Managing caries in virtual dental homes using interim therapeutic restorations.

The Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry has developed the virtual dental home (VDH) system, which uses allied dental professionals trained to place interim therapeutic restorations (ITR) under the general supervision of dentists. This paper reviews the scientific basis for the ITR, as used in the VDH system, in managing caries lesions and delivering oral health care to underserved and vulnerable populations.

Community-based prevention and early intervention strategies.

Many people in California face significant barriers to obtaining dental care. Creation of a community-based oral health delivery system that could deliver preventive and simple therapeutic oral health services in community settings where these populations live or receive social and/or general health services has been one of the proposed strategies for improving access to oral health care. Two of the newer techniques are caries management by risk assessment and interim therapeutic restoration.

The virtual dental home: bringing oral health to vulnerable and underserved populations.

Large and increasing oral health disparities in the U.S. population led the Institute of Medicine to call for expanded research and demonstration of delivery systems that test new methods and technologies. These new methods include delivering oral health services in nontraditional settings, using nondental professionals, expanded roles for existing dental professionals and new types of dental professionals, and incorporating telehealth technologies. The virtual dental home is a system that demonstrates the characteristics called for by the IOM.

In-person versus "virtual" dental examination: congruence between decision-making modalities.

This study evaluated the agreement of a dentist's conclusions reached through an in-person versus a virtual examination. The dentist determined whether a patient was healthy enough to be treated only by allied dental personnel in a community setting or whether the patient needed to be seen by a dentist. The study concludes that a virtual examination is a strong substitute for an in-person examination and validates the application of telehealth-enabled examinations.

Reducing nasopharyngeal trauma: the urethral catheter-assisted nasotracheal intubation technique.

Nasal intubation is an advantageous approach for dental procedures performed in the hospital, ambulatory surgery center, or dental office, when possible. Although many who provide anesthesia services are familiar and comfortable with nasal intubation techniques, some are reluctant and uncomfortable because of lack of experience or fear of nasopharyngeal bleeding and trauma. It has been observed from experiences in various settings that many approaches may be adapted to the technique of achieving nasal intubation. The technique that is described in this paper suggests a minimally invasive approach that introduces the nasoendotracheal tube through the nasopharyngeal pathway to the oropharynx in an expedient manner while preserving the nasopharyngeal structures, thus lessening nasal bleeding and trauma to soft tissues. The technique uses a common urethral catheter and can be incorporated along with current intubation armamentaria. As with all techniques, some limitations to the approach have been identified and are described in this paper. Cases with limited mouth opening, neck injury, and difficult airways may necessitate alternative methods. However, the short learning curve along with the many benefits of this technique offers the anesthesia professional additional options for excellent patient care.

Creating and maintaining oral health for dependent people in institutional settings.

The absolute number and percentage of the population of dependent individuals in institutional settings are growing dramatically in the United States. The current dominant office-based oral health delivery system is not adequately addressing the oral health needs of these populations and is unlikely to do so in the future. There are multiple challenges in providing oral health services for dependent people in institutional settings. To achieve improvements in the oral health of these populations, we must change the education of oral health professionals, educate staff in institutional settings about oral health, integrate oral health activities into general health and social service systems, use existing oral health professionals in new ways in community settings, develop new categories of oral health professionals, and reform oral health delivery and reimbursement systems. Developing new models of oral health services for dependent individuals in institutional settings may provide an opportunity to create a new paradigm of care based on integration of oral health services with general health and social services with an emphasis on prevention and health promotion activities.

Improving and maintaining oral health for people with special needs.

The number of people in the United States population with disabilities and other special needs is growing dramatically. These individuals present unique challenges for oral health professionals in planning and carrying out dental treatment and for the oral health delivery system. Because it has been recognized that the current delivery system is not working well for these populations, new workforce, financing, and delivery models are beginning to emerge that may hold promise for creating and maintaining oral health for currently underserved populations, including people with disabilities and other special needs. This article discusses the implications of this for the oral health profession, describes the challenges of providing oral health services for this population, and discusses the implications of these challenges for the organization of the oral health delivery system.

Tuberous sclerosis complex: a case report.

Tuberous Sclerosis Complex (TSC) was first described in the late 1800s as a relative of neurofibromatosis, but it has since been identified as a discrete disorder. Patients with TSC typically present with facial adenomas, seizure disorder, and a developmental disability. The syndrome is caused by mutations in either chromosomes 9 or 16, both of which code for cell development and maturation. This case report describes the unique findings of TSC, and suggests areas for future study. By understanding the dental and medical implications of TSC, early intervention may vastly improve a patient's overall quality of life.

