More than fear? Brain activation patterns of dental phobic patients before and after an exposure-based treatment.

Hyperactivation of brain networks conferring defensive mobilization is assumed to underlie inappropriate defensive-preparation in patients with Specific Phobia. However, studies targeting Dental Phobia (DP) yielded quite heterogeneous results and research concerning the effects of exposure treatments on phobic brain activation so far is missing. This functional Magnetic Resonance Imaging (fMRI) study aimed to investigate activation patterns in DP patients during exposure to phobia-related stimuli and the effects of an exposure-based fear treatment on phobia-related activation. Seventeen patients with DP and seventeen non-phobic, healthy controls participated in this fMRI experiment presenting dental-related and neutral auditory and visual stimuli. After completing a short exposure-based CBT program, patients were scanned a second time to illustrate treatment-related changes in brain activation patterns. Pre-treatment fMRI results demonstrate enhanced activation in DP-patients mainly in the precuneus and lateral parietal cortex. Moreover, a small activation focus was observed in the amygdala and anterior cingulate cortex (ACC) as parts of classically fear-related structures. Activation in all these clusters decreased significantly from pre- to post-treatment assessment and in the case of the ACC was correlated with dental fear reduction. Activation changes in the precuneus and lateral parietal cortex suggest a pronounced first-person perspective memory processing including a vivid recall of contextual information from an egocentric perspective triggered by exposure to phobia-related stimuli. Besides a treatment-sensitive hyperactivity of fear-sensitive structures, DP may also be characterized by a disturbed memory retrieval that can be reorganized by successful exposure treatment.

Quality of root canal fillings and prevalence of apical radiolucencies in a German population: a CBCT analysis.

OBJECTIVES: The aim of this study was to determine the frequency and quality of root canal fillings (RCF) and the prevalence of apical radiolucency (AR) in a German population. MATERIAL AND METHODS: Five hundred randomly selected full-size CBCT images (Planmeca ProMax 3D, FOV = 8 × 8 cm, voxel size 160 µm or 200 µm) were obtained from German patients (40.6% = ♂; 59.4% = ♀; mean age = 50.21 ± 12.45 years). A total of 8254 teeth were examined for pathology (AR, widened periodontal ligament). The relationship between AR and existing RCF and the quality of RCF were documented. Frequency and correlations between the left and right sides and gender distribution were analyzed statistically using the chi-square test. RESULTS: The overall prevalence of AR was 3.8%, whereas for teeth with RCF, it was 42.5%. Patients had approximately 1.4 root canal-filled teeth (8.2% of all teeth). RCF terminated more than 2 mm short of the radiological apex in 31.2%, 5.1% reached beyond the apex, 8.1% were associated with extruded sealer, and 5.3% presented untreated root canals. Odds ratio of having an AR was highest in teeth with RCF beyond the apex (OR = 27.0) followed by RCF <2 mm short of the apex (OR = 4.4), untreated root canals (OR = 2.9), and inhomogeneity of RCF (OR = 1.2). Extrusion of sealer was least associated with AR. Molars were most frequently associated with AR (P < 0.05). Root canal-filled teeth showed significantly more AR in men compared with women (P < 0.05). CONCLUSIONS: About 42.5% of root canal-filled teeth were associated with AR, and in about one-third of these teeth, the RCF terminated more than 2 mm short of the apex. CLINICAL RELEVANCE: Each step in root canal therapy influences treatment outcome and prevalence of periapical radiolucencies. Determination of the working length is still one of the key points to achieve predictable periapical healing, and homogenous root canal filling reaching the foramen major seems to be essential.

The Return of Fear: Variation of the Serotonin Transporter Gene Predicts Outcome of a Highly Standardized Exposure-Based One-Session Fear Treatment.

