Therapeutic patient education in dental practice: For a pedagogical commitment / Du concept d'éducation thérapeutique du patient à la pratique des chirurgiens-dentistes : pour un engagement pédagogique

The exponential development of chronic noncommunicable diseases requires a rethinking of health systems, which are commonly focused on the curative management of diseases. There is a need to reinvent them to involve lifelong health promotion. For patients, it is no longer just a matter of surviving an acute disease, but also of avoiding its occurrence, and even more often, learning to live and age with it. This is where therapeutic patient education (TPE) plays a role. Supporting this paradigm shift in practice requires a commitment through initial training to help the student­ future dentist­to acquire the knowledge, skills, and attitudes relevant and easily applicable to the field of oral medicine, even in independent practice. Integrating TPE teaching into the curriculum is undeniably a challenge, but also a chance for students to develop a different stance and become conscious, competent, and committed professionals.

Le développement exponentiel des maladies non transmissibles à caractère chronique oblige à repenser les systèmes de santé, communément centrés sur une prise en charge curative des maladies. Ils doivent se réinventer pour y associer la promotion de la santé tout au long de la vie. Pour les patients, il ne s'agit plus seulement de survivre à une maladie aiguë, mais aussi d'en éviter la survenue, et encore plus souvent d'apprendre à vivre et à vieillir avec celle-ci. La prévention et la stabilisation de nombreuses maladies bucco-dentaires requièrent l'adoption et le maintien tout au long de la vie de comportements adaptés. L'éducation thérapeutique du patient (ETP) trouve alors toute sa place. Soutenir ce changement de paradigme dans les pratiques nécessite de s'engager dans la formation initiale pour aider l'étudiant ­ futur chirurgien-dentiste ­ à acquérir des connaissances, des savoir-faire et savoir-être pertinents et facilement applicables dans le champ de la médecine bucco-dentaire, et ce, même en pratique libérale. Intégrer l'enseignement de l'ETP au curriculum constitue indéniablement un défi, mais aussi une chance pour les étudiants de développer une autre posture et de devenir des professionnels conscients, compétents et engagés.

Knowledge, Attitude, Access and Confidence in Evidence-based practice amongst French dental undergraduates: A transcultural adaptation and psychometrics analysis of French version of the KACE questionnaire.

OBJECTIVE: The aim of this study was to provide a reliable instrument to assess evidence-based practice (EBP) dimensions in French-speaking dental students. To do so, a transcultural adaptation into French of the self-administered KACE questionnaire (Knowledge, Attitude, Access and Confidence Evaluation) and the evaluation of its psychometric properties in a sample of French dental students and teachers were performed. The effects of individual and academic factors on student performance in the KACE were also investigated. METHOD: Teachers and fourth-year students completed once the translated KACE and fifth-year students completed twice the questionnaire before and after an epidemiology course. Cronbach's alpha coefficient analysis, Kruskal-Wallis and post hoc Dunn's tests, paired samples Wilcoxon tests and a generalised linear mixed model were performed to assess the psychometric properties (reliability, internal consistency, discriminant validity and responsiveness) of the questionnaire and to identify the factors associated with KACE scores, respectively. RESULTS: 186 participants completed the survey. Cronbach's alpha ranged from 0.06 to 0.48 for Knowledge, 0.21 to 0.59 for Attitude, 0.42 to 0.76 for Access and 0.82 to 0.93 for Confidence. The discriminant value and sensitivity of the French KACE revealed significant differences amongst students and teachers and accurately identified the effect the training course had on the students who had completed it. Preparing for a residency programme or having received add-on modules in science improved the students' performance in the test. Being female negatively impacted the KACE Confidence score. CONCLUSION: This version of the KACE is appropriate to assess EBP dimensions in French dental students. Academic background and gender may affect test performance.

What do we know about portable dental services? A scoping review.