Dental Care for Geriatric and Special Needs Populations.

This article reviews considerations for oral health care associated with the most common causes of mortality and morbidity in older adults. Many of these diseases result in functional or cognitive impairments that must be considered in treatment planning to ensure appropriate, safe, and effective care for patients. Many of these considerations parallel those of adults who have lived with developmental disabilities over a lifetime and similar principles can be applied. Systemic diseases, conditions, and their treatments can pose significant risks to oral health, which requires prevention, treatment, and advocacy for oral health care as integral to chronic disease management.

Interprofessional Collaboration in Improving Oral Health for Special Populations.

People with complex medical, physical, and psychological conditions are among the most underserved groups in receiving dental care and consequently have the most significant oral health disparities of any group. The traditional dental care delivery system is not able to deliver adequate services to these people with "special needs" for a variety of reasons. New systems of care are evolving that better serve the needs of these groups by using interprofessional teams to reach these individuals and integrate oral health services into social, educational, and general health systems.

Pre- and postdoctoral dental education compared to practice patterns in special care dentistry.

There has been limited research into the impact of predoctoral experiences and postdoctoral general dentistry residencies on the practice patterns of dentists in the care of patients with special or complex needs. This study was undertaken to determine if educational experiences with special populations had a relationship to practice patterns after graduation or residency. University of the Pacific alumni who graduated between 1997 and 2007 were surveyed regarding their pre- and postdoctoral dental education and their practice patterns for the care of patients categorized as medically compromised, frail elders, and developmentally disabled. Definitions for each patient category were provided. Alumni were asked about their practice setting and postdoctoral education. Thirty-one percent (n=526) of those surveyed responded. Regression analyses showed respondents not in private practice were more likely to have completed a postdoctoral general dentistry program (Advanced Education in General Dentistry or General Practice Residency) after dental school compared to respondents in private practice (p<0.001). Across all age groups, respondents not in private practice treated significantly more patients with developmental disabilities than those in private practice (p<0.001). Respondents not in private practice treated more medically compromised patients younger than age sixty-five compared to respondents in private practice (p<0.01). Interestingly, those in private practice treated significantly more patients over sixty-five who were also classified as medically compromised (p<0.05). Pacific alumni who completed postdoctoral training in general dentistry were found to practice more often in non-private practice settings. Alumni in non-private practice settings reported treating a higher percentage of medically compromised patients below age sixty-five than their counterparts in a typical private practice. The pre- and postdoctoral experiences of treating special needs populations appear to have a relationship to graduates' practice setting and patient population.

Perceptions of predoctoral dental education and practice patterns in special care dentistry.

The objective of this research project was to compare alumni perceptions of predoctoral dental education in the care and management of patients with complex needs to alumni practice patterns. Alumni from the University of the Pacific Arthur A. Dugoni School of Dentistry who graduated from 1997 to 2007 were surveyed regarding perceptions of their predoctoral education in the care of patients categorized and defined as medically compromised, frail elders, and developmentally disabled, as well as their practice patterns. Perceptions were rated on a Likert scale. Regression analyses were utilized. Three primary relationships were identified: 1) positive relationships emerged between perceptions of educational value, as students and practitioners, of the training they received compared to percentages of medically compromised patients they currently treat (p≤0.05); 2) after practice experience, 2003-07 graduates reported significantly higher value of their education in this area compared to 1997-2002 graduates; and 3) alumni who reported treating more patients with complex needs during school reported treating significantly more of these patients in practice (p≤0.05). We conclude that alumni who reported educational experiences as more valuable treat more patients with complex needs compared to those who valued them less. Alumni who reported having more opportunities to treat patients with complex needs as students treat a higher percentage of those patients than those reporting fewer. Even positive perceptions may underestimate the value of educational experiences as they relate to future practice.

Planning dental treatment for people with special needs.

People with disabilities and other special needs present unique challenges for oral health professionals in planning and carrying out dental treatment. This article presents a schema for planning dental treatment that encourages the oral health provider to fully consider multiple medical, social, psychologic and dental findings when preparing treatment recommendations for a patient with special needs. If these factors are fully integrated, the resulting treatment recommendations provide the best chance of helping the individual achieve and maintain a lifetime of oral health.