How dentists learn behaviour support skills for adults with intellectual developmental disorders: A qualitative analysis.

INTRODUCTION: An understanding of how dentists develop patient support techniques for use with adults with intellectual developmental disorders (IDD) may lead to a better understanding of how these techniques can be taught. In this study, we explored how skilled dentists developed non-physical, non-pharmacological patient support techniques (nPSTs) for use with adults with IDD. MATERIALS AND METHODS: Adopting a qualitative descriptive design, a synchronous online group interview was undertaken with six dentists. Informants were subsequently contacted in pairs, or individually, for further interview. All data were analysed using thematic content analysis. Author biases and rigour are considered. RESULTS: Three categories emerged: Motivation to learn; Formal learning; and Informal learning, and the latter had three subcategories: Observation; Trial; and error and Experience. Motivators to learn PST skills included perceived empathy and a sense of responsibility towards patients with IDD. Formal undergraduate learning was lacking leaving dentists to rely on paediatric training "A paediatric model from your training… needs to be restructured and re-emphasised with people with disabilities as they progress through the lifespan.", whereas specialist training was reported to be helpful where available. Over time, practitioners developed an individualised skillset through observation, trial and error and experience. "You learn. Just like any job, you learn on the job. You learn a lot from experience and mistakes." DISCUSSION: Essential patient support skills appear to be acquired in an ad hoc manner. How dentists learn their skills has implications for dental training for future and current dental professionals. CONCLUSIONS: Specific recommendations to improve education are made.

Oral hygiene interventions for people with intellectual disabilities.

