Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants.

OBJECTIVE: The aims were (1) to search the scientific literature from 2007 to 2012 for guidelines and new studies on the dental management of patients using oral antithrombotic medication; (2) to summarize the articles' evidence and recommendations; and (3) to propose an updated clinical practice guideline for general dentists. STUDY DESIGN: A systematic literature search in MEDLINE, Embase, and the Guideline websites, from October 2007 to October 2012, produced articles that were critically evaluated. RESULTS: The systematic literature search for guidelines yielded 74 citations (MEDLINE, 45; Embase, 22; and the Guideline websites, 7). Of these, only 2 guideline publications and 2 systematic reviews met the inclusion criteria. They yielded 32 recommendations. CONCLUSIONS: The evidence and subsequent recommendations from published guidelines all point in the same direction: do not interrupt oral antithrombotic medication, not even dual antiplatelet therapy, in simple dental procedures.

Pain related to mandibular block injections and its relationship with anxiety and previous experiences with dental anesthetics.

OBJECTIVE: Anesthetic injections should reassure patients with the prospect of painless treatment, but for some patients it is the main source of their fear. We investigated pain resulting from mandibular block injections in relation to anxiety and previous experience with receiving injections. STUDY DESIGN: Patients (n = 230) filled out questionnaires before oral surgery. They were then asked to raise their hand when they felt pain as a result of the injection. The injection was administered, and pain intensity (11-point numeric rating scale) and pain duration (in seconds) was measured. RESULTS: In general, patients expected (mean 4.2, SD 2.7) significantly more pain than they experienced (2.4 ± 2.2). About 8.3% of patients reported a score in the range of 7 to 10. On average, pain lasted for 6.2 seconds (range 1-24.5 s), ≈ 36% of patients raised their hand for ≤ 2 seconds, and 14.6% raised their hand for ≥ 10 seconds. Pain was significantly positively associated with anxiety and the way previous injections were experienced. CONCLUSIONS: Mandibular block injections can be considered to be mildly painful, with pain lasting only a few seconds. The pain experience of a mandibular block seems only partly dependent on experienced anxiety and previous experiences with receiving injections.

Treating dental patients who use oral antithrombotic medication: a survey of dentists in the Netherlands.

BACKGROUND: For many years, international guidelines have advised health care professionals not to adjust oral antithrombotic medication (OAM) regimens before invasive dental procedures. The authors conducted a study to examine the opinions of Dutch general dentists regarding the dental care of patients receiving treatment with these medications. METHODS: The authors invited via e-mail 1,442 general dentists in the Netherlands to answer a 20-item Internet-based questionnaire that they developed. Survey items consisted of questions about medical history taking, number of patients in the dental practice receiving OAM therapy, frequency of consulting with medical and dental colleagues and suggested dental treatment of patients during various invasive dental procedures. RESULTS: A total of 487 questionnaires were returned (response rate of 34 percent). The mean age of respondents was 47 years, and 77 percent were male. The majority of dentists responded that they obtain medical histories, but that they did not know how many of their patients were receiving OAM treatment. Dentists reported that they consult with medical colleagues frequently about antithrombotic medication. Ninety-one percent of respondents stated that they obtained their medical knowledge primarily in dental school. More than 50 percent of the dentists reported that they were not familiar with the international normalized ratio. The majority of dentists responded that they felt a need for clinical practice guidelines. CONCLUSIONS: According to the results of our survey, most dentists remain cautious when performing invasive dental procedures in patients who are treated with OAMs. Moreover, survey respondents tended to estimate that the risk of bleeding during dental procedures when OAM therapy is continued is higher than the risk of rethrombosis when use of antithrombotic medication is interrupted. CLINICAL IMPLICATIONS: A growing proportion of elderly patients and those with medically complex conditions are being treated in dental practices in the Netherlands. Consequently, more needs to be done to ensure that dentists are offered evidence-based guidance when treating patients who receive OAMs.

The structure of common fears: comparing three different models.

