Prioritization, Incentives, and Resource Use for Sustainable Dentistry: The EU PRUDENT Project.

KNOWLEDGE TRANSFER STATEMENT: The EU PRUDENT project aims to enhance the financing of oral health systems through novel evidence and implementation of better financing solutions together with citizens, patients, providers, and policy makers. The multicountry nature of the project offers unique windows of opportunity for rapid learning and improving within and across various contexts. PRUDENT is anticipated to strengthen capacities for better oral care financing in the EU and worldwide.

Gender Inequalities in the Dental Workforce: Global Perspectives.

The aim of this review is to investigate the growth of diversity and inclusion in global academic dental research with a focus on gender equality. A diverse range of research methodologies were used to conduct this review, including an extensive review of the literature, engagement of key informants in dental academic leadership positions around the world, and review of current data from a variety of national and international organizations. Results provide evidence of gender inequalities that currently persist in dental academics and research. Although the gender gap among graduating dental students in North America and the two most populous countries in Europe (the United Kingdom and France) has been narrowed, women make up 30% to 40% of registered dentists in countries throughout Europe, Oceania, Asia, and Africa. In academic dentistry around the globe, greater gender inequality was found to correlate with higher ranking academic and leadership positions in the United States, United Kingdom, several countries in European Union, Japan, and Saudi Arabia. Further disparities are noted in the dental research sector, where women make up 33% of dental researchers in the European Union, 35% in North America, 55% in Brazil, and 25% in Japan. Family and societal pressures, limited access to research funding, and lack of mentoring and leadership training opportunities are reported as also contributing to gender inequalities. To continue advancing gender equality in dental academia and research, efforts should be geared toward the collection and public dissemination of data on gender-specific distributions. Such evidence-driven information will guide the selection of future strategies and best practices for promoting gender equity in the dental workforce, which provides a major pipeline of researchers and scholars for the dental profession.

Treatment of neuromyelitis optica with rituximab: a 2-year prospective multicenter study.

OBJECTIVE: Neuromyelitis optica (NMO) is a very severe autoimmune disorder of the central nervous system. It affects young subjects and has a poor prognosis both on a functional and vital level. Therefore, it is imperative to reduce the frequency of relapses. The purpose of this study was to evaluate the clinical and neuroradiological effectiveness of rituximab (RTX) on active forms of NMO. METHODS: We conducted a 2-year open prospective multicenter study that included 32 patients treated with RTX at a dose of 375 mg/m2/week for 1 month. When the number of circulating CD19+ B cells reached 1%, a maintenance therapy was started, consisting of two infusions of 1 g of RTX, administered at a 15-day interval. The primary objective was to reduce the annual relapse rate (ARR), in comparison to that observed in the 2 years before treatment onset. RESULTS: Rituximab administration reduced the ARR from 1.34 to 0.56 (p = 0.0005). The average Expanded Disability Status Scale (EDSS) score significantly improved by 1.1 point, from 5.9 (2-9) to 4.8 (0-9) after 2 years (p = 0.03). Anti-aquaporin-4 antibodies' level predicted treatment failure (p = 0.03). Frequency of Gad+ lesions in spinal cord decreased from 23.3 to 14.2%. RTX treatment did not prevent the death of three patients (treatment failure in two patients and acute myeloid leukemia in a patient previously treated with mitoxantrone). CONCLUSION: Rituximab is clinically effective in active forms of NMO, although few patients are resistant to the treatment.

The healthcare system and the provision of oral healthcare in EU Member States: France.

The French oral health system is based on the provision of dental treatment and is organised around a fee-per-item model. The system is funded by a complex mix of public and complementary health insurance schemes. The system is successful in that it provides access to affordable dental treatment to the majority of the French population. However, France had the highest health expenditure as a share of gross domestic product (GDP) of all European Union countries in 2008 and rising oral health inequalities may be exacerbated by the manner in which oral health care is provided and funded. In addition, there is no organised national strategy for the prevention of oral diseases or for oral health promotion.

[Status of health and oral health of the elderly population in Lebanon]. / État des lieux sanitaire et bucco-dentaire de la population gériatrique libanaise.

