Dentists' Perceptions of Personal Infection Control Measurements in Response to COVID-19.

OBJECTIVE: To explore through focus groups (FGs) the perceptions of dental practitioners (DPs) from different countries of the challenges of implementing coronavirus disease 2019 (COVID-19) related biosafety measures, especially personal protection equipment (PPE), during the COVID-19 pandemic period. METHODS: DPs from Colombia, Germany, the United Kingdom, and the United States were invited to participate in country-based FGs. These were facilitated by an experienced moderator who explored the factors that guided the implementation of COVID-19 related biosafety measures and PPE use. Data were analyzed through thematic analysis on the basis of categories defined by the researchers deductively and inductively. RESULTS: A total of 25 DPs participated in 3 FGs (Colombia:n = 8; United Kingdom: n = 7; United States: n = 9) and 1 in an in-depth interview (Germany). DPs described using several processes to judge which guidance document to adopt and which aspects of the guidance were important in their practice. These included making judgments concerning the views of any indemnity organization to which the DPs were responsible, the staff's views in the practice, and the views of patients. In the absence of a single overarching guidance document, DPs filtered the available information through several considerations to find a level of PPE that they deemed "implementable" in local practice. CONCLUSIONS: The findings suggest that the implementation of evidence-based practice is subject to modification through a lens of what is "feasible" in practice. KNOWLEDGE TRANSFER STATEMENT: Clinicians, educators, and policy makers can use the results of this study to understand the process through which guidance is transformed into implementable patient care pathways in the dental practice.

Agreement in Medications Reported in Medical and Dental Electronic Health Records.

INTRODUCTION: The historical separation between medicine and dentistry has resulted in the creation of separate health records, which have the potential to negatively impact patient care and safety. Of particular importance, errors or omissions in medication lists in separate electronic health records (EHRs) may lead to medical errors and serious adverse outcomes. OBJECTIVE: This study aimed to compare medication lists reported in the EHRs of active patients treated by both the University of Michigan School of Dentistry and Michigan Medicine to determine if differences exist. METHODS: In this cohort study, EHRs of a population of 159,733 patients that the University of Michigan medical and dental clinics share in common were investigated for agreement in the reporting of 16 medications. After exclusion of minors and patients not seen in the last 5 y, records of 27,277 patients were examined. RESULTS: The maximum percentage of agreement in medications reported in both records was 52% for levothyroxine, and the minimum was 7% for sildenafil. The medical record had a significantly higher number of unique medications than the dental record, suggesting higher underreporting in the dental setting. CONCLUSION: The lack of agreement in the report of medications with serious dental and medical implications argues in favor of unification of records and use of available technology to increase accurate medication reporting. KNOWLEDGE TRANSFER STATEMENT: The results demonstrate a lack of agreement between medications reported in medical and dental records, which can have serious implications to patients' health. A unified health record, employing available technology to increase accurate medication reporting, would mitigate this problem.

In Silico Modeling of Hyposalivation and Biofilm Dysbiosis in Root Caries.

Root caries progression is aggravated by hyposalivation, which can accelerate the conversion of a dental biofilm from having a symbiotic microbial relationship with the host (predominance of nonaciduric species) to a dysbiotic one (dominated by aciduric species). Using a mathematical model previously employed to investigate factors associated with biofilm dysbiosis, we systematically explored the deleterious effect of hyposalivation on the composition of the biofilm and the risk of root dentin demineralization. By varying the clearance half-times of sugar (i.e., readily fermented dietary carbohydrates), we simulated hyposalivation and investigated its effect on 1) the time that the biofilm pH spends below the minimum for dentin or enamel demineralization and 2) the conversion of the biofilm from a symbiotic to dysbiotic composition. The effect of increasing sugar clearance half-times on the time that the biofilm pH is below the threshold for demineralization was more pronounced for dentin than for enamel (e.g., increasing the clearance half-time from 2 to 6 min doubled the time that the biofilm pH was below the threshold for dentin demineralization). The effect on biofilm composition assessed at 50 d showed that the conversion from a symbiotic to a dysbiotic biofilm happened around a frequency of 6 sugar intakes per day when the clearance half-time was 2 min but only 3 sugar intakes per day when the clearance half-time was 6 min. Taken together, the results confirm the profound effect that prolonged sugar clearance has on the dynamics of dental biofilm composition and the subsequent risk of root caries. This in silico model should be applied to study how interventions that alter salivary clearance rates or modify biofilm pH can affect clinical conditions such as root caries.

Post-allogeneic Hematopoietic Stem Cell Transplantation (HSCT) changes in inorganic salivary components.