Previous studies showed discrepant findings regarding the factor structure of common fears. The purpose of the present study was to expand on these findings and contribute to the development of a descriptive framework for a fear classification. Using data from the Dutch general population (n = 961; 50.9% women), an exploratory factor analysis was performed to delineate the multidimensional structure of 11 common fears previously used in a factor analytic study by Fredrikson, Annas, Fischer, and Wik (1996). An independent sample (n = 998; 48.3% women) was used to confirm the newly derived model by means of confirmatory factor analysis. In addition, the model was tested against the DSM-IV-TR model and a model found earlier by Fredrikson et al. (1996). Although support was found for a 3-factor solution consisting of a blood-injection-injury factor, a situational-animal factor, and a height-related factor, confirmatory factor analysis showed that this 3-factor model and the DSM-IV-TR 4-factor model fitted the data equally well. The findings suggest that the structure of subclinical fears can be inferred from the DSM classification of phobia subtypes and that fears and phobias are two observable manifestations of a fear response along a continuum.

Instrument-order effects: using the Oral Health Impact Profile 49 and the Short Form 12.

Whereas it is well known that the ordering of items can influence research outcomes considerably, very little literature addresses instrument-order effects. Therefore, the aim of this study was to evaluate the effect of changing the administrative order of the Short-Form-12 (SF-12) and the Oral Health Impact Profile-49 (OHIP-49). It was hypothesized that if the SF-12 was administered first, the results would show poorer scores on the SF-12 subscales, as responses would not be restrained to only the oral impacts described by the OHIP-49. Using the Mann-Whitney U-test no significant instrument-order effects were found, except for the Psychological discomfort scale of the OHIP-49, where subjects scored higher when receiving the OHIP-49 first. However, the effect size was negligible (-0.08). These results suggest that no instrument-order effects occurred. Nonetheless, more research dealing with different instruments is needed. This study was performed within a dental setting and we recommend that instrument-order effects should be studied outside this domain.

Value of bitewing radiographs for detecting approximal caries in 6-year-old children in the Netherlands.

BACKGROUND: When diagnosing caries using clinical judgment only, the prevalence of approximal caries is highly underestimated. Yet, surveys on this topic predominantly included adolescents and young adults. AIM: To determine the additional diagnostic value of bitewing radiographs in 6-year-old children and to detect approximal dentin caries in the primary dentition. DESIGN: A total of 50 children were assessed both clinically (dmfs, oral hygiene) and radiographically by two experienced dentists. The relation between dmfs-scores and amount of plaque was established using Pearson's correlation coefficients at a significance level of 0.05. RESULTS: In nine patients (18%) it was impossible to make radiographs. Bitewing radiography appeared to have an additional effect of 97% when only caries in dentin is considered. The additional value for detecting inadequate restorations was 600%. Furthermore, the dmfs was highly correlated to the amount of plaque found. CONCLUSION: Although not possible to achieve in all 6-year-old children, bitewing radiographs can reveal a considerable amount of carious surfaces and inadequate restorations, which appear clinically sound or adequate.

Preparatory information for third molar extraction: does preference for information and behavioral involvement matter?

OBJECTIVE: The objectives of the present study were to: (1) evaluate the impact of high versus low information provision in terms of anxiety towards third molar extraction (TME) as well as satisfaction with information provision. (2) Investigate how preference for information and behavioral involvement, interacted with the provision of information in terms of satisfaction with information and anxiety related to TME. METHODS: Psychology freshmen completed the Krantz Health Opinion Survey and questions concerning anxiety about TME (pretest). They were randomly allocated into 2 conditions and asked to read either high or low information concerning TME. A posttest questionnaire (anxiety items and evaluation of the information) was then completed. RESULTS: Data for 320 subjects were analysed (mean age=20.3, S.D.=4.0, range 16-51 years). Individual differences in preference for information did not affect outcome variables. There was a clear effect for information condition. The high information text was rated as more informative, requiring less additional information, and led to higher satisfaction by all participants. CONCLUSION: Results suggest that more information is preferred, even when taking into account differences in preference for information and behavioral involvement. PRACTICE IMPLICATIONS: Although more work is needed within samples of actual TME patients, these preliminary findings may have important implications for information provision for this common procedure.

Patients' and parents' expectations of orthodontic treatment.