BACKGROUND: Methodological problems of existing research, such as the application of unstandardized treatments in heterogeneous samples, has hampered clear conclusions about the extent and direction to which allelic variation of the serotonin transporter gene-linked polymorphic region (5- HTTLPR) is associated with a differential response to psychological treatment. The present study aimed to investigate the effects of the 5-HTTLPR genotype on treatment outcome under highly standardized environmental conditions. METHODS: We treated 222 medication-free adults highly fearful of spiders, dental surgeries or blood, injuries and injections with a highly standardized exposure-based 1-session treatment and genotyped them for the 5-HTTLPR. Participants' subjective fear was assessed before, immediately after treatment and at 7 months of follow-up. RESULTS: There were no differences between 5-HTTLPR genotypes in treatment outcome effects at the immediate posttreatment assessment. However, we observed a highly significant genotype × treatment effect (p = 0.004) at the 7-month follow-up. Fear levels of homozygous S allele carriers differed from those heterozygous (p = 0.026) and homozygous (p = 0.012) for the L allele. Compared to posttreatment assessment, LL allele carriers exhibited a further fear decrease at the follow-up assessment. In contrast, SS allele carriers displayed a strong return of fear. CONCLUSIONS: Results suggest that genetic variation of the serotonin transporter is associated with differential stability of inhibitory learning processes, potentially reflecting heightened susceptibility for context-related processes that facilitate a return of fear in S allele carriers. If replicated, results suggest the 5-HTTLPR might represent a biomarker for the long-term outcome of brief exposure-based fear treatments and might inform genotype-based selection of psychotherapeutic interventions.

DNA methylation levels of the serotonin transporter gene are not associated with the outcome of highly standardized one-session exposure-based fear treatment.

Epigenetic alterations are regarded as a potential mechanism mediating the effects of environmental risk factors on vulnerability for a range of mental health problems. Recent studies have addressed the question whether DNA methylation patterns predict the outcome of psychological interventions and whether treatment effects might be associated with changes of DNA methylation. We assessed phobic fear symptoms, treatment-relevant traits and treatment response in 308 adults free of psychotropic medication - highly fearful of either spiders, blood-injury-injections, dental-treatments or heights - all subjected to highly standardized exposure-based one-session fear treatment. DNA methylation level of the promotor region of the serotonin transporter gene (SLC6A4) was assessed in either saliva samples (spider and dental treatment fear cohorts) or oral mucosa (BII, heights) to check whether possible effects are independent of the surrogate tissue examined. Moreover, in order to examine possible DNA methylation by genotype effects, patients were assessed for genetic variation of the serotonin transporter-linked polymorphic region (5-HTTLPR). DNA methylation levels were neither associated with pre-treatment fear levels, treatment relevant traits or treatment outcome data even when allelic variation of the 5HTTLPR was considered. Overall DNA methylation levels were higher in saliva samples compared to buccal samples. In saliva samples there was a small pre- to post-treatment increase in DNA methylation, which, however, was also not associated with the investigated phenotypes. We conclude that DNA methylation of SLC6A4 is no suitable biomarker for response efficacy to highly standardized one-session exposure-based fear treatments.

Recognizing and differentiating dental anxiety from dental phobia in adults: a systematic review based on the German guideline "Dental anxiety in adults".

Objectives: The prevalence of "dental anxiety" (DA) is often underestimated and numerous diagnostic methods are available for dental practitioners. It is difficult to differentiate between a dental phobia requiring an interdisciplinary approach and DA, which can be managed by dental practitioners alone. The appropriate use of diagnostic tools is key for the successful management of highly anxious and/or phobic patients. The aim was to provide a guideline to recognize dental fear and to differentiate DA from patients who are highly anxious or even have a phobia. Data sources: In total, 8,929 articles that were selected for the development of the German guidelines for "Dental anxiety in adults" in PubMed, Web of Science, Embase, and MedPilot were filtered for diagnosis of DA disorder. The focus for this review was on the use of scales to measure DA levels. The methods and tools used in the 51 reviewed articles to assess DA levels were evaluated in terms of their practicability and suitability in daily practice to differentiate between phobia (ie, DA disorder) and nonpathologic anxiety. In addition, the internal consistency (Cronbach alpha) of the questionnaires/tools was determined. Conclusion: All identified DA questionnaires validated in the German language had an acceptable to excellent internal consistency (0.7 to 0.986). The only validated questionnaire-free method was galvanic skin reaction measurement. For the assessment of DA and diagnosis of a DA disorder in adults, the survey by means of any suitable questionnaire or even several questionnaires in combination with a behavioral observation of the patient is currently the method of choice.