BACKGROUND: Periodontal (gum) disease and dental caries (tooth decay) are the most common causes of tooth loss; dental plaque plays a major role in the development of these diseases. Effective oral hygiene involves removing dental plaque, for example, by regular toothbrushing. People with intellectual disabilities (ID) can have poor oral hygiene and oral health outcomes. OBJECTIVES: To assess the effects (benefits and harms) of oral hygiene interventions, specifically the mechanical removal of plaque, for people with intellectual disabilities (ID). SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases to 4 February 2019: Cochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Register of Studies), MEDLINE Ovid, Embase Ovid and PsycINFO Ovid. ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. The Embase search was restricted by date due to the Cochrane Centralised Search Project, which makes available clinical trials indexed in Embase through CENTRAL. We handsearched specialist conference abstracts from the International Association of Disability and Oral Health (2006 to 2016). SELECTION CRITERIA: We included randomised controlled trials (RCTs) and some types of non-randomised studies (NRS) (non-RCTs, controlled before-after studies, interrupted time series studies and repeated measures studies) that evaluated oral hygiene interventions targeted at people with ID or their carers, or both. We used the definition of ID in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). We defined oral hygiene as the mechanical removal of plaque. We excluded studies that evaluated chemical removal of plaque, or mechanical and chemical removal of plaque combined. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened search records, identified relevant studies, extracted data, assessed risk of bias and judged the certainty of the evidence according to GRADE criteria. We contacted study authors for additional information if required. We reported RCTs and NRSs separately. MAIN RESULTS: We included 19 RCTs and 15 NRSs involving 1795 adults and children with ID and 354 carers. Interventions evaluated were: special manual toothbrushes, electric toothbrushes, oral hygiene training, scheduled dental visits plus supervised toothbrushing, discussion of clinical photographs showing plaque, varied frequency of toothbrushing, plaque-disclosing agents and individualised care plans. We categorised results as short (six weeks or less), medium (between six weeks and 12 months) and long term (more than 12 months).Most studies were small; all were at overall high or unclear risk of bias. None of the studies reported quality of life or dental caries. We present below the evidence available from RCTs (or NRS if the comparison had no RCTs) for gingival health (inflammation and plaque) and adverse effects, as well as knowledge and behaviour outcomes for the training studies.Very low-certainty evidence suggested a special manual toothbrush (the Superbrush) reduced gingival inflammation (GI), and possibly plaque, more than a conventional toothbrush in the medium term (GI: mean difference (MD) -12.40, 95% CI -24.31 to -0.49; plaque: MD -0.44, 95% CI -0.93 to 0.05; 1 RCT, 18 participants); brushing was carried out by the carers. In the short term, neither toothbrush showed superiority (GI: MD -0.10, 95% CI -0.77 to 0.57; plaque: MD 0.20, 95% CI -0.45 to 0.85; 1 RCT, 25 participants; low- to very low-certainty evidence).Moderate- and low-certainty evidence found no difference between electric and manual toothbrushes for reducing GI or plaque, respectively, in the medium term (GI: MD 0.02, 95% CI -0.06 to 0.09; plaque: standardised mean difference 0.29, 95% CI -0.07 to 0.65; 2 RCTs, 120 participants). Short-term findings were inconsistent (4 RCTs; low- to very low-certainty evidence).Low-certainty evidence suggested training carers in oral hygiene care had no detectable effect on levels of GI or plaque in the medium term (GI: MD -0.09, 95% CI -0.63 to 0.45; plaque: MD -0.07, 95% CI -0.26 to 0.13; 2 RCTs, 99 participants). Low-certainty evidence suggested oral hygiene knowledge of carers was better in the medium term after training (MD 0.69, 95% CI 0.31 to 1.06; 2 RCTs, 189 participants); this was not found in the short term, and results for changes in behaviour, attitude and self-efficacy were mixed.One RCT (10 participants) found that training people with ID in oral hygiene care reduced plaque but not GI in the short term (GI: MD -0.28, 95% CI -0.90 to 0.34; plaque: MD -0.47, 95% CI -0.92 to -0.02; very low-certainty evidence).One RCT (304 participants) found that scheduled dental recall visits (at 1-, 3- or 6-month intervals) plus supervised daily toothbrushing were more likely than usual care to reduce GI (pocketing but not bleeding) and plaque in the long term (low-certainty evidence).One RCT (29 participants) found that motivating people with ID about oral hygiene by discussing photographs of their teeth with plaque highlighted by a plaque-disclosing agent, did not reduce plaque in the medium term (very low-certainty evidence).One RCT (80 participants) found daily toothbrushing by dental students was more effective for reducing plaque in people with ID than once- or twice-weekly toothbrushing in the short term (low-certainty evidence).A benefit to gingival health was found by one NRS that evaluated toothpaste with a plaque-disclosing agent and one that evaluated individualised oral care plans (very low-certainty evidence).Most studies did not report adverse effects; of those that did, only one study considered them as a formal outcome. Some studies reported participant difficulties using the electric or special manual toothbrushes. AUTHORS' CONCLUSIONS: Although some oral hygiene interventions for people with ID show benefits, the clinical importance of these benefits is unclear. The evidence is mainly low or very low certainty. Moderate-certainty evidence was available for only one finding: electric and manual toothbrushes were similarly effective for reducing gingival inflammation in people with ID in the medium term. Larger, higher-quality RCTs are recommended to endorse or refute the findings of this review. In the meantime, oral hygiene care and advice should be based on professional expertise and the needs and preferences of the individual with ID and their carers.

Total tooth loss without denture wear is a risk indicator for difficulty eating among older adults with intellectual disabilities.

OBJECTIVES: This study tests whether total tooth loss is a risk indicator for difficulty eating among a population with intellectual disability and whether complete denture wear mediates this risk. METHODS: Dentate status and difficulty eating were reported for a Nationally representative sample of 690 adults over forty with intellectual disabilities as part of The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing (IDS-TILDA). A logistic regression model tested the relationship between the Difficulty eating and Dentate status, controlling for the effects of other factors. RESULTS: Of the 690 participants, 505 had some teeth (Group 1), 56 had no teeth and reported wearing dentures (Group 2) and 129 had no teeth, not using dentures (Group 3). A parsimonious regression model was developed including all 406 cases with no missing data. Adjusting for the effects of other factors, it was found that, compared to Group 1, the odds of difficulty eating was twice as great (OR = 2.01, 95% CI = 1.02-4.03) among people without teeth, not using dentures (Group 3). Conversely, edentulous participants who had dentures (Group 2) had far lower odds (OR = 0.21, 95% CI = 0.06-0.64) of reporting difficulty eating compared with Group 1. CONCLUSIONS: For adults with ID, total tooth loss was predictive of difficulty eating only when untreated. People with disabilities should be encouraged to maintain a functional dentition through preventive and conservative treatment. When adults with ID become edentulous, oral rehabilitation may reduce the risk of difficulty eating. Dental assessment should be undertaken if people with ID present with difficulty eating.