Lebanon is in demographic transition as more people reach increasingly older age; 10% of the population in Lebanon is elderly. The incidence of chronic diseases and oral diseases increases significantly with age. However, 55% of the elderly have no health insurance and 82% have no dental insurance. Both noncommunicable diseases (NCDs) and oral diseases are a major health burden in the country and share the same risk factors. The WHO strategy for prevention and control of noncommunicable diseases should therefore be a new approach for the prevention and control of dental diseases among Lebanese elderly. This paper aims to increase the awareness of the medical community in Lebanon about the interrelationship between general and oral health in the elderly and concludes with the need for the Ministry of Health to develop policies and national action plans against NCDs to reduce not only mortality from NCDs but also morbidity from oral diseases.

Periodontal disease and stroke: a meta-analysis of cohort studies.

This review aimed to determine the association between periodontal disease and stroke incidence by a meta-analysis of cohort studies. Cohort studies that evaluated the incidence of stroke (fatal or non-fatal, ischaemic or haemorrhagic) and baseline periodontal status and calculated relative risk values were included. The quality of the included studies was assessed using an evaluation grid. The analyses were conducted separately for three outcomes: periodontitis, gingivitis and loss of teeth. Adjusted values of relative risk or of hazard ratio were used to assess risk values in each study. Random effects meta-analyses were conducted when data could be pooled. From the 743 references retrieved, only nine cohort studies were suitable for inclusion in this review. Quality scores of the studies varied greatly. Three prospective studies, which used reliable indicators of periodontal disease, obtained the highest scores. Conversely, three studies that used a subjective evaluation of stroke incidence or diagnosed stroke without imaging obtained the lowest score. The results of the meta-analyses varied depending on the outcome considered and the type of stroke. The risk of stroke was significantly increased by the presence of periodontitis [relative risk 1.63 (1.25, 2.00)]. Tooth loss was also a risk factor for stroke [relative risk 1.39 (1.13, 1.65)]. The risk of stroke did not vary significantly with the presence of gingivitis. This review shows that periodontitis and tooth loss are associated with the occurrence of stroke.

Using e-learning to train dentists in the development of standardised oral health promotion interventions for persons with disability.

BACKGROUND: This study aims to evaluate whether an e-learning curriculum was sufficient to impart the necessary knowledge to dentists to allow them to implement an oral health promotion intervention in an institution for persons with disability. MATERIALS AND METHODS: Participants were asked to complete a 10-module online training course and to implement a standardised intervention in an institution. The outcome measures were as follows: online tracking of progress; multiple choice questionnaires completed at the end of most modules; self-efficacy questionnaire completed before and after online training; completion of training and calibration in the use of a standardised risk assessment form; initiation and full completion of an oral health promotion intervention in an institution; satisfaction of participants with the online training experience; and evaluation of the impact of the intervention by the institution staff. RESULTS: The study sample included 26 dentists. The 10 modules were passed by 24 dentists, and the mean value of the highest overall score recorded in the multiple questionnaires was 88.4% (± 4.0). Twenty participants completed the self-efficacy questionnaire before and after training; the mean values of scores after training were statistically different and higher than those at baseline. Questionnaire regarding satisfaction with the online training experience was completed by 22 participants; all of them stated that they were satisfied with the online training experience. CONCLUSIONS: The results indicate that the online training course helped participants to increase self-efficacy and to provide interventions in institutions. This study could have implications for both undergraduate and postgraduate dental education in France.

Response to interferon-Beta treatment in afro-caribbeans with multiple sclerosis.

Background. Multiple sclerosis (MS) patients of African ancestry have a more aggressive disease course than white patients and could be resistant to interferon-beta (INFB). Methods. We studied the impact of INFB in treatment-naive Afro-Caribbean (AC) with clinically definite MS using our European Database for Multiple Sclerosis (EDMUS) (2003-2010). Main outcome measures were annual relapse rate after 2 years of treatment, proportion of exacerbation-free subjects 48 weeks after initiating INFB, and time to first relapse. Results. 76 AC-MS (59F/17M) were identified. Annual relapse rate of 1.29 decreased to 0.83 (-35.6%) after 2 years of treatment. The proportion of relapse-free patients at 48 weeks was 46.2%. Median time to first relapse was 52 weeks. Conclusion. INFB is not strong enough to control AC-MS patients in many cases which is problematic in a population of worse MS prognosis.