BACKGROUND: Delivering dental care to patients in their home or residential institutions is known as "portable dentistry". The demand for portable dental services is on the rise, but dentists remain reluctant to adopt portable practices. OBJECTIVES: To explore the literature on portable dental services and understand (a) the process of planning and delivering portable dental services and (b) the benefits and challenges of portable dentistry for service providers and patients. METHODS: A systematic scoping search was conducted. We retrieved 3994 documents, 28 of which were included in the final synthesis. Three authors read the papers and conducted thematic content analyses independently. RESULTS: We present a synthesis of the literature and proposed a model of portable dentistry containing three levels with the patient is at the centre surrounded by concentric rings representing the dentist (dental team) and society. At each of these levels, our model is further subdivided into three components: 1) organisation of the service; 2) arrival and set-up of the service; and 3) delivery of the service. In addition, each level includes 1) human factors, which are related either to the dental professional or the patient; 2) non-human factors, which refer to either the equipment or the physical environment; and 3) financial factors, which are related to cost and remuneration. CONCLUSIONS: We propose a model for portable dentistry that dentists and dental educators interested in this practice should find useful.

Prevalence of sensitive teeth and associated factors: a multicentre, cross-sectional questionnaire survey in France.

BACKGROUND: As far as we know, little data, whether obtained from self-administered questionnaires or upon dental clinical examination, has been published on the prevalence of sensitive teeth (ST) in the French adult population. The objectives of the present work were to estimate ST prevalence and characteristics in the general population of France and to explore the associated factors. METHOD: A multicentre cross-sectional study was conducted between November 2011 and March 2013 in six French cities. Adult passers-by in public places were invited to answer an electronic questionnaire on a tablet computer. Only people who declared having at least one natural tooth were included in the study. A logistic regression model was used for the multivariate analysis. RESULTS: The prevalence of ST during the previous 12 months reported by the sample of 2413 participants was 42.2% [95% CI: 40.2-44.1%]. The final logistic regression model showed significant statistical associations between ST and female gender, use of tobacco, consumption of soft drinks, limited access to oral care and poor oral hygiene habits (p < 0.05). CONCLUSIONS: This study provides prevalence data on ST in a general population in France, which seems to remain high despite the existence of many therapies. It should alert professionals to a clinical manifestation that is becoming increasingly prevalent and that they will have to take into consideration to help reduce the discomfort arising from it.

Obstacles to comprehensive dental care in patients with sustained limitations of their decision-making abilities: findings from a Delphi study.

The objective of this study was to explore the therapeutic limitations experienced by a panel of special-care dentists in France when treating patients with sustained limitations of their decision-making abilities. We used a Delphi technique conducted in three rounds from 01 June 2014 to 30 September 2015. A first questionnaire comprising open-ended questions was addressed to 72 panellists. A content analysis of the returned questionnaires served to draft a second questionnaire comprising closed-ended questions; this was sent to the 28 panellists who responded in the first round. A third questionnaire was sent to the 20 panellists who responded in the second round to give them an opportunity to reconsider their response in the context of the second-round response group. Sixteen panellists answered the last round. A large majority agreed on the importance of providing comprehensive care, but they encountered obstacles at two time points: (i) when proposing the care; and (ii) when setting it up. The panel put forward recommendations in two main areas: (i) the training of those involved in oral health decisions; and (ii) dental care management and organization of the care system. The study provided a foundation for building future orientations in health care for patients with limited decision-making abilities.

Could Ethical Tensions in Oral Healthcare Management Revealed by Adults with Intellectual Disabilities and Caregivers Explain Unmet Oral Health Needs? Participatory Research with Focus Groups.

BACKGROUND: Cognitively impaired patients often present poor oral health status that may be explained by ethical tensions in oral healthcare management. This participatory study explored such tensions among adults with intellectual disabilities and with caregivers. The second objective was to specify, with caregivers, the points that should be developed in a future study among dentists. MATERIALS AND METHODS: Three focus groups involving adults with intellectual disabilities, family caregivers and professional caregivers were organized in France in 2013. RESULTS: The thematic content analysis identified discrepancies between experiences and expectations, which were particularly marked for the dentist's competence and attitudes, the dentist's role in decisions, the dental care management and the French socio-political context. CONCLUSIONS: These discrepancies could partly explain multiple attempts to find the 'right' dentist or the fact that care was abandoned, and could at least contribute to oral health needs being unmet.

Clinical research activity in periodontal medicine: a systematic mapping of trial registers.