Genes in treatment: Polygenic risk scores for different psychopathologies, neuroticism, educational attainment and IQ and the outcome of two different exposure-based fear treatments.

OBJECTIVES: Evidence for a genetic influence on psychological treatment outcome so far has been inconsistent, likely due to the focus on candidate genes and the heterogeneity of the disorders treated. Using polygenic risk scores (PRS) in homogenous patient samples may increase the chance of detecting genetic influences. METHODS: A sample of 342 phobic patients treated either for clinically relevant dental fear (n = 189) or other (mixed) phobic fears (n = 153) underwent highly standardised exposure-based CBT. A brief five-session format was used to treat dental fear, whereas longer multi-session treatments were used with the mixed-fear cohort. PRS were calculated based on large genetic studies of Neuroticism, Educational Attainment (EA), Intelligence, and four psychopathology domains. We compared PRS of post-treatment and follow-up remitters and non-remitters and regressed PRS on fear reduction percentages. RESULTS: In the dental fear cohort, EA PRS were associated with treatment outcomes, i.e. drop-out, short- and long-term remission state, fear reduction, and attendance of subsequent dental appointments. In the mixed fear treatment cohort, no gene effects were observable. CONCLUSIONS: Results indicate the importance of EA-related traits for outcomes following brief, but not long, standardised exposure-based CBT. Such use of PRS may help inform selection and tailoring of treatments.

Mechanisms, genes and treatment: Experimental fear conditioning, the serotonin transporter gene, and the outcome of a highly standardized exposure-based fear treatment.

There is considerable interindividual variation in response to psychotherapeutical intervention. In order to realize the long-term goal of personalised treatment approaches, it is important to identify behavioural and biological moderators and mediators of treatment responses. Here, we tested the predictive value of experimental fear extinction efficacy as well as the role of genetic variation of the serotonin transporter gene for the outcome of a fear-exposure treatment. A discriminative fear conditioning paradigm was conducted in 159 adults highly fearful of spiders, dental surgeries or blood, injuries and injections. Participants were genotyped for the long (L) and short (S) allelic variant of the serotonin transporter gene linked polymorphic region (5HTTLPR) and treated with a highly standardized exposure-based one-session treatment. Participants' subjective fear was assessed during experimental fear conditioning and extinction. Furthermore, subjective phobic fear was assessed at pre-, post and at 7 months follow-up treatment assessment. A threat-biased contingency learning pattern characterized by exaggerated fear responses to the CS- was associated with larger initial subjective fear reduction immediately following the large-group treatment, p = .03. There were no learning pattern-associated differences in subjective fear at 7-month follow-up. The odds of homozygous s-allele carriers to display a threat-biased contingency learning pattern were 3.85 times larger compared to l-allele carriers, p = .01. Fear-recovery in homozygous S-allele carriers at follow-up assessment, p = .01, emerged regardless of the experimental fear acquisition pattern. Our results suggest the homozygous S-allele carriers are biologically biased towards ignoring safety signals in threat-related situations. Short-term, this response pattern might be positively related to the outcome of exposure treatments, potentially due to increased responding to safe context conditions or a stronger violation of threat expectancies. However, alterations in inhibiting the response to cues formerly signalling threat evidenced for S-allele carriers can have negative impact on exposure success.