Communication-based behaviour support for adults with intellectual disabilities receiving dental care: A focus group study exploring dentists' decision-making and communication.

A better understanding of how communication-based behaviour supports are applied with adults with intellectual disabilities may reduce reliance on restrictive practices such as holding, sedation and anaesthesia in dentistry. In this study, we explore how communication is used by dentists who provide treatment for adults with intellectual disabilities. A descriptive qualitative study, adopting synchronous online focus groups, was undertaken with six expert dentists in Ireland. Members were contacted again in pairs or individually for further data collection, analysed using thematic content analysis. Two relevant categories emerged from the data, relating to the selection and application of communication-based behaviour support for adults with intellectual disabilities. Decision-making processes were explored. Building on these categories, a co-regulating process of communication emerged as the means by which dentists iteratively apply and adapt communicative strategies. This exploration revealed rationalist and intuitive decision-making. Implications for education, practice and research are identified.

Oral health-related quality of life and early childhood caries among preschool children in Trinidad.

BACKGROUND: Early childhood caries (ECC) is a public health problem in developed and developing countries. The purpose of this study was to describe the relationship between oral health-related quality of life (OHRQoL) and ECC among preschool children in a Caribbean population. METHOD: Parents/primary caregivers of children attending nine, randomly selected preschools in central Trinidad were invited to complete an oral health questionnaire and have their child undertake an oral examination. The questionnaire included the Early Childhood Oral Health Impact Scale (ECOHIS). Visible caries experience was assessed using WHO criteria. Logistic regression models were used to determine the factors associated with OHRQoL and ECC. RESULTS: Three hundred nine parents/caregivers participated in the study (age-range 25-44 years) and 251 children (mean age 3.7 years) completed oral examinations. Adjusting for other factors, the odds for a child aged 4 years of having dental caries were greater than the odds for a child aged 3 years (OR 3.61; 95% CI (1.76, 6.83). The odds for children having difficulty drinking hot or cold drinks were greater for those with dental caries than the odds for children who have no such difficulty. Similarly, the odds for children who had difficulty eating were greater for those with dental caries than the odds ratios for children who had no difficulty eating (OR 8.29; 95% CI (2.00, 43.49). Adjusting for the effects of other factors, the odds of parents/caregivers feeling guilty were greater if their child had experienced dental caries in comparison to parents/caregivers whose child did not have dental caries (OR 3.50; 95% CI (1.32, 9.60). Adjusting for other factors, the odds of parents/primary caregivers having poor quality of life was increased when they had a child with a dmft in the range 1-3 (OR 2.68; 95% CI (1.30, 5.64) dmft > 4 (OR 8.58; 95%CI (3.71, 22.45), in comparison to those whose child had a dmft = 0. CONCLUSION: In this sample of preschool children OHRQoL was associated with ECC. More negative impacts were found in children with a greater severity of visible caries experience. This suggests the need for strategies to prevent and manage ECC in this Caribbean population.

The effect of motivational interviewing on oral healthcare knowledge, attitudes and behaviour of parents and caregivers of preschool children: an exploratory cluster randomised controlled study.