AIM: The primary aim of the study was to systematically map registration records on periodontal medicine in clinical trial registers. The secondary aim was to assess the evolution of periodontal medicine in clinical periodontal research as a whole. MATERIAL AND METHODS: We searched all registration records related to periodontology in the World Health Organization International Clinical Trials Registry Platform. For registration records classified in the field of periodontal medicine, we assigned the 2015 MeSH(®) term for the most precisely corresponding systemic condition. RESULTS: Fifty-seven systemic conditions have been hypothesized to be linked with periodontal diseases, covering nearly 2% of the diseases indexed in MeSH. In addition to diabetes, cardiovascular disease or preterm birth, other systemic conditions have been the subject of registration records, such as anaemia, liver diseases, dyspepsia or ankylosing spondylitis. A trend towards increasing diversification of systemic conditions has appeared over time. About a third of registration records in clinical periodontal research deals with periodontal medicine. CONCLUSIONS: Periodontal medicine now constitutes an important part of clinical periodontal research. Research activity in periodontal medicine has grown continuously since the early 2000s, and exploration of registers gives a useful up-to-date snapshot of this constantly evolving field of research.

Oral health-related quality of life among outpatients with rheumatoid arthritis.

OBJECTIVES: The aims of the Oral Status And Rheumatoid Arthritis (OSARA) cross-sectional study were to study the oral health-related quality of life and to assess the associated factors in a population of outpatients with rheumatoid arthritis in France. METHODS: The data were collected by five trained and standardised dentists who asked each subject the questions of a socio-demographic, behavioural and medical questionnaire, which was completed with the medical records, and performed the dental examination. Each subject filled out two self-assessment questionnaires: the Health Assessment Questionnaire and the General Oral Health Assessment Index. RESULTS: Seventy-three subjects were included. The mean age of the participants was 60.2 ± 11.9 years and 75.3% were women. For 58.3% of the subjects, their self-perceived oral health-related quality of life was described as poor. The logistic regression analysis found that a small number of teeth and marked difficulties in dressing and grooming were associated with bad oral health-related quality of life [ORa = 10.5 (1.96-56.19) and ORa = 4.3 (1.15-15.77), respectively]. CONCLUSIONS: More care should be given to the prevention of dental diseases in order to improve the oral health-related quality of life of patients with rheumatoid arthritis and their self-esteem, which will already be heavily affected.

[Dental status and related factors in an occupational health service in Northern France]. / Santé dentaire et facteurs associés dans un service de santé au travail du Nord (France).

BACKGROUND: Few data are available concerning the dental health of adults in France. This study was designed to describe dental status, oral health behaviour and factors associated with caries among workers followed by an occupational health service in Northern France. METHODS: A representative sample of workers was selected between May and July 2006. Data were collected by occupational health physicians using a questionnaire completed during a face-to-face interview and a dental examination. After descriptive analysis of the variables, two groups were defined according to the degree of caries as assessed by the Significant Caries Index. Factors associated with the degree of caries were investigated using logistic regression adjusted to age. RESULTS: 420 workers with a mean age of 34.6(±10.4) years were included. The mean DMFT (Decayed Missing Filled Teeth) score and the mean number of decayed teeth were 8.9 (± 6.5) and 1.3 (±2.8), respectively. Three independent factors associated with high caries rates were identified: level of education less than Baccalaureate (ORa = 1.85; p < 0.05), regular consumption of sweet snacks and/or sweet drinks (ORa = 2.01; p < 0.05) and a last dental visit motivated by pain or a reason other than preventive care (ORa = 1.89; p < 0.05). CONCLUSION: This study showed a high need for care and oral health education in this population of workers. More oral health education programmes should be set up in the adult working population by occupational health services.

Effect of Lactobacillus reuteri on Gingival Inflammation and Composition of the Oral Microbiota in Patients Undergoing Treatment with Fixed Orthodontic Appliances: Study Protocol of a Randomized Control Trial.

The effect of probiotics in improving or maintaining oral health in orthodontic patients is understudied. The aim of this study is to evaluate the effect of probiotic administration in addition to tooth brushing on clinical gingival inflammation, plaque formation, subgingival microbiota composition, and salivary biomarkers of inflammation in adolescents with fixed orthodontic appliances. The present study is a 6-month, double-blind, two-arm, placebo-controlled, single-center trial, in which 116 adolescent volunteers aged 12-16 years will be recruited from the patients of the orthodontics clinic of the University Hospital of Lille, France. Subjects who meet the eligibility criteria will be allocated to one of the following groups: (i) control: two placebo lozenges per day for 90 days together with regular oral hygiene, (ii) test: two probiotic lozenges per day for 90 days together with regular oral hygiene. Clinical assessment and biological sample collection will be performed at baseline, 3 and 6 months. In addition, compliance outcomes and adverse events will be monitored.

