TMD with SB. STUDY DESIGN: A retrospective chart review was conducted from November 1, 2015, to April 1, 2018, on patients with completed International Network for Orofacial Pain and Related Disorders Methodology history questionnaires and Diagnostic Criteria for Temporomandibular Disorder clinical examinations. Fifty-two patients, including 12 with TMD only and 40 with TMD with SB, met the study criteria. Subjective descriptions and objective measurements of patient symptoms were investigated. The χ2 test and Fisher's exact test were used for statistical analysis. RESULTS: The TMD with SB group exhibited increased oral behaviors compared with the TMD-only group (P = .0004). The TMD with SB group also experienced more headaches compared with the TMD-only group (P = .045). CONCLUSIONS: Our results revealed that patients with jaw pain who self-report increased oral behaviors and/or exhibit temporal headaches should be evaluated for sleep bruxism.

Should Pass/Fail Grading Be Used Instead of Traditional Letter Grades in Dental Education? Two Viewpoints: Viewpoint 1: Pass/Fail Grading Improves Learning Experiences for Students and Viewpoint 2: Traditional Letter Grading Provides Objective Evaluation for Dental Education.

Discussions about which grading system (letter grade or pass/fail) is more effective in dental education have been occurring for several decades. As more institutions continue to consider the change from the traditional five-tier letter grading system (A/B/C/D/F) to a two-tier grading system (pass/fail), this debate will likely continue. This point/counterpoint article examines arguments for and against each type of grading system, taking into consideration academic performance, learning outcomes, psychological well-being, learning environment, acceptance/performance in postgraduate educational programs, and student motivation. Viewpoint 1 supports the position that a pass/fail system improves learning experiences for dental students, whereas Viewpoint 2 argues that the traditional letter grading system provides for more objectivity and reliability in student evaluation.

Gender and Smoking Correlations of Surfactant Lipids and Proteins in the Saliva of Dental Patients.

We sought to determine the effects of smoking on surfactant lipids and proteins in saliva. Levels of sphingomyelin (Sph) phosphatidylcholine (PC) and lyso-PC (LPC) were determined by thin layer chromatography. Levels of surfactant protein A (SP-A) were determined by western analysis using antibodies specific for SP-A. Significance of the results was determined by the student's t-test. The LPC/PC ratio had a tendency to be much higher in smokers compared to nonsmokers. LPC levels were significantly higher in females smokers compared to male smokers. Additionally, levels of SP-A were significantly reduced in females smokers compared to non-smokers. Smoking alters surfactant protein and LPC/PC ratios in saliva. There is a significant difference in the effects in females compared to males. Findings suggest smoking alters the composition of saliva that may reduce protection of the oral cavity, which may explain why women smokers are at greater risk of developing oral mucositis.

Medical and Dental Students' Perceptions and Attitudes towards Interprofessional Clinical Education.

This article was migrated. The article was marked as recommended. Purpose: Interest and expansion of interprofessional education (IPE) has increased tremendously over the last decade due to need and regulatory requirements. Methods: Third-year medical students and third and fourth-year dental students participated in a combined IPE experience at a dental assessment clinic. All participating students completed the Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire before the session, and medical students completed an evaluation after the session. Results: All students agreed that IPE is important and needed for the development of skills, and they see benefit to shared learning. The only RIPLS question in which students did not agree was "Clinical problem solving can only be learnt effectively with students/ professionals from own school/organization." The dental students agreed with this more than medical students (p=0.04). Age of medical and dental students was related with outcomes of RIPLS questions 2, 7, 14, and 16 (p=0.03, 0.02, 0.03, and 0.02, respectively). Older participants from both schools tended not to agree with statements related to importance of working together benefiting patients, improving working relationships, welcoming the opportunity to work on small group projects with other health/social care students, and whether shared learning/practice will help clarify the nature of patients' problems. Medical student evaluations of the dental IPE experience were very positive, and mild changes in the curriculum improved medical student perception of the experience from year 1 to 2. Conclusion: Guidelines and standardized curricula could help medical and dental school faculty create clinically appropriate and effective IPE interactions for learners of all ages.

Assessment of Diagnosed Temporomandibular Disorders and Orofacial Pain Conditions by Predoctoral Dental Students: A Pilot Study.