BACKGROUND: Motivational Interviewing (MI) has been used across primary healthcare and been shown to be effective in reducing the prevalence of early childhood caries (ECC) in preschool children. This study aimed to compare the effect of MI, in contrast to traditional dental health education (DHE), on oral health knowledge, attitudes, beliefs and behaviours among parents and caregivers of preschool children in Trinidad. METHOD: The design of this exploratory study included a cluster randomised controlled trial and semi-structured focus groups. Six preschools (79 parents and caregivers) in Eastern Trinidad were randomly assigned to a test or control group (3 preschools in each group). Parents and caregivers in the test-group (n = 25) received a talk on dental health using an MI approach and the control-group (n = 54) received a talk using traditional DHE. Both groups received additional, written dental health information. The MI group also received two telephone call follow-ups as part of the MI protocol. Both groups were given questionnaires before the talks and four months later. Question items included oral health knowledge, beliefs, attitudes, brushing behaviour, oral health self-efficacy, oral health fatalism and a specific instrument to asses 'readiness for change', the Readiness Assessment of Parents Concerning Infant Dental Decay (RAPIDD). Participants in the test-group were also invited to take part in a focus group to share their views on the dental health talk. RESULTS: At four month follow-up, knowledge items on fluoride use, tooth brushing, dietary practice and dental attendance increased in both the test (DHE + MI) and control (DHE) groups ((p < 0.05, Chi Square test). In the test-group there were increases in mean child tooth brushing frequency and reduction in oral health fatalism (p < 0.05 t-test). Findings from a thematic analysis of the focus group suggested that the MI talk and telephone follow-up were well accepted and helpful in supporting parent and caregiver efforts to improve oral health practices for their preschool children. CONCLUSION: In this exploratory controlled study there was some evidence that using an MI approach when delivering oral health information had a positive effect on parent/ caregiver oral health knowledge, attitudes and behaviours compared to traditional DHE. There is need for further research involving the use of brief-counselling techniques in this Caribbean population.

Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management.

OBJECTIVES: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e-Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. METHODS: Following a registered protocol, a modified e-Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. RESULTS: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. DISCUSSION: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care.

Socio-behavioural factors and early childhood caries: a cross-sectional study of preschool children in central Trinidad.

BACKGROUND: Early childhood caries (ECC) is a public health problem due to its impact on children's health, development and well being. Little is known about early childhood oral health in the West Indies or the influence of social and behavioural factors on the prevalence and severity of early childhood caries in this preschool population. The aims of this study were to describe the prevalence and severity of ECC in preschool children in a region of central Trinidad and to explore its relationship with social and behavioural factors. METHOD: A cross-sectional survey was undertaken on children aged 3-5 years-old from a random sample of preschools in central Trinidad. Oral health examinations were conducted for children for whom parental consent was given, using WHO criteria (visual diagnosis / cavitation at d3). A self-reported questionnaire was distributed to all parents and caregivers. Variables included socio-demographics, oral health knowledge, attitudes and behaviours, visible caries experience and treatment need. RESULTS: 251 children were examined, 50.2% were male with a mean age of 3.7 years (SD 0.67) and 71% were of Indian ethnicity. The prevalence of ECC was 29.1% and the prevalence of severe early childhood caries (S-ECC) was 17.5%. 29.9% of children had some treatment need, with 12% in need of urgent care or referral. Poisson generalized linear mixed model analysis found a higher rate of visible caries experience for children who ate sweet snacks more than twice a day (p < 0.001), had poorer parental dental health ratings (p < 0.0001), a previous dental visit (p < 0.0001) and difficulty finding dental care (p < 0.001). CONCLUSION: The prevalence and severity of ECC in central Trinidad was related to oral health behaviours and access to dental care. Oral health promotion should include more supportive and practical advice for parents and caregivers of preschool children along with improved access to dental care to enable primary prevention and management of ECC.

Dental extractions do not predict further use of dental general anesthesia in people with disabilities: A longitudinal analysis.

OBJECTIVES: This paper describes treatments completed under dental general anesthesia (DGA) for a cohort of adults with disabilities. This patient cohort was followed up a number of years later to determine outcomes and identify factors that predict further use of DGA. METHODS: A retrospective patient record review and cross-sectional survey was carried out on a convenience sample of 64 patients who had previously received dental treatment under general anesthesia. Patient record review extracted data on patient demographics and treatment provided under DGA. Cross-sectional survey a number of years post-DGA collected data on oral care habits and current oral health based on a standardized clinical examination. Statistical analysis was carried out to identify predictors of repeat DGA. RESULTS: Participants received extensive treatment under DGA including preventive care, restorations, extractions, and root canal treatment. At follow-up 89.1% of participants had gingival disease and 56.3% had active dental caries. The mean number of teeth present was 21.2 (SD 6.9, range 6-32). Only caries risk status was found to be a significant predictor (p = 0.03) with those with a high caries risk status 6.9 times (95%CI 1.2-39.3) more likely to receive a second DGA. CONCLUSIONS: Dentists extract teeth for people with disabilities under DGA in the mistaken belief that this will avoid the need for further DGA. This study found that extraction of teeth does not prevent the need for repeated episodes of DGA. Therefore, dentists should stop extracting teeth for this reason. Rather, if dentists want to avoid further DGA, they should do the basics well: consistent, evidence-based caries risk assessment and risk reduction.