Different HLA class II (DRB1 and DQB1) alleles determine either susceptibility or resistance to NMO and multiple sclerosis among the French Afro-Caribbean population.

BACKGROUND: Despite similarities, neuromyelitis optica (NMO) can be distinguished from multiple sclerosis (MS) by clinical, radiological and serological findings. OBJECTIVE: This case-control study aimed to determine whether patients with NMO or with MS in an Afro-Caribbean population originating from French West Indies shared the same or different HLA class I and II pattern distribution. METHODS: The association with HLA class II (DRB1 and DQB1) alleles was tested in 42 NMO patients, 163 MS patients and 150 healthy controls. HLA-DRB1 and DQB1 typing was undertaken on genomic DNA extracted from peripheral blood leucocytes. RESULTS: By comparison with healthy controls, significantly increased frequency of HLA-DRB1 03 (26.2% vs. 13%, odds ratio 2.4, 95% confidence interval 1.31-4.28, p after correction, cp 0.045) was observed in patients with NMO. By contrast, in MS patients, HLA-DRB1 15 (24.8% vs. 13%, odds ratio 2.21, 95% CI 1.45-3.36, cp < 0.0015), but not DRB1 03 allele, was positively associated with the disease. Moreover, a modest protective effect of HLA-DRB1 11 in the MS group, independently of DRB1 15 association, was found (13.7% vs. 7% in controls, odds ratio 0.48, p 0.006), but did not survive Bonferroni correction. CONCLUSION: In conclusion, comparison of the HLA-DRB1 and DQB1 distribution in NMO and MS in this Afro-Caribbean population shows important differences in the HLA associations among NMO and MS.

[Development and evaluation of an information leaflet for patients consulting an university hospital dental clinic]. / Elaboration et évaluation d'une plaquette d'information destinée aux patients consultant un service hospitalo-universitaire d'odontologie. Information en odontologie hospitalière.

BACKGROUND: Dental clinics in university hospitals have several roles; dental care is delivered to patients while dental students learn clinical practice. Patients are subjected thus to specific constraints in those mixed hospital-university structures. Patients should be informed of how these structures work and their consent must be carefully sought. Otherwise, patients could manifest their refusal to receive care by interrupting the treatment process. METHODS: This study was aimed to develop an information leaflet about the organisation of the dental clinic of the university hospital of Clermont-Ferrand. A quasi-randomised controlled study was conducted to evaluate the impact of this leaflet on patients' knowledge and absenteeism. The types of information to be included in the leaflet were determined using focus groups with patients, students and practitioners. The design, appropriateness and clarity of the leaflet were pilot tested among 30 patients. The evaluation of the impact of the leaflet was conducted among new patients who visited the dental clinic in 2007-2008. Patients were randomly allocated to three groups; one group (G1) received the leaflet at home by mail before the first visit, one group (G2) benefited from the leaflet during the first visit and one group (G3) did not receive the leaflet. The number of patients present at their appointment was recorded during the first visit (G1, G2, G3) and the second one (G2, G3). The knowledge of the patients about the dental clinic was evaluated by using a self-administered questionnaire before (except G1) and after reading the leaflet. RESULTS: The study population included 269 patients; 94 answered the two successive questionnaires (G1=32, G2=30, G3=31). At baseline, patients did not have sufficient knowledge about the way the dental clinic was functioning. The leaflet partly improved the level of knowledge of the patients when it was given during the first visit. About 25 % of the patients were not present at their appointment and this rate was not influenced by the distribution of the leaflet. CONCLUSION: The distribution of a leaflet, explaining the organisation of a university dental clinic, slightly improves the knowledge of new patients about this kind of care structure.

[Cannabis-induced cerebral and myocardial infarction in a young woman]. / Infarctus cérébral et myocardique après consommation de cannabis chez une femme jeune.

