Effectiveness of fluorides in root caries prevention, Department of Veterans Affairs (2009-2018).

AIMS: The aim of this study was to examine the effectiveness of topical fluorides in prevention of root caries-related treatment in high caries risk Veterans. METHODS: This retrospective analysis of longitudinal data examined the effectiveness of professionally applied or prescription (Rx) fluoride treatment, in VHA clinics from FY 2009-2018. Professional fluoride treatments included 5% Sodium Fluoride (NaF) varnish (22 600 ppm fluoride), 2% NaF gel/rinse (9050 ppm fluoride), and 1.23% APF gel (12 300 ppm fluoride). The Rx for daily home use was 1.1% NaF paste/gel (5000 ppm fluoride). Outcomes studied were new root caries restorations or extractions and percent of patients with treatment over 1 year. Logistic regressions were adjusted for age, gender, race, ethnicity, chronic medical or psychiatric conditions, number of medication classes, anticholinergic drugs, smoking, baseline root caries treatment, preventive care, and time between first-last restoration in the index year. RESULTS: Root caries at baseline was associated with a high risk for new root caries. Veterans without root caries during the index year who received a fluoride gel/rinse intervention were 32-40% less likely to receive caries-related treatment for root caries during the follow-up period. Once Veterans had root caries, fluorides did not exhibit a positive effect. CONCLUSION: In older adults with high caries risk, early fluoride prevention is key, before root caries requires treatment.

Providing Effective Dental Care for an Ageing Population.

BACKGROUND: Effective treatment produces improved outcomes from the patient and clinician perspectives. The focus of this article is effective dental care for ageing patients. This concept must be embraced through research, education and, finally, clinical care. RESEARCH: Older adults often carry a higher burden of health and socioeconomic issues that limit their participation in clinical trials. This leaves providers to extrapolate care decisions from research in other age groups. However, electronic health records allow researchers to converge extensive medical, pharmacologic, and dental data, thereby including older patients in research questions. EDUCATION: Dental and medical educators are tasked with teaching skills specific to ageing patients. This requires teaching and active use of concepts such as whole health and patient-centred outcomes. PROVISION OF CARE: For ageing patients, effective care is precision care (the right care to the right patient at the right time). Clinicians must be trained and then actively participate in the interdisciplinary approach to assure good oral health for all older patients.

Validation of a Subjective Caries Risk Assessment Tool.

OBJECTIVE: The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record. METHODS: This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification. RESULTS: The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination. CONCLUSIONS: The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period. CLINICAL SIGNIFICANCE: The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

Alternatives to opioids for acute pain management after dental procedures: A Department of Veterans Affairs consensus paper.

BACKGROUND: Opioid misuse is a widespread public health problem, and opioids are often prescribed in the dental environment. These recommendations provide alternatives to opioids to reduce or eliminate dental procedure-related acute pain. METHODS: A multidisciplinary working group developed these clinical recommendations to specifically address procedure-related acute pain. These recommendations, which are based on published peer-reviewed research and guidelines, include therapies used before, during, and after dental procedures. When evidence is not definitive, the best practices, which are based on experts' consensus, are included. The recommendations are not intended to be exhaustive. RESULTS: These recommendations are a summary of the evidence and best practices for opioid alternatives to treat acute pain related to dental procedures. CONCLUSIONS: Dental providers should prioritize opioid stewardship when managing procedure-related pain with strategies such as thorough preprocedure pain assessment, minimally invasive techniques, preemptive analgesia, intraprocedure pain management, and appropriately selected postprocedure pharmacologic therapy. PRACTICAL IMPLICATIONS: These recommendations are a concise resource for clinical providers. It is important to address patients' procedure-related pain, using nonopioids whenever possible. Alternatives are outlined, allowing providers to make informed decisions.

Department of Veterans Affairs Consensus: Preradiation dental treatment guidelines for patients with head and neck cancer.