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines.

INTRODUCTION: There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS). METHODS: This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques. RESULTS: From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non-pharmacological). CONCLUSIONS: This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients.

Oral healthcare of preschool children in Trinidad: a qualitative study of parents and caregivers.

BACKGROUND: Little is known about oral health in early childhood in the West Indies or the views and experiences of caregivers about preventive oral care and dental attendance The aims of this study were to explore and understand parents and caregivers' experience of oral healthcare for their preschool aged children and how, within their own social context, this may have shaped their oral health attitudes and behaviours. These data can be used to inform oral health promotion strategies for this age group. METHOD: After ethical approval, a qualitative study was undertaken using a focus group approach with a purposive sample of parents and caregivers of preschool children in central Trinidad.Group discussions were initiated by use of a topic guide. Audio recording and field notes from the three focus groups, with a total of 18 participants, were transcribed and analysed using a thematic approach. RESULTS: Despite some ambivalence toward the importance of the primary teeth, the role of fluoride and confusion about when to take a child for their first dental visit, most participants understood the need to ensure good oral hygiene and dietary habits for their child. Problems expressed included, overcoming their own negative experiences of dentistry, which along with finding affordable and suitable dental clinics, affected their attitude to taking their child for a dental visit. There was difficulty in establishing good brushing routines and controlling sweet snacking in the face of many other responsibilities at home. Lack of availability of paediatric dental services locally and information on oral health care were also highlighted. Many expressed a need for more contact with dental professionals in non-clinic settings, for oral health care advice and guidance. CONCLUSION: Parents and caregivers in this qualitative study showed generally positive attitudes towards oral health but appear to have encountered several barriers and challenges to achieving ideal preventive care for their child, with respect to healthy diet, good oral hygiene and dental attendance. Oral health promotion should include effective dissemination of oral health information, more practical health advice and greater access to dental care for families with preschool children.

Outcomes from the first mouth cancer awareness and clinical check-up day in the Dublin Dental University Hospital.

PURPOSE OF THE STUDY: To increase public awareness about mouth cancer, the Dublin Dental University Hospital (DDUH) hosted an awareness day and free mouth check-up in September 2010. The messages of information, self-examination and risk management, and the importance of early detection, were available to all attendees. The role of general dental and medical practitioners in examination of the mouth was stressed. MATERIAL AND METHODS: A questionnaire regarding knowledge about the causes of and risk factors for mouth cancer, and a clinical check-up, were completed. RESULTS: A total of 1,661 individuals (675 male, 986 female) were examined. The mean age was 59.6 years. Just over one-third (36.5%) of those examined required no action, and slightly less (30%) were advised to return to their general dental or medical practitioner (GDP/GMP). Some 21% were advised about self-examination of the mouth, and 8% about smoking cessation. Of the remainder, 52 people (3.5%) were sent for a second opinion. Of these, 30 individuals were referred for further investigation, including biopsy in 27 cases. Following biopsy, five individuals were diagnosed with carcinoma in situ or carcinoma. CONCLUSIONS: The diagnosis of five people with mouth cancers, who may not otherwise have been identified for early treatment, highlights the need for regular mouth examination. It is inappropriate that such an exercise would remain the preserve of the dental teaching hospitals, and it is vital that all dentists take on the responsibility for regular mouth checks for all of their patients. More should be done to encourage those identified as high risk to visit their dentist. There is a need for recognition of the additional resources required for the detection and timely management of such cancers.

Dental decision-making under general anesthesia for patients with disabilities: A qualitative study.