INTRODUCTION: Cannabis is the most consumed drug in the world particularly in young adults. Few reports have suggested a causal role of cannabis in the development of cerebral or cardiovascular events. We describe the first association of myocardial infarction and stroke after heavy cannabis consumption in a 45-year-old woman. OBSERVATION: Stroke occurred in relation with a right carotid and middle cerebral artery thrombosis after cannabis abuse. The patient was successfully treated with intravenous rt-PA. Two days after her admission, she presented a myocardial infarction due to a coronary thrombosis. Cerebral and coronary arteries were angiographically normal. Etiological tests were negative and a toxic cause in relation with cannabis consumption was concluded. CONCLUSION: Cannabis can be associated with vascular events by different mechanisms. Thrombosis may occur in cerebral and/or coronary arteries. We suggest that it might be useful to search for cannabis consumption systematically in young subjects victims of stroke and myocardial infarction.

Caries management decision: influence of dentist and patient factors in the provision of dental services.

OBJECTIVES: Little is known about how dentists implement caries management and provide restorative dental services in everyday practice. This study explored whether or not recent concepts in caries management were implemented in practice by private practitioners. The influence of patient and practitioner characteristics on the provision of restorative dental services was also investigated through multidimensional analyses. METHODS: A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth. The data collection form was designed to explore dentists' attitudes towards caries management and their use of minimally invasive therapies. RESULTS: Twenty-six practitioners recorded the characteristics of 921 treatments performed on 457 patients. Results indicate that participants rarely performed non-invasive treatments. They used an inappropriate detection tool, as most of decisions to treat were based on visual inspection frequently associated with probing. Multidimensional analysis showed that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice. CONCLUSIONS: Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors.

Dentists' experience with low-income patients benefiting from a public insurance program.

France has a system of public coverage that guarantees low-income earners full payment of basic dental health costs. In spite of this coverage and major needs for care, deprived populations have lower access to dental care. The aim of this qualitative study was to explore dentists' experience with low-income patients benefiting from the French universal healthcare coverage system. This study is based on 17 one-on-one semistructured interviews carried out with French private dentists. Dentists distinguished two categories of low-income patients: 'good patients', described as being regular attenders; and 'bad patients', whose main characteristic is irregular attendance. Dentists explained that they have difficulties in dealing with patients who do not keep their appointments. First, dentists feel that they fail in conducting their mission of being a care provider (therapeutic failure). The absence of the patient is also seen as a lack of recognition (relationship failure). Furthermore, dentists do not earn money when patients miss their appointments (financial failure). In this context, many dentists feel discouraged and powerless (personal failure). Moreover, dentists do not understand why patients renounce the dental-care opportunities offered under the system of public coverage (failure of the system). Dentists who repeatedly experience failures related to irregular attendance tend to adopt exclusion strategies.

Caries prevalence and fluoride use in low SES children in Clermont-Ferrand (France).

OBJECTIVE: To evaluate the association between dental caries experience and preventive behaviours of children residing in a deprived area in Clermont-Ferrand (France). PARTICIPANTS AND METHODS: All 4-5 yr-olds attending nine schools in deprived areas of the city were invited to participate and 81% (n=282) consented and were examined. Dental caries was recorded at the dentine threshold. Parents completed a questionnaire concerning family demographics and the child's use of fluoride. Non-parametric tests and logistic regression assessed the relative importance of SES and fluoride variables on dental status (dt>1). RESULTS: Fifty four (19%) of the examined children were living in families with an immigrant background, 33% were fully covered by the national health insurance programme for deprived families. Caries experience was high; mean dft was 1.94 (3.31) and 30% of the children had >1 carious teeth. Thirty percent of the families reported using fluoridated salt. Tooth brushing once daily was reported for 39% and twice daily for 26%. Parents declared supervising tooth brushing for 60%. Two thirds of the children, according to their parents, used fluoride supplement between birth and two years. Supervised tooth brushing was significantly correlated with lower mean dt scores. Systemic fluoride use was poorly related to dental caries Immigrant background, family size, type of health insurance and mother's unemployment were significantly correlated with caries prevalence. In multivariate analysis, immigrant status, supervised tooth brushing and parental knowledge about fluoride in toothpastes were significant caries predictors. CONCLUSIONS: The majority of low SES children did not practice effective caries prevention; few reported twice daily brushing with fluoride toothpaste. Caries experience was very high and much was untreated. Immigrant status, supervised tooth brushing and parental knowledge about fluoride in toothpastes were significant caries predictors.