What do we know about the mechanisms of action of probiotics on factors involved in the pathogenesis of periodontitis? A scoping review of in vitro studies.

OBJECTIVE: Probiotics are increasingly used in oral prevention and treatment conditions, but little is known about their abilities. The aim of this review is to clarify, summarize and disseminate current knowledge about the mode of action of in vitro probiotics on factors involved in the pathogenesis of periodontitis. METHOD: 2495 articles were identified in three databases (Medline, Web of Science, SpringerLink) and 26 studies included in this scoping review. RESULTS: Twenty-three probiotic species were identified, the majority of which were Lactobacilli or Bifidobacteria. Lactobacillus rhamnosus (30.8 %) and Lactobacillus reuteri (42.3 %) were found to be the two predominantly studied probiotic species and three main mechanisms of action of probiotics could be classified as: (i) modulation of the immuno-inflammatory response, (ii) direct actions of probiotics on periodontopathogens by adhesion or nutritive competitions and/or the secretion of antimicrobial molecules and (iii) indirect actions through environmental modifications. A combination of several probiotic strains seems to be beneficial via synergistic action amplifying the functions of each strain used. However, heterogeneity of the methodologies and probiotic species included in studies leads us to consider the following avenues for future research: (i) implementation of standardized periodontal models as close as possible to in vivo periodontal conditions to identify the functions of each strain for appropriate medication, (ii) updating data about interactions within oral biofilms to identify new candidates and to predict then analyze their behavior within these biofilms. CONCLUSION: Probiotics may have their place in the response to inter-individual variability in periodontitis, provided that the choice of the probiotic strain or combination of them will be personalized and optimal for each patient.

A scoping review on dental clinic accessibility for people using wheelchairs.

AIMS: We aimed to explore the scientific literature on accessible dental clinics for wheelchair users. More specifically, we sought out literature addressing how the human environment and physical space shape the dental services of accessible dental clinics. METHODS: We conducted a scoping review (May 2019) in Embase, PubMed, Web of Science, and the Avery index of architectural Periodicals (3994 articles). We followed Arksey and O'Malley's recommended procedures; after screening, we retained 17 articles. We performed a critical appraisal, followed by thematic content analyses of extracted data. RESULTS: The articles originated mainly from the United States and United Kingdom. Only three reported original research. We illustrated the results within a three-step dental care pathway cycle. In each step, the interaction between accessibility of the physical and human environments (ie, the layout/design of the clinic and the attitudes and skills of the dental professional, respectively) contributed to the overall accessibility. We also found that empirical evidence on clinics' accessibility was lacking: many articles resorted to broad "one size fits all" recommendations and fragmented information on accessibility. Finally, the voice of wheelchair users was missing. CONCLUSION: There are knowledge gaps in terms of dental clinics' accessibility. We thus invite researchers to conduct original studies with dental professionals, wheelchair users, and their caregivers.

Periodontal diseases and cardiovascular events: meta-analysis of observational studies.

OBJECTIVE: Many studies have investigated the relationship between periodontal and cardiovascular diseases but their results are heterogeneous. Meta-analyses were conducted to examine the association between exposure to periodontitis and cardiovascular diseases. MATERIAL AND METHODS: Studies published between 1989 and 2007 were retrieved from seven databases. The included articles reported the results from observational studies (cohort, cross-sectional and case-control studies) and assessed the link between periodontal exposure and cardiovascular diseases as confirmed by one of the following criteria: diagnosed coronary artery disease, angina pectoris, acute myocardial infarction, mortality caused by cardiac pathology. The study characteristics were abstracted by independent researchers following a standardised protocol. The MOOSE guidelines for meta-analysis of observational studies were followed. RESULTS: From 215 epidemiological studies, 47 were observational, of which 29 articles could be combined by the meta-analysis methodology. The pooled odds ratio calculated from the 22 case-control and cross-sectional studies was 2.35 (95% CI [1.87; 2.96], p < 0.0001). The risk of developing cardiovascular disease was found to be significantly (34%) higher in subjects with periodontal disease compared to those without periodontal disease (pooled relative risk from the 7 cohort studies was 1.34 (95% CI [1.27; 1.42], p < 0.0001). CONCLUSIONS: It seems from observational studies that subjects with periodontal diseases have higher odds and higher risks of developing cardiovascular diseases but the reduction in the risk of cardiovascular events associated with the treatment of periodontitis remains to be investigated.