AIMS: This paper explores the variables which influence decision-making processes in dentists providing dental care for people with disabilities under general anesthesia (GA). METHODS: Face-to-face semi-structured interviews were undertaken on a purposive sample. Audio recordings were transcribed and checked for accuracy. Using thematic content analysis methods open codes were developed inductively. Codes were analyzed further by three authors adopting a deductive approach, leading to final coding, sorting and themes, subtheme and framework development. RESULTS: Three themes emerged. The first theme explored Shared Decision Making, or lack thereof, as it influenced clinical reasoning. The second (Systematic, Analytical) and third (Intuition, and heuristics) themes explored features of clinical judgment as considered under dual process theory. Dentists primarily used intuitive decision-making processes and heuristic styled processes (or cognitive mental frames) assisted in intuition to extract teeth, without engaging type 2 processes. CONCLUSION: The dentists experience subtle modifiers to their decision-making that ultimately promote extraction of teeth under GA for people with disabilities. Bias training, simulation and post-hoc reflection are examples of recommendations which may be used to improve decision-making in this area.

BeSiDe time to move behavior support in dentistry from an art to a science: A position paper from the BeSiDe (Behavior Support in Dentistry) Group.

AIMS: To share the need for agreement in terminology around how people are supported to receive dental care. METHOD: In this position paper, we make the case for a shift in behavior support in dentistry from an art to a science. RESULTS: We outline why we need agreement on the definition of behavior support across dentistry, agreement on underlying theory, aims and values, and why we need agreement on terms for specific techniques. CONCLUSIONS: We share how patients and dental teams can benefit through better science, education and practice of dental behaviour support.

Microbiological screening of Irish patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy reveals persistence of Candida albicans strains, gradual reduction in susceptibility to azoles, and incidences of clinical signs of oral candidiasis without culture evidence.

Patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) are prone to chronic mucocutaneous candidiasis, which is often treated with azoles. The purpose of this study was to characterize the oral Candida populations from 16 Irish APECED patients, who comprise approximately half the total number identified in Ireland, and to examine the effect of intermittent antifungal therapy on the azole susceptibility patterns of Candida isolates. Patients attended between one and four clinical evaluations over a 5-year period, providing oral rinses and/or oral swab samples each time. Candida was recovered from 14/16 patients, and Candida albicans was the only Candida species identified. Interestingly, clinical diagnosis of candidiasis did not correlate with microbiological evidence of Candida infection at 7/22 (32%) clinical assessments. Multilocus sequence typing analysis of C. albicans isolates recovered from the same patients on separate occasions identified the same sequence type each time. Fluconazole resistance was detected in isolates from one patient, and isolates exhibiting a progressive reduction in itraconazole and/or fluconazole susceptibility were identified in a further 3/16 patients, in each case correlating with the upregulation of CDR- and MDR-encoded efflux pumps. Mutations were also identified in the ERG11 and the TAC1 genes of isolates from these four patients; some of these mutations have previously been associated with azole resistance. The findings suggest that alternative Candida treatment options, other than azoles such as chlorhexidine, should be considered in APECED patients and that clinical diagnosis of oral candidiasis should be confirmed by culture prior to the commencement of anti-Candida therapy.

A survey to assess the provision of conscious sedation by general dental practitioners in the Republic of Ireland.

AIM: To quantify and qualify how conscious sedation was used in general dental practice before the introduction of formal sedation teaching in the Republic of Ireland. OBJECTIVES: 1. To determine the extent of use of oral, inhalational and intravenous sedation; 2. to determine the training and experience of general dental practitioners providing conscious sedation; 3. to determine the perceived barriers to the practice of conscious sedation; and, 4. to gauge the level of interest in a postgraduate course in conscious sedation. METHOD: Postal questionnaire sent to one general practitioner in seven, selected randomly from the General Dental Council register, in 2007. RESULTS: Seventy six percent of respondents agreed that the provision of conscious sedation in general dental practice is important. However, the current provision of inhalation and intravenous sedation by respondents is low in comparison to provision in the UK. The main barrier to the use of conscious sedation in general dental practice appears to be lack of availability of training. CONCLUSIONS: The data from this study indicated the need for postgraduate training in conscious sedation in Ireland and a need for increased awareness of the Dental Council Code of Practice on sedation.