Recent studies have considered the qualitative and quantitative assessment of salivary flow, as well the biochemical components of saliva, as possible biomarkers that might contribute to the pathogenesis of chronic graft-versus-host disease (cGHVD) in hematopoietic stem cell transplantation (HSCT) patients. The aim of this study was to evaluate prospectively the inorganic salivary status at different periods of allogeneic HSCT. Saliva collection and oral examination were performed prior to the HSCT, ​between days 8 and 10, days 80 and 100, and at the cGVHD onset. Concentrations of calcium (Ca), phosphate (Pi), chloride (Cl), magnesium (Mg), potassium (K), and sodium (Na) were performed using colorimetric reactions and atomic absorption. Fifty-five consecutive patients undergoing first allogeneic HSCT were included in this study. Between days 8 and 10, the salivary flow rate was significantly higher (p = 0.05), Pi concentration was decreased (p = 0.007), and Na and Cl were increased (p = 0.001 and p = 0.001, respectively), compared with the baseline. Salivary flow rate during the same period showed a negative correlation with Pi concentration (p = 0.02) and a positive correlation with Na and Cl concentrations (p = 0.003 and p = 0.001, respectively). The salivary flow rate was decreased between days 80 and 100 (p = 0.02) and Na, Cl, and K concentrations were increased (p = 0.03, p = 0.02, and p = 0.003, respectively). Salivary flow rate showed a negative correlation with Na and Cl (p = 0.01 and p = 0.013, respectively). At cGVHD onset, the salivary flow rate showed no statistical difference compared with the other studied periods. A trend was observed in the higher Na concentration compared with the baseline (p = 0.06) and Pi concentration presented a significant decrease (p = 0.004). Ca and Mg concentrations showed no changes during all evaluation periods. The present study showed changes in inorganic salivary components in post-HSCT periods, mainly during the early period post-HSCT and at the cGVHD onset. We speculate that Na, Cl, and Pi in saliva could be used as a potential biomarker in further studies.

A calcium prerinse required to form calcium fluoride in plaque from a sodium fluoride rinse.

The purpose of this study is to determine whether a calcium (Ca) prerinse used before a 228 µg/g (ppm) fluoride (F) rinse would induce the formation of 'calcium fluoride-like' (CaF2-like) deposits in human dental plaque. Sixty minutes after the use of the Ca prerinse/F rinse, plaque samples were collected from 10 volunteers, homogenized, and split into 2 aliquots. The plaque mass from one aliquot was then extracted with a 'plaque-like' solution that extracted all the CaF2-like deposits. The total F in both aliquots was then determined and compared. The results demonstrated that, as in previous studies, the Ca prerinse induced large increases in plaque fluid and total plaque F. However, unlike previous results without the Ca prerinse, 30% of the plaque F deposits were CaF2 or CaF2-like. Given that maintaining an elevated F concentration in the vicinity of a developing lesion may play an important role in the cariostatic effect of this ion, and the potential advantages of CaF2-like deposits as an F source, these results suggest that a Ca prerinse may increase the cariostatic effect of topical agents.

Comparing the efficacy of a dentifrice containing 1.5% arginine and 1450 ppm fluoride to a dentifrice containing 1450 ppm fluoride alone in the management of primary root caries.

OBJECTIVE: To compare the efficacy of a new dentifrice containing 1.5% arginine and 1450 ppm fluoride to a positive control dentifrice containing 1450 ppm fluoride alone in arresting and reversing primary root caries lesions in adults. STUDY DESIGN: A total of 3779 subjects from Piracicaba, Säo Paulo, Brazil were screened; 284 had at least one leathery primary root caries lesion and were eligible for the study. The new dentifrice contained 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride, as sodium monofluorophosphate; the matched positive control dentifrice contained 1450 ppm fluoride. One lesion for each subject was selected for inclusion in the study and was examined at baseline, 3 and 6 months. RESULTS: A total of 253 subjects completed the study with 129 of 144 subjects included in the final statistical analysis for the test dentifrice and 124 of 140 for the positive control. The mean age of subjects was 45.7 (±9.19) years and 56.5% were female. After 6 months product use, 70.5% of root caries lesions improved for subjects using the arginine-containing dentifrice compared to 58.1% for subjects using the positive control. The difference in the number of root caries lesions becoming hard in the two groups was statistically significant (p=0.038). CONCLUSION: A new dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride, as sodium monofluorophosphate, provided statistically significantly superior efficacy in arresting and reversing active root caries lesions in adults compared to a matched positive control dentifrice containing fluoride alone.

Fluoride gastrointestinal absorption from Na2FPO3/CaCO3- and NaF/SiO2-based toothpastes.