Effect of a Person-Centered Course on the Empathic Ability of Dental Students.

Person-centered or patient-centered care (PCC) focuses on the individual's needs and concerns. Although PCC is widely acknowledged as a core value of modern medicine, there has been a lack of research on how dental curricula could engage future dentists in PCC approaches. The aim of this study was to assess the impact of a PCC course on empathy in dental students. A controlled study was conducted with fourth-year dental students in four dental faculties in France in 2014-15. The test group (n=63) received 20 hours of PCC training including arts-based approaches, narrative dentistry activities, and workshops on communication based on the Calgary-Cambridge guide. There was no change in the curriculum of the control group (n=217). Pretest and posttest measures with the Toronto Empathy Questionnaire (TEQ) and Jefferson Scale of Physician Empathy (JSPE) were compared for the two groups. The comparisons showed no significant differences on the TEQ or JSPE (p=0.25 and p=0.08, respectively). However, there was a higher proportion of students with more than an eight-point decrease in TEQ values in the control group (p=0.02). The stabilization of empathic ability in the test group may have counteracted the tendency for natural erosion of empathy among students during their clinical activities. These results suggest that PCC training constitutes a promising approach to developing dental students' empathic ability, but there is a need to assess the effects of such training over longer periods.

A charter for biomedical research ethics in a progressive, caring society.

BACKGROUND: Given that advances in research continuously raise new ethical issues, a multidisciplinary working group of investigators involved in biomedical research has gathered to discuss and compare ethical viewpoints in their daily practice. METHODS: The working group has drafted a Charter for Ethics in Biomedical Research that encompasses all the steps in the research process, i.e. from the initial idea to analysis and publication of the results. RESULTS: Based on key principles for ethically responsible research, the Charter may serve as a tool for performing research, discussing research issues and training researchers. CONCLUSIONS: The Charter should stimulate researchers to think about their responsibility for research in a progressive, caring society.

Oral health status in outpatients with rheumatoid arthritis: the OSARA study.

BACKGROUND: Observational studies and clinical trials are increasingly highlighting significant associations between periodontitis (chronic, infectious, inflammatory disease affecting tooth supporting tissues) and rheumatoid arthritis (chronic systemic autoimmune disease). OBJECTIVE: The aim of the study was to describe the dental, periodontal and oral prosthetic status of outpatients with Rheumatoid Arthritis (RA). MATERIAL AND METHODS: The study was conducted from June 2010 to March 2011 in the Rheumatology Day Care Department of the University Teaching Hospital, Toulouse. Activity of the RA was defined according to disease activity score 28 (DAS28). 74 subjects with RA were included. Periodontal status was determined using measurements of pocket depth, bleeding on probing and attachment loss. Periodontal Epithelial Surface Area (PESA) and Periodontal Inflamed Surface Area (PISA) were calculated. RESULTS: The study population was 60.3 ± 11.9 years old with 75.7% women. 48.6% of the subjects had moderate RA (3.2 < DAS28 ≤ 5.1) and 22.2% high RA activity (DAS28 > 5.1); 93.2% were treated by biotherapy. The mean number of natural teeth was 18.9 ± 9.7. The mean number of teeth replaced by removable prostheses was 7.1 ± 10.5. The mean PISA was 291.9 mm(2) ± 348.7 and the PISA:PESA ratio was 33.2% ± 24.2. 94% of patients had periodontitis, which was moderate in 48% and severe in 46%. CONCLUSION: This study highlights the need for prevention and for adequate dental care to improve global and oral quality of life of subjects with rheumatoid arthritis. Given the frequency of periodontitis and some physiopathological hypotheses, clinical trials are needed to assess if periodontal treatment could improve RA biological and clinical parameters.