Effectiveness of Systematic Periodontal Treatment in Male HIV-Infected Patients after 9 Years: A Case Series.

OBJECTIVE: To investigate effectiveness of systematic periodontal treatment in the long term in HIV-infected patients undergoing highly active antiretroviral treatment. METHODS: Longitudinal, prospective, open-label case series over a period of nine years. Periodontal treatment was performed by scaling and root planing and supportive periodontal care (SPC) at regular intervals. To measure effectiveness, reductions of pocket probing depths were defined as primary study endpoint. RESULTS: During the study period, there was a proportional increase in periodontal pockets ≥4 mm of +53% and in pockets ≥ 6 mm of +100%. Mean pocket depth reductions on patient's level were, however, 0.4 mm nine years after scaling and root planing and supportive periodontal care (p=0.180). No teeth were lost during the observation period. CONCLUSIONS: In terms of best evidence available, it is concluded that systematic periodontal treatment including SPC is effective in virologically controlled HIV infection and can be performed in dental practice safely.

Early Childhood Caries and Caries Experience in Permanent Dentition: A 15-year Cohort Study.

In Germany, caries of young people has been declining since the late 1980s, while the prevalence of early childhood caries has remained steady. Data from a number of regional studies suggest a current prevalence between 10% and 15%. However, there is a dearth of longitudinal observational study data on the risk of caries in the permanent teeth of persons who as children had to undergo comprehensive treatment for caries under intubation general anesthesia. The aim of this study was to compare caries experience in the permanent teeth of patients who had to undergo surgical treatment under general anesthesia as a result of non-compliance with caries treatment in early childhood with the experience of patients who did not develop caries at a young age. Analysis of the data revealed that severe caries experience during early childhood resulted in a more severe caries experience during adulthood (difference: 14.8 DMFS; p = 0.001). This increase in caries experience applied to both untreated and treated carious surfaces, and was also apparent in relation to tooth extractions. When compared with persons whose first teeth had been caries-free, patients with severe childhood caries experience tended to show poorer dental hygiene in relation to smooth (p < 0.06) and interproximal (p < 0.04) surfaces. Patients who had been non-compliant as young children were not found to suffer from dental anxiety as young adults. Patients in the treatment and control groups differed with regard to dental health. Aside from being statistically relevant, these differences also have implications for clinical dental practice.

Large Group Exposure Treatment: A Feasibility Study of Exposure Combined with Diaphragmatic Breathing in Highly Dental Fearful Individuals.

A large-group one session treatment (LG-OST) combining exposure and diaphragmatic breathing as a bodily coping element was carried out to investigate its feasibility and effectiveness in a sample of 43 highly dental fearful individuals treated simultaneously. We assessed subjective dental fear, dysfunctional dental-related beliefs, and perceived control pre- and post-intervention and at four-month follow-up. Participants additionally performed a behavioural approach test (BAT) pre- and post-intervention. During the applied exposure exercises, four participants (9.3%) discontinued the program all reporting too high levels of distress. Regarding subjective dental fear and dysfunctional dental related beliefs post treatment effects, LG-OST showed medium to large effect sizes, ranging from Cohen's d = 0.51 to d = 0.84 in the Intention-to-Treat analysis. Subjective dental fear improved clinically significantly in about one fourth (25.6%) of therapy completers. All post-treatment effects remained stable over time. Concerning the behavioral fear dimension, we observed a strong ceiling effect. Already at pre-assessment, participants accomplished more than six out of seven BAT-steps. Thus, behavioral approach did not increase significantly following treatment. Overall, the LG-OST protocol proved feasible and efficient. Compared to other one-session individual and multi-session group treatments the observed LG-OST effects were smaller. However, if LG-OST could match the efficacy of highly intensive short treatments delivered in an individual setting in the future, for example, by applying a wider array of exposure exercises, it could be a very useful treatment option as an intermediate step within a stepped care approach.