Few protocols have been published for the dental management of patients with head and neck cancer to prevent complications from head and neck radiation therapy. Radiation therapy not only affects the tumor cells targeted, but also the dentition, bone, salivary gland, and oral soft tissue structures. A comprehensive dental evaluation prior to head and neck radiation therapy can help prevent many complications. The following clinical guidelines were established by a workgroup of oral health providers within the Department of Veterans Affairs. This workgroup focused on developing a set of recommendations regarding dental care prior to the initiation of head and neck radiation therapy based on the best clinical evidence and expert consensus. A systematic algorithm was developed for the evaluation including pre-exam data gathering, examination, education, and treatment, followed by maintenance and postradiation dental follow-up. This document is evidence-based, patient-centered, consistent with accepted practices of care and safety, and in accordance with applicable statutes and regulations.

Caries prevalence and associations with medications and medical comorbidities.

OBJECTIVES: To use extensive electronic dental, medical, and pharmacy databases to estimate the prevalence of dental caries in a cohort of new patients during a 5-year period (FY2010-FY2015) and determine whether medication use and medical comorbidities are associated with caries prevalence. METHODS: This was a retrospective analysis of existing data from the Department of Veterans Affairs (VA). The number of teeth treated due to a caries-related diagnosis was determined and outcomes were presented as number of teeth/person and proportion of patients receiving caries-related treatment. Logistic and negative binomial regression modeled teeth/person with caries-related treatment; covariates included age, gender, race, ethnicity, physical and mental comorbidities, and use of prescription medications and prescription drugs with strong anticholinergic properties. RESULTS: The study population included 95,850 dentate dental patients: 92.1 percent were male, mean age of 58.7 ± 12.6 years, 73.2 percent were White/Caucasian, and 21.3 percent were Black/African American. They were taking a mean of 10.6 ± 5.9 VA prescription drug classes, 0.6 ± 0.4 drugs with strong anticholinergic properties, and had 3.6 ± 2.2 physical and 1.4 ± 1.2 mental comorbidities. On average, 2.2 teeth/person received caries-related treatment and 58 percent of the study population received any caries-related treatment. An increase in the rate of caries-related treatment in Veterans was statistically significantly associated with increased prescription medication use; one or more drugs with strong anticholinergic properties and with 1+ mental comorbidities. Increased physical comorbidity was not statistically significantly associated with caries-related treatment. CONCLUSIONS: This study demonstrates a high prevalence of caries among Veteran dental patients, with an increased prevalence in those taking higher numbers of prescription medications.

Salivary biomarkers and cardiovascular disease: a systematic review.

BACKGROUND: The purpose of this systematic review is to summarize the literature examining associations between salivary biomarkers and cardiovascular disease (CVD) status. CONTENTS: An advanced search was conducted using MeSH terms related to salivary biomarkers and CVD, and entered into the PubMed, Web of Science, and Google Scholar search databases. Four hundred and thirty-three records were narrowed to 22 accepted articles. Included titles were assessed for quality using the Newcastle-Ottawa scale, and ranked into categories of low, moderate, or high. SUMMARY: A total of 40 salivary biomarkers were analyzed among accepted articles. The most studied markers were salivary creatine kinase isoform MB, C-reactive protein (CRP), matrix metalloproteinase-9, troponin I, myeloperoxidase, myoglobin, and brain natriuretic peptide. Salivary CRP provided the most consistent trends. Statistically significant increases of salivary CRP were present with CVD in every study that analyzed it. The remaining six markers demonstrated varying patterns. OUTLOOK: Existing studies provide insufficient data to draw definitive conclusions. Current research shows that there is an association between some salivary biomarkers and CVD, but the details of existing studies are conflicting. Despite inconclusive results, the diagnostic potential of saliva shows promise as a non-invasive means of cardiovascular risk assessment.

Appropriate Recall Interval for Periodontal Maintenance: A Systematic Review.