OBJECTIVE: To investigate the expectations of children and their primary care-givers towards orthodontic treatment and to compare the results with those of a UK sample. DESIGN: A questionnaire survey of children and their primary care-givers attending for their first consultation. SETTING: The Department of Orthodontics at the Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands. SUBJECTS AND METHODS: A total of 168 subjects (84 patients and 84 parents) completed the questionnaire. The children were aged 10 to 14 years. The responses of the children and parents and differences between boys and girls were examined using parametric statistical methods. The data from the Dutch sample were compared with a similar UK sample. RESULTS: Patients and parents shared similar expectations of orthodontic treatment, with the exception of expectations of having a brace fitted at the first appointment, orthodontic treatment involving headgear, any problems with orthodontic treatment, duration of orthodontic treatment and concerning reactions from the public. Among the child participants, boys and girls only differed in their expectations of orthodontic treatment involving jaw surgery. Differences between Dutch and English participants were found regarding the first visit, type of orthodontic treatment, reactions from the public, and pain and problems with orthodontic treatment. CONCLUSIONS: Since the expectations of patients and their parents differ on several aspects, effective communication between the orthodontist, patient and parent is considered to be essential. Our hypothesis that Dutch patients' and parents' expectations of orthodontic treatment differ from the expectations of English patients and parents was supported.

Model specification in oral health-related quality of life research.

The aim of this study was to analyze conventional wisdom regarding the construction and analysis of oral health-related quality of life (OHRQoL) questionnaires and to outline statistical complications. Most methods used for developing and analyzing questionnaires, such as factor analysis and Cronbach's alpha, presume psychological constructs to be latent, inferring a reflective measurement model with the underlying assumption of local independence. Local independence implies that the latent variable explains why the variables observed are related. Many OHRQoL questionnaires are analyzed as if they were based on a reflective measurement model; local independence is thus assumed. This assumption requires these questionnaires to consist solely of items that reflect, instead of determine, OHRQoL. The tenability of this assumption is the main topic of the present study. It is argued that OHRQoL questionnaires are a mix of both a formative measurement model and a reflective measurement model, thus violating the assumption of local independence. The implications are discussed.

Young children's Oral Health-Related Quality of Life and dental fear after treatment under general anaesthesia: a randomized controlled trial.

During the past decade the research interest in Oral Health-Related Quality of Life (OHRQoL) has been prospering. This study was performed to test (using a randomized controlled trial design) the hypothesis that young children's OHRQoL improves after oral rehabilitation under general anaesthesia (GA). A further aim of this study was to explore whether dental fear also changes. One-hundred and four children (54 boys; mean age 4.08 yr, standard deviation = 1.09), who had been referred to a specialized clinic in paediatric dentistry, were randomly assigned, based on a Solomon four-group design, to two treatment (GA) and two control conditions. The Early Childhood Oral Health Impact Scale (ECOHIS) and the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) were used to assess OHRQoL and dental fear, respectively, before and after the rehabilitation procedures. A 2 x 2 analysis of variance revealed that the total ECOHIS score after GA was more positive in the GA group than in the control group. There was no effect found of the pre-test and there was also no interaction between the pre-test and treatment. In the total CFSS-DS scores no effects were found. The results of this study showed that the child's OHRQoL improved after treatment under GA. Furthermore, children need guidance in reducing dental fear after treatment under GA.

Anxiety and pain during dental injections.

OBJECTIVES: The aim of this study was to study the relationship between anxiety and pain felt during a dental injection in a sample of 'normal' patients about to undergo 'invasive' dental treatment. METHODS: Duration and intensity of pain during a dental injection were measured within a sample of 247 patients. In addition, data on dental anxiety, fear of dental pain, type of treatment, amount of anesthetic fluid, injection location and the use of surface anesthesia were also collected. RESULTS: Anxious patients felt more pain and of longer duration than less anxious patients. 28% of variance on the duration of pain felt could be accounted for by fear of dental pain, the use of surface anesthesia and gender. For the intensity of pain felt, 22% of variance could be accounted for by anxiety felt for the injection and dental anxiety. CONCLUSIONS: Pain felt during dental injections is dependent on dental anxiety, fear of dental pain, fear for the injection, gender and amount of injection fluid (rather than the use of surface anesthesia). In other words, some patients are expected to feel elevated levels of pain during dental injection and would benefit from extra attention and care from the dentist.

Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines.

OBJECTIVES: The aims were: 1) to identify the guidelines available for management of dental invasive procedures in patients on antithrombotic drugs; 2) to assess their quality with the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument; and 3) to summarize their conclusions and recommendations. STUDY DESIGN: Systematic literature search for guidelines in several electronic databases. Retrieved guidelines were evaluated with the AGREE instrument for quality assessment. RESULTS: The systematic search yielded 93 results, of which only 4 were evidence-based practice guidelines. Two of these guidelines could be recommended for clinical use on the basis of the AGREE instrument. These 2 guidelines drew 68 conclusions from the existing literature and provided 58 recommendations. CONCLUSIONS: Two evidence-based clinical practice guidelines, satisfactorily fulfilling the criteria of the AGREE instrument and both published in 2007, advise to not routinely discontinue antiplatelet and anticoagulation medication before dental surgery. The majority of the recommendations, however, were not sufficiently linked to levels of evidence.