The integration of oral health-related best practice recommendations in the management of patients with diabetes: a cross-sectional survey of primary care physicians.

OBJECTIVE: To determine whether best practice recommendations are being followed by primary care physicians (PCPs) by examining the integration of oral health-related practices in their management of patients with diabetes. METHODS: A cross-sectional study design was used to examine PCPs' knowledge of the bidirectional link between diabetes and periodontal disease (PD), their adherence to international best practice recommendations, and their experience of interprofessional collaboration with dentists via an online survey. RESULTS: In total, 79 of 173 PCPs completed the online survey. Almost 90 percent of PCPs neither inform patients with diabetes about the link with PD nor advise dental care. Approximately, one-third of PCPs (32 percent) felt confident facilitating access to dentists. However, 93 percent of PCPs do not refer patients with diabetes to dentists as part of diabetes management. CONCLUSION: PCPs tend not to inform their patients with diabetes of the bidirectional link with PD, or provide advice or referral to attend dental care as part of diabetes management.

Oral features and dental health in Hurler Syndrome following hematopoietic stem cell transplantation.

BACKGROUND: Hurler Syndrome is associated with a deficiency of a specific lysosomal enzyme involved in the degradation of glycosaminoglycans. Hematopoietic stem cell transplantation (HSCT) in early infancy is undertaken to help prevent the accumulation of glycosaminoglycans and improve organ function. AIM: To investigate the oral features and dental health of patients with Hurler Syndrome who have undergone successful HSCT. MATERIALS AND METHODS: Twenty-five patients (median age 8.6 years) post-HSCT (mean age 9.4 months) underwent oral assessment (mean of 7.5 years post-HSCT). RESULTS: Dental development was delayed. Numerous occlusal anomalies were noted including: open-bite, class III skeletal base, dental spacing, primary molar infra-occlusion and ectopic tooth eruption. Dental anomalies included hypodontia, microdontia, enamel defects, thin tapering canine crowns, pointed molar cusps, bulbous molar crowns and molar taurodontism. Tooth roots were usually short/blunted/spindle-like in permanent molars. The prevalence of dental caries was low in the permanent dentition (mean DMFT 0.7) but high in the primary dentition (mean dmft 2.4). Oral hygiene instruction with plaque and or calculus removal was indicated in 71% of those that were dentate. CONCLUSION: Patients with Hurler Syndrome post-HSCT are likely to have delayed dental development, a malocclusion, and dental anomalies, particularly hypodontia and microdontia.

Tooth agenesis in patients referred to an Irish tertiary care clinic for the developmental dental disorders.

PURPOSE: This study was carried out to determine the prevalence, severity and pattern of hypodontia in Irish patients referred to a tertiary care clinic for developmental dental disorders. MATERIALS AND METHODS: Details of 168 patients with hypodontia referred during the period 2002-2006 were entered in a database designed as a national record. Tooth charting was completed using clinical and radiographic examinations. The age of patients ranged from 7-50 years, with a median age of 20 years (Mean: 21.79; SD: 8.005). RESULTS: Hypodontia referrals constituted 65.5% of the total referrals. Females were more commonly affected than males with a ratio of 1.3:1. The number of referrals reflected the population density in this area; the majority were referrals from the public dental service. Mandibular second premolars were the most commonly missing teeth, followed by maxillary second premolars and maxillary lateral incisors; maxillary central incisors were the least affected. Symmetry of tooth agenesis between the right and left sides was an evident feature. Slightly more teeth were missing on the left side (n = 725) than on the right side (n = 706) and in the maxillary arch (n = 768) as compared to the mandibular arch (n = 663). Some 54% of patients had severe hypodontia with more than six teeth missing; 32% had moderate hypodontia, with four to six teeth missing. The most common pattern of tooth agenesis was four missing teeth. CONCLUSION: Hypodontia was a common presentation in a population referred to this tertiary care clinic. The pattern and distribution of tooth agenesis in Irish patients appears to follow the patterns reported in the literature.