Temporomandibular disorders and orofacial pain (TMD/OFP) conditions are challenging to diagnose for predoctoral dental students due to the multifactorial etiology, complexity, and controversial issues surrounding these conditions. The aim of this study was to determine if patients in the clinic of one U.S. dental school reported existing signs and symptoms of TMD/OFP, whether the dental students diagnosed the condition based on the reported signs and symptoms, and if the condition was then treated. The study was based on a retrospective analysis of electronic health record data over a three-year period. The results showed that, during the study period, 21,352 patients were treated by student providers. Of those patients, 5.33% reported signs or symptoms associated with TMD/OFP; 5.99% received a TMD/OFP diagnosis; and 0.26% received at least one form of TMD/OFP treatment that had either a diagnosis or signs/symptoms of TMD/OFP. In addition, a small percentage (0.24%) of patients with no documented diagnosis received some sort of TMD/OFP-related treatment. A randomly selected sample of 90 patient charts found that no diagnoses of TMD/OFP were recorded in any of them. The results suggested that students had only marginally diagnosed the problems. Training for students including comprehensive didactic courses and clinical experiences to gain knowledge, context, and skill may be required to ensure they reach the required level of competence and prepare them to face the diagnostic challenges of TMD/OFP after graduation.

Does use of an electronic health record with dental diagnostic system terminology promote dental students' critical thinking?

The Consortium for Oral Health Research and Informatics (COHRI) is leading the way in use of the Dental Diagnostic System (DDS) terminology in the axiUm electronic health record (EHR). This collaborative pilot study had two aims: 1) to investigate whether use of the DDS terms positively impacted predoctoral dental students' critical thinking skills measured by the Health Sciences Reasoning Test (HSRT), and 2) to refine study protocols. The study design was a natural experiment with cross-sectional data collection using the HSRT for 15 classes (2013-17) of students at three dental schools. Characteristics of students who had been exposed to the DDS terms were compared with students who had not, and the differences were tested by t-tests or chi-square tests. Generalized linear models were used to evaluate the relationship between exposure and outcome on the overall critical thinking score. The results showed that exposure was significantly related to overall score (p=0.01), with not-exposed students having lower mean overall scores. This study thus demonstrated a positive impact of using the DDS terminology in an EHR on the critical thinking skills of predoctoral dental students in three COHRI schools as measured by their overall score on the HSRT. These preliminary findings support future research to further evaluate a proposed model of critical thinking in clinical dentistry.

Why use oral splints for temporomandibular disorders (TMDs)?

Several etiologic routes have either been determined or proposed for Temporomandibular Disorders (TMD). Notable among these are myofascial, disc displacement, and arthritides disorders. The absence of concrete and universally accepted evidence-based treatment approaches means that debates as to the precise etiology and treatment of TMDs continue while practitioners attempt to treat and improve the lives of patients who present with these debilitating disorders. The use of oral splints (OS) by clinicians with responsibility to manage TMDs is quite popular, even though its mechanism of action and efficacy remains unclear. This article reviews the rationale for the continued use of OS for the management of TMDs.

Why use oral splints for temporomandibular disorders (TMDs)?

Several etiologic routes have either been determined or proposed for temporomandibular disorders (TMD). Notable among these are myofascial, disc displacement, and arthritides disorders. The absence of concrete and universally accepted evidence-based treatment approaches means that debates as to the precise etiology and treatment of TMDs continue while practitioners attempt to treat and improve the lives of patients who present with these debilitating disorders. The use of oral splints (OS) by clinicians with responsibility to manage TMDs is quite popular, even though its mechanism of action and efficacy remains unclear. This article reviews the rationale for the continued use of OS for the management of TMDs.

Cone beam computed tomography in dentistry: what dental educators and learners should know.

Recent advances in cone beam computed tomography (CBCT) in dentistry have identified the importance of providing outcomes related to the appropriate use of this innovative technology to practitioners, educators, and investigators. To assist in determining whether and what types of evidence exist, the authors conducted PubMed, Google, and Cochrane Library searches in the spring of 2011 using the key words "cone beam computed tomography and dentistry." This search resulted in over 26,900 entries in more than 700 articles including forty-one reviews recently published in national and international journals. This article is based on existing publications and studies and will provide readers with an overview of the advantages, disadvantages, and indications/contraindications of this emerging technology as well as some thoughts on the current educational status of CBCT in U.S. dental schools. It is the responsibility of dental educators to incorporate the most updated information on this technology into their curricula in a timely manner, so that the next generation of oral health providers and educators will be competent in utilizing this technology for the best interest of patients. To do so, there is a need to conduct studies meeting methodological standards to demonstrate the diagnostic efficacy of CBCT in the dental field.

Chronic lingual papulosis: new, independent entity or "mature" form of transient lingual papillitis?