OBJECTIVES: A systematic review of the literature was undertaken to assess the evidence to support a specific time interval between periodontal maintenance (PM) visits. METHODS: Relevant articles were identified through searches in MEDLINE, EMBASE and PubMed using specific search terms, until April, 2014, resulting in 1095 abstracts and/or titles with possible relevance. Critical Appraisal Skills Programme (CASP) guidelines were used to evaluate the strength of studies and synthesize findings. If mean recall interval was not reported for study groups, authors were contacted to attempt to retrieve this information. RESULTS: Eight cohort studies met the inclusion criteria. No randomized control trials were found. All included studies assessed the effect of PM recall intervals in terms of compliance with a recommended regimen (3-6 months) as a primary outcome. Shorter PM intervals (3-6 months) favored more teeth retention but also statistically insignificant differences between RC and IC/EC, or converse findings are also found. In the 2 studies reporting mean recall interval in groups, significant tooth loss differences were noted as the interval neared the 12 month limit. CONCLUSIONS: Evidence for a specific recall interval (e.g. every 3 months) for all patients following periodontal therapy is weak. Further studies, such as RCTs or large electronic database evaluations would be appropriate. The merits of risk-based recommendations over fixed recall interval regimens should be explored.

Fluoride effectiveness in high caries risk and medically complex Veterans.

BACKGROUND: The Global Burden of Disease Study showed there was a 34.5% increase in years lived with disability due to dental caries from 1990 to 2010. With the aging of 76 million baby boomers, dental caries will continue to pose a significant challenge for older adults. OBJECTIVE: Test the effectiveness of prescription or professionally applied fluoride in the prevention of new dental restorations in a clinical setting where patients are medically compromised and more dentally impaired than the general population. METHODS: A retrospective cohort study, using multiple electronic databases within the Department of Veterans Affairs. Propensity scores were used to adjust for confounding by indication and logistic regression modeled the outcome and included all expected covariates. RESULTS: The study sample included 140,114 high caries risk Veterans with a mean of 3.4 physical comorbidities, 1.2 mental comorbidities, and 11 medication groups per patient. Patients who received clinical fluoride treatments had 17-20% decreased odds of requiring a restoration during the follow-up period. CONCLUSIONS: Prescription self-applied or professionally applied fluoride provided either before or during an episode of care significantly reduced the likelihood of new restorations in high caries risk and medically compromised Veterans.

Longitudinal outcomes of using a fluoride performance measure for adults at high risk of experiencing caries.

BACKGROUND: Staff of the VA Office of Dentistry, the dental care arm of the U.S. Department of Veterans Affairs' Veterans Health Administration, developed a performance measure (PM) regarding appropriate fluoride use. The authors hypothesized that after the implementation of this PM, veterans at high risk of experiencing caries would require fewer new dental restorations than in the past. METHODS: In a retrospective longitudinal analysis, the authors evaluated the effectiveness of a PM in reducing restoration rates in veterans at high risk of experiencing caries. They evaluated changes in restoration rates for all eligible veterans, as well as the subpopulation at high risk of experiencing caries (defined as receiving two or more restorations in 12 months) both before and after the implementation of the PM. RESULTS: In 2012, 81 percent of clinics provided fluoride for more than 90 percent of their patients at high risk of experiencing caries. After use of the PM for four years, there were 8.6 percent fewer patients needing two or more restorations, a 10.8 percent decrease in the mean number of restorations and a modest 3.4 percent fewer patients at high risk of experiencing caries who required new restorations after the initial 12-month period. CONCLUSIONS: Fluoride use for patients at high risk of experiencing caries rose from 51.8 percent in 2008 to 93.6 percent in 2012. Restoration rates rose before implementation of the PM and fell consistently after its implementation. Practical Implications Fluoride use reduces the need for future restorations in adults at high risk of experiencing caries.

Supplemental fluoride use for moderate and high caries risk adults: a systematic review.