[Actinomycosis: an unusual cause of spinal cord compression. Case report and review of the literature]. / Actinomycose : une cause rare de compression médullaire.

Actinomycosis is an unusual and unrecognized cause of spinal cord compression of infectious origin. We report the case of a 57-year-old immunocompetent woman admitted for sub-acute lower limb ataxia. The diagnosis of spinal cord compression secondary to actinomyces infectious arthritis was established. Surgical decompression and long-term antibiotic treatment enabled complete recovery. Data from the literature indicate that actinomycosis is a potential cause of several neurological manifestations. Unusual but treatable, actinomycosis is a potential alternative when the main etiologies have been ruled out.

Impact of disease-modifying treatments in North African migrants with multiple sclerosis in France.

BACKGROUND: Multiple Sclerosis in North African migrants (MS-NA) is more aggressive with mostly primary progressive forms and cerebellar symptoms. Despite an earlier onset in NA patients, the disease progresses more rapidly, with a higher proportion showing incomplete recovery from the first relapse, a shorter time between the first two relapses, a higher number of relapses in the first 5 years, and a shorter time to reach an EDSS of 4.0 and 6.0. We collected data and studied the impact of disease-modifying therapies (DMT) in NA patients with MS, among the 4144 MS patients treated in our MS clinics. METHODS: We performed a descriptive population-based study of MS-NA patients. Data were crossed with expected age- and gender-matched characteristics available in our EDMUS databases for the period 1995-2007. RESULTS: A total of 133 patients, representing 66% of the MS-NA patients included in the database were identified: mean age at the first documented symptom: 29.7 years; mean time from diagnosis to the beginning of DMT: 1.2 years. 40% of MS-NA patients had an EDSS >3 at the beginning of treatment (vs. 25%; P=0.002). A majority of patients were treated initially with immunomodulatory drugs (MS-NA: 48% vs. CT: 51%, P=0.8). NA patients were treated earlier after diagnosis (1.3 years vs. 4.5 years, P=0.003), with the frequent use of immunosuppressive drugs: for remitting forms, mitoxantrone (18.5% vs. 7.8%, P=0.0001) and for progressive forms, cyclophosphamide (38% vs. 28%, P=0.003). CONCLUSIONS: Considering EDSS follow-up during DMT, MS-NA patients appear as responsive as other MS patients to treatment, despite the earlier treatment prescription and the more frequent use of immunosuppressors.

[Characteristics of the patients needing emergency dental treatment at the hospital of Clermont-Ferrand (France)]. / Caractéristiques des patients ayant recours à l'unité d'urgence odontologique du CHU de Clermont-Ferrand (France).

BACKGROUND: Data on the profile of patients attending hospital dental emergencies units in France, and the activity of these units is scarce. Such knowledge is nevertheless necessary not only to optimize care, but also as the first step in a quality assurance process. METHODS: A cross-sectional study was conducted in the Clermont-Ferrand University Hospital dental emergencies unit to estimate its activity and ascertain the profile of the attending patients. The unit's computerized database was used to list the time distribution of the consultations as well as the profile of the patients attending in 2003 (N=2207). Furthermore, patients attending in February and March 2003 (N=383) completed a questionnaire about why they consulted and their regular dental follow-up. The emergency diagnoses as well as the treatment applied were also noted. RESULTS: The general profile of patients who attended the unit in 2003 was as follows: age of most patients 20-29 years, 52% of the patients were male, majority (85.4%) lived in Clermont-Ferrand or its suburbs, 13.5% had subsidized health insurance for disadvantaged people and 43% consulted the unit only when they suffered from a dental emergency. There were more consultations in the afternoons (59.2%) and their number decreased gradually during the week. The results from the questionnaire indicated that: pain (42%) and prosthetic problems (34%) were the most frequent reasons for consulting, 38.8% of the patients waited more than 7 days before attending and 50.8% had not seen a dentist in the previous year except in case of emergency. CONCLUSION: The patients attending the hospital units for dental emergencies have a special profile. These units should adapt care to the needs of attending patients who generally do not consult regular dental care facilities.