OBJECTIVE: Several acute, usually pediatric variants of edematous, symptomatic fungiform lingual papillitis have been reported since the 1990s, most notably transient lingual papillitis (TLP); but no chronic forms have been mentioned. Is there a chronic counterpart, akin to the older palatal examples of inflammatory papillary hyperplasia? The objective of this study was to clinicopathologically characterize a previously unreported entity with clustered, chronic fibrous papules (nonsyndromic) of the tongue. METHODS: Cases were collected from clinics in 2 dental schools. RESULTS: Five women and 4 men were identified with multiple, moderately firm, slightly pedunculated, normally colored masses clustered at the tip of the tongue (n = 4), covering the dorsal surface (n = 4) or on the lateral border (n = 1); 2 showed several erythematous or edematous papules (similar to TLP) admixed with fibrous papules. Patient ages ranged from 31 to 62 years (average 49) and all lesions had been present for many years. All lesions were asymptomatic except for the lateral border lesion, which presented with a burning sensation and mild tenderness (disappeared with antifungal medication). Five cases were associated with mouth breathing or a tongue-thrust habit; 4 were associated with geographic tongue or fissured tongue. Four papules were biopsied. All were composed of dense, avascular fibrous tissue with no or very few inflammatory cells; one showed focal mild neovascularity and edema. The lesion appeared to represent altered filiform papillae, more so than fungiform papillae. CONCLUSIONS: Chronic lingual papulosis (CLP) is an innocuous entity represented by focal or diffuse enlargement of numerous lingual papillae, primarily the filiform papillae. It appears to usually have an adult onset and most likely represents papillary reaction to very low-grade, chronic irritation or desiccation. Some cases with childhood onset, however, seem to be variations of normal anatomy. No treatment or biopsy is required, but a number of systemic disorders and syndromes must be ruled out before applying the CLP diagnosis.

Assessing the delivery of comprehensive care at a dental school.

A key mission of a dental school is to train students to be competent dentists through the delivery of comprehensive care to patients. Comprehensive care is defined as a seamless and integrated dental treatment that addresses all patients' dental needs. Identification of a health care problem is the essential first step in quality improvement to medical education curriculum and its outcomes. It is critical for students to receive adequate clinical experience and for patients to receive needed treatment. This study assessed the degree to which comprehensive care was delivered from the patient and student perspective, and to determine why patients discontinue their course of treatment. We conducted a retrospective analysis of electronic health record (EHR) data in one group practice at the University of Texas School of Dentistry at Houston. Semistructured interviews of patients, students and faculty were also conducted. The results showed that 29% of assessed and admitted patients received comprehensive care. A large proportion of dropouts occurred after the third or fourth visit. It took on average 9.8 visits and 210 days for patients to complete their planned treatments. Dental students had a patient family of 25-29 patients, delivered 75% of their care in their fourth year, and predominantly provided restorative treatments compared with other dental disciplines. Interview transcripts were analyzed to determine strengths, weaknesses, and opportunities relating to the provision of comprehensive care. Patients perceived that they received cost effective and high quality care. Students and faculty provided suggestions for streamlining care. Findings from both the retrospective analysis of EHR data and semi-structured interviews revealed several areas for improvement. One solution that was subsequently piloted was to combine the separate assessment and treatment planning appointments into a single all-day session to reduce patient dropouts. During the pilot period over the summer session, 84 patients were scheduled in the combined assessment and treatment planning session. Of this population, 69% percent were accepted and deemed suitable for undergraduate care. And 83% among those accepted received a treatment plan on the first appointment. In the future we expect to integrate more formal evidence-based exercises and reassess the impact of these changes in improving educational and clinical care outcomes. In addition we expect to adopt evidence-based solutions and reassess the impact of these changes in improving educational and clinical care outcomes.

Conflicts of interest in research: is clinical decision-making compromised? An opinion paper.

Lack of transparency in funded research can compromise clinical decision-making in an evidence-based practice. Transparency can be defined as full disclosure of all financial assistance and support to authors and investigators. There is a perception that ethical principles are eroding and that research data can be biased due to conflicts of interest. These research outcomes biased or not, are used for clinical decision-making in the evidence-based practice. One suggested solution to this common ethical dilemma is to continue the dialogue on transparency in research and to create oversight bodies which include representatives from business and industry, private practice, academia, and research. There is increasing evidence of the need for more ethics education at all levels.

Removal of an irritation fibroma using an Er,Cr:YSGG laser: a case report.

The irritation fibroma is a benign proliferation that occurs as a response to local irritation. It is an elevated pedunculated or sessile lesion that ranges in size from a few millimeters to a few centimeters and is normal in color, although it may appear to be more pale than the normal mucosa. This article describes the case of a 39-year-old woman with an asymptomatic nodular lesion that involved the left buccal mucosa. The lesion was removed using an Er,Cr:YSGG laser. Only topical anesthesia was applied to the fibroma and adjacent mucosa and no infiltration was required. No pain medication or antibiotics were required after surgery and wound healing was excellent and achieved rapidly. The oral pathology report confirmed the presurgical clinical diagnosis. Laser excision is a modern approach for treating oral soft tissue lesions and should be considered as an alternative to conventional scalpel surgery.