OBJECTIVES: Multiple systematic reviews have evaluated fluorides for caries prevention in children, but a need to review the literature regarding supplemental fluoride use in adults still remains. The purpose of this systematic review is to evaluate the research regarding professional and/or supplemental self-applied fluoride for preventing and remineralizing caries in moderate and high caries risk adults. METHODS: Utilizing multiple databases, a comprehensive search was undertaken in both foreign and English languages. Studies included were randomized control trials (RCT) or clinical trials conducted in moderate or high caries risk adult populations, evaluating self- or professionally applied fluoride with the outcomes of caries reduction/remineralization. Studies were excluded if they were in situ, in vitro, split mouth design, or with unclear outcomes specific to fluorides. A quality evaluation of the studies used a checklist of critical domains and elements for an RCT. RESULTS: Seventeen studies were included in the systematic review. Findings were categorized into the following groups: sodium fluoride (NaF) and amine/potassium fluoride mouthrinses of varying strengths, NaF gels and pastes, NaF varnish, and stannous fluoride. Quality evaluation scores varied from 50.2 percent to 88.9 percent. CONCLUSIONS: The strongest studies demonstrated the following modalities as moderately effective in higher caries risk adults: low strength NaF rinses [risk reduction (RRR) for carious lesions: 50-148 percent]; 1.1 percent NaF pastes/gels (RRR for root lesion remineralization: 35-122 percent); fluoride varnishes [RRR for RC remineralization: 63 percent; RRR for decrease in decayed, missing, and filled surfaces: 50 percent]. Evidence regarding 1.1 percent NaF and 5 percent NaF varnishes related primarily to root caries and older adults.

Dental treatment improves self-rated oral health in homeless veterans--a brief communication.

OBJECTIVE: The aim of this study was to assess homeless veterans' perception of their oral health and the impact that oral disease and treatment have on self-assessed quality of life. METHODS: Outcomes included measures of general and oral-specific quality of life and functional status. Single-item self-report of oral health and the General Oral Health Assessment Index were assessed at baseline and after treatment. RESULTS: One hundred and twelve veterans completed the baseline questionnaire, and 48 completed the follow-up. Veterans who were eligible for ongoing dental care had improved General Oral Health Assessment scores, while patients who received only emergency dental care saw a decreased score (2.46 versus -2.12). General Oral Health Assessment improvement was significantly related to fewer teeth at baseline (18 versus 23), a lower baseline General Oral Health Assessment (23.6 versus 28.1), having a denture visit (22 versus 35 percent), and improvement in self-reported oral health (25 versus 42 percent). CONCLUSION: There was significant improvement in homeless veterans'perceived oral health after receiving dental care.

Adverse events associated with chlorhexidine use: results from the Department of Veterans Affairs Dental Diabetes Study.

BACKGROUND: The authors report adverse events (AEs) related to the use of chlorhexidine gluconate mouthrinse in a clinical trial of the efficacy of periodontal treatment in older adults with diabetes. METHODS: Participants were U.S. veterans with uncontrolled diabetes (hemoglobin A(1c) value > or =8.5 percent) and periodontal disease. Treatment included periodontal scaling, 0.12 percent chlorhexidine lavage during ultrasonic scaling and use of chlorhexidine mouthrinse at home. RESULTS: Forty-four (31 percent) of 140 subjects reported having AEs. Most common were taste changes and tooth staining, sore mouth and/or throat, tongue irritation and wheezing/shortness of breath; the latter was reported more commonly before chlorhexidine use than after. Only body mass index greater than 30 was significantly related to AEs. CONCLUSIONS: AEs are common among subjects using chlorhexidine mouthrinse. Most AEs (taste change and staining) were resolved easily by subjects' discontinuing mouthrinse use and receiving dental prophylaxis. No serious AEs were reported. CLINICAL IMPLICATIONS: Clinicians should advise patients using chlorhexidine mouthrinse of possible side effects. If necessary, patients should discontinue mouthrinse use and obtain medical care. Careful monitoring of AEs in patients using chlorhexidine is warranted.