Prevalence of dental fear and phobia relative to other fear and phobia subtypes.

The purpose of the present study was to estimate the point prevalence of dental fear and dental phobia relative to 10 other common fears and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR subtypes of specific phobia. Data were also analysed to examine differences with regard to severity, presence of distressing recollections of fear-related events, gender, and prevalence across age. Data were obtained by means of a survey of 1,959 Dutch adults, 18-93 yr of age. Phobias were assessed based on DSM-IV-TR criteria, whereas severity of present fears was assessed using visual analogue scales. The prevalence of dental fear was 24.3%, which is lower than for fear of snakes (34.8%), heights (30.8%), and physical injuries (27.2%). Among phobias, dental phobia was the most common (3.7%), followed by height phobia (3.1%) and spider phobia (2.7%). Fear of dental treatment was associated with female gender, rated as more severe than any other fear, and was most strongly associated with intrusive re-experiencing (49.4%). The findings suggest that dental fear is a remarkably severe and stable condition with a long duration. The high prevalence of dental phobia in the Netherlands is intriguing and warrants investigation in other countries.

Burnout development among dentists: a longitudinal study.

Knowledge on the development of burnout among dentists is important for purposes of prevention and intervention. Using a two-wave longitudinal design, this study examined the chronological sequence of the three dimensions of the Maslach Burnout Inventory: emotional exhaustion; depersonalization; and personal accomplishment. Structural Equation Modelling was employed among a representative sample of Dutch dentists to examine the fit of several models proposed in earlier research. The results indicated that a model in which emotional exhaustion precedes depersonalization, which in turn precedes personal accomplishment, shows an adequate fit among dentists. However, an alternative model, in which personal accomplishment precedes emotional exhaustion, had an even better fit. In addition to the test of these a priori models, an ad hoc model was constructed that best fitted the current data. This model indicated emotional exhaustion to precede the development of depersonalization and personal accomplishment independently. Although not univocal, the results showed that emotional exhaustion should not be discarded as an early sign of burnout. This is in line with the view that emotional exhaustion can be considered as the key dimension of burnout.

Dutch primary schoolchildren's attitudes toward their dental appearance.

PURPOSE: This study's purpose was to examine children's attitudes toward dental appearance and compare these with attitudes toward general health, body shape, grades in school, friends, money, and sports. The study also explored whether subjects reporting that they have attractive teeth believed themselves to have higher grades in school, more friends, a slim body shape, and better health than subjects reporting that they have unattractive teeth. METHODS: A sample of 216 9- to 13-year-old Dutch children participated. The methods of paired comparisons and direct ranking were used to investigate children's judgments about the importance of dental appearance. The subjects were also asked to indicate how strongly they believed that they had high grades in school, a lot of friends, money, success in sports, attractive teeth, a slim body shape, and good health. RESULTS: High grades in school, a slim body shape, good health, a lot of friends, and more money were preferred to attractive teeth. Children reporting that they have attractive teeth believed themselves to have higher grades in school, a slimmer body shape, more friends, more money, and better health than children reporting that they have unattractive teeth. CONCLUSIONS: Although attractive teeth are highly valued in general, children give priority to other issues in their lives.

Linking oral health, general health, and quality of life.

The aim of this work was to assess the association among oral health, general health, and quality of life (QoL). The Oral Health Impact Profile (OHIP-49) and the RAND-36 were distributed amongst 118 psychology freshmen. Additionally, two single items self-rated general health (SRGH) and self-rated oral health (SROH) - were administered. Kruskal-Wallis and Mann-Whitney U-tests were used to evaluate differences between SRGH and SROH categories, regarding OHIP subscale scores and RAND subscale scores. More than 75% of the subjects rated their oral and general health as good. Mean OHIP scores and RAND scores indicated a relatively good oral- and general health-related QoL respectively. The correlation between oral and general health was weak. Significant differences were found between SRGH categories regarding RAND subscale scores, except for the 'role emotional' and 'mental health' subscales. Significant differences were also found between SROH categories regarding OHIP subscale scores, except for the 'psychological disability' subscale. However, no significant differences were found between SRGH categories regarding OHIP subscale scores, or between SROH categories regarding RAND subscale scores. The findings suggest that oral health, general health, and QoL have different determinants. Furthermore, oral health and general health appear to be mostly unrelated in this seemingly healthy population. It is proposed that if no apparent disease is present, oral and general health must be regarded as separate constructs.

The Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ): a measure of severity of exposure to distressing dental events.

To understand the development of dental anxiety better and to identify those at increased risk of developing dental anxiety, the Level of Exposure-Dental Experiences Questionnaire (LOE-DEQ) was developed. The aim of the current study was to determine the psychometric properties (i.e. factor structure, reliability, and validity) of the LOE-DEQ and to determine its suitability as an additional screening instrument for dentally anxious patients. Five different samples were used: (i) highly dentally anxious patients (n = 119); (ii) general dental patients (n = 480); (iii) students (n = 186); (iv) psychiatric outpatients (n = 17); and (v) oral surgery patients (n = 34). Results of the factor analysis revealed a four-factor solution. The LOE-DEQ has sufficient internal consistency (Cronbach's alpha values ranging from 0.69 to 0.85) and satisfactory test-retest reliability (intraclass correlation coefficient = 0.78). The results further suggest that this instrument has adequate discriminant, concurrent, and predictive validity. It is concluded that the LOE-DEQ is a useful tool for assessing patients' background in terms of previous exposure to distressing dental events, which is considered a vulnerability factor in the development of dental anxiety.

Item-order effects in the Oral Health Impact Profile (OHIP).

Items and subscales in quality of life questionnaires generally have a part-whole combination, making the content of one item more general than another. Consequently, order effects can occur. The aim of this study was to evaluate the effect of changing the item order of the Oral Health Impact Profile (OHIP). Two versions of the OHIP were randomly distributed amongst psychology freshmen. Subjects who filled out the version in which more general items were presented first showed higher subscale scores. Using the Mann-Whitney U-test, small, but statistically significant, differences between the two versions of the OHIP were found on the Psychological disability scale, the Social disability scale, and the Handicap scale. Subscale intercorrelations of both versions of the OHIP were compared to investigate whether item order also influences the factor structure. Statistically significant differences between subscale intercorrelations were found, indicating a different factor structure for both versions. In conclusion, the OHIP seems to be susceptible to order effects, implying that the original item order of the OHIP should be upheld, especially when considering comparing research outcomes with other studies.

Confirmative factor analysis of the dimensions of the Child Oral Health Impact Profile (Dutch version).

The aim of this study was to examine the subscales of the Child Oral Health Impact Profile (COHIP). The Dutch version of the COHIP consists of the subscales 'Oral Symptoms', 'Functional Well-being', 'Emotional Well-being', 'School', and 'Peer Interaction'. The questionnaire was administered to a sample of 510 children in Amsterdam. Missing data were replaced with the personal mean. Subsequently, questionnaire reliability was investigated by means of corrected item-total correlations and Cronbach's alpha if-item-deleted. Based on these results, six items were excluded from further analysis. Then, the questionnaire and its subscales were examined using confirmative factor analyses. One-factor models were fitted on each subscale and a five-factor model was applied to the entire questionnaire. In several cases, model fit was below an acceptable level. In conclusion, the structure of five subscales does not seem to be entirely supported in this study population.

On the severity of impacts captured by the dimensions of the Oral Health Impact Profile.

The Oral Health Impact Profile (OHIP), containing seven dimensions, is based on a hierarchical model. Therefore, one could argue that events described by dimensions higher in the hierarchy are judged as having a more severe impact on quality of life than events described by dimensions lower in the hierarchy. The aim of this study was to test this assumption and to assess the relative severity of impact on daily life with which each dimension is judged relative to all other dimensions. The subjects were psychology freshmen. Subjects' judgments were assessed using the method of direct ranking and the method of paired comparison. The results showed differences between dimensions, with Handicap and Psychological disability being regarded as having the most severe impact on daily life. The results demonstrated the tenability of Locker's hierarchical model as the foundation of the OHIP, in that subjects rank the dimensions in a similar order of severity as intended by this model. It is suggested that the difference of the severity of impact should be compensated for, either by including subscale weights or by increasing the number of items of subscales where the impact on Quality of Life (QoL) is judged as being more severe.