The effects of xerogenic medications on oral mucosa among the Veterans Dental Study participants.

OBJECTIVES: To examine the association of xerogenic medications with the oral mucosa inflammation score (OMS) in US male veterans. METHODS: The relationship of having the worst 25th percentile in OMS and intake of xerogenic medications with different pharmacologic indications was analyzed by logistic regression, controlling for age in 3 categories (< or =44, 45-64, > or =65), smoking, disease burden index, alcohol abuse, and the duration of medication, in 290 subjects participating in the Veterans Dental Study. RESULTS: When polypharmacy and denture-wearing status in addition to the aforementioned covariates were controlled, the odds ratios for cardiovascular disease medications and sympathetic agonists were 2.82 (95% confidence interval [CI] 1.35-5.91, P < .006), and 2.96 (CI 1.21-7.26, P < .02), respectively, and those for psychotropics and antihistamines were 2.12 (CI 0.94-4.80, P < .06) and 2.09 (CI 0.80-5.48, P < 0.14), respectively. CONCLUSION: Xerogenic medication may be associated with oral mucosal pathology.

Study design, recruitment, and baseline characteristics: the Department of Veterans Affairs Dental Diabetes Study.

OBJECTIVES: We are conducting a clinical trial of the efficacy of periodontal therapy in the improvement of glycaemic control in veterans with poorly controlled diabetes. This report describes study design, recruitment and randomization and compares baseline characteristics of the sample frame with those randomized into study groups. METHODS: Veterans with poorly controlled diabetes were randomized in two groups: immediate periodontal therapy ("early treatment") or usual care followed by periodontal therapy ("deferred treatment"). Half of each group continued care for 12 months; the other half returned to their usual care. We studied baseline patient characteristics, self-reported health measures, and clinical examination data. We examined means for continuous variables, frequencies for categorical variables and compared groups using t-tests and chi(2) tests (alpha=0.05 for both). RESULTS: The 193 randomized participants were younger (58 years) and had slightly higher HbA1c (10.2%) than the 2534 non-randomized participants (64 years, HbA1c =9.8%). The deferred treatment group was more likely than the early treatment group to have a history of stroke, transient ischaemic attacks, and less likely to be current or former smokers. CONCLUSIONS: The mechanism for randomization was largely successful in this study.

Does periodontal care improve glycemic control? The Department of Veterans Affairs Dental Diabetes Study.

OBJECTIVES: Report results of a randomized-clinical trial of the efficacy of periodontal care in the improvement of glycemic control in 165 veterans with poorly controlled diabetes over 4 months. METHODS: Outcomes were change in Haemoglobin A1c (HbA1c) in the Early Treatment versus untreated (Usual Care) groups and percent of participants with decreases in HbA1c. Analyses included simple/multiple variable linear/logistic regressions, adjusted for baseline HbA1c, age, and duration of diabetes. RESULTS: Unadjusted analyses showed no differences between groups. After adjustment for baseline HbA1c, age, and diabetes duration, the mean absolute HbA1c change in the Early Treatment group was -0.65% versus -0.51% in the Usual Care group (p=0.47). Adjusted odds for improvement by 0.5% in the Early Treatment group was 1.67 (95% confidence interval: 0.84, 3.34, p=0.14). Usual Care subjects were twice as likely to increase insulin from baseline to 4 months (20% versus 11%, p=0.12) and less likely to decrease insulin (1% versus 6%, p=0.21) than Early Treatment subjects. Among insulin users at baseline, more increased insulin in the Usual Care group (40% versus 21%, p=0.06). CONCLUSIONS: No significant benefit was found for periodontal therapy after 4 months in this study; trends in some results were in favour of periodontal treatment.