Depending on toothpaste formulation, part of the fluoride is insoluble and would not be totally absorbable in the gastrointestinal tract, thus changing dental fluorosis risk estimation. This hypothesis was tested with formulations with either all fluoride in a soluble form (NaF/SiO2-based toothpaste, 1,100 µg F/g as labeled, 1,129.7 ± 49.4 µg F/g soluble fluoride as analyzed) or with around 20% of insoluble fluoride (Na2FPO3/CaCO3-based toothpaste, 1,450 µg F/g as labeled, 1,122.4 ± 76.4 µg F/g soluble fluoride as analyzed). Toothpastes were evaluated either fresh or after accelerated aging, which increased insoluble fluoride to 40% in the Na2FPO3/CaCO3-based toothpaste. In a blind, crossover clinical trial conducted in five legs, 20 adult volunteers ingested 49.5 µg of total fluoride/kg body weight from each formulation or purified water (control). Whole saliva and urine were collected as bioavailability indicators, and pharmacokinetics parameters calculated showed significantly (p < 0.05) lower fluoride bioavailability for Na2FPO3/CaCO3 toothpaste, which was reduced further after aging. A significant correlation between the amount of soluble fluoride ingested, but not total fluoride, and fluoride bioavailability was found (r = 0.57, p < 0.0001). The findings suggest that the estimated fluorosis risk as a result of ingestion of Na2FPO3/CaCO3-based toothpastes should be calculated based on the toothpaste's soluble rather than total fluoride concentration.

Mineral ions in the fluid of biofilms formed on enamel and dentine shortly after sugar challenge.

To test the effect of distinct solubilities of dentine and enamel on mineral ion concentration in the biofilm fluid during a sugar-induced pH drop, dental biofilms were formed in situ for 4 days on acrylic (control), dentine or enamel. On the 5th day, they were treated with water (control) or 20% glucose and collected 5 min later. Significantly lower pH values and higher calcium concentrations were found in the biofilm fluid after glucose exposure, without significant differences among the three substrates. During pH drop, biofilm reservoirs release calcium to the fluid, masking the differential solubility between enamel and dentine.

Effect of acidulated phosphate fluoride gel application time on enamel demineralization of deciduous and permanent teeth.

Although the effect of acidulated phosphate fluoride gel (APF gel) on caries reduction in permanent teeth is based on evidence, the relevance of the clinical application time is still under debate. Also, the effect of 4- versus 1-min application has not been evaluated in deciduous enamel. In a blind, crossover, in situ study of 14 days, 16 adult volunteers wore palatal appliances containing slabs of human permanent and deciduous enamel. At the beginning of each phase, the slabs were submitted to one of the following treatments: no APF application (negative control); APF gel (1.23% F) application for 1 or 4 min. Biofilm accumulation on the slab surface was allowed and the slabs were subjected eight times a day to 20% sucrose, simulating a high cariogenic challenge condition. On the 15th day of each phase, fluoride retained as CaF(2) and fluorapatite (FAp) was determined on the enamel of the slabs and demineralization was assessed by cross-sectional microhardness. Fluoride as CaF(2) and FAp, formed by APF gel application on the enamel slabs not subjected to the cariogenic challenge, was also determined. APF gel reduced demineralization in both enamel types (p < 0.05), but the difference between 1 and 4 min was not statistically significant (p > 0.05). CaF(2) and FAp formed and retained on deciduous and permanent enamel was significantly higher in APF gel groups (p < 0.05), but no significant difference was found between 1 and 4 min (p > 0.05). The findings suggest that 1 min of APF gel application provides a similar effect on inhibition of demineralization as 4 min, for both permanent and deciduous enamel.

Use of professionally administered topical fluorides in Asia.

Professionally applied topical fluoride varnish, gel, and solution have been shown to be effective in preventing and in arresting dental caries. Their use in different countries in Asia varies greatly and may not correlate with the dental caries situation of the populations in the countries. In the higher-income countries, use of fluoride varnish and gel is common among dental professionals. In contrast, the use of professionally administered topical fluorides is not common in the lower-income countries. Fluoride varnish, being easy to apply and safe, has been the preferred agent for the prevention of early childhood caries, which is prevalent in many developing countries in Asia. The relatively high cost of professionally administered fluoride agents and the shortage of a dental workforce, especially in lower income countries, have hampered the widespread adoption of these effective caries prevention methods in the private and public dental services. Government health policies should be pursued to lower the cost of treatment, either through incentives for local production and/or elimination of taxes and tariffs on imported fluoride products.

Initial erosion models.

Initial dental erosion - the very first tooth surface changes caused by short-term acidic exposures before any tissue loss is observed - has been studied using in vitro and in situ/in vivo protocols. This paper describes the events that should be considered when modelling initial erosion, the available protocols and their strengths and limitations. In vitro initial erosion models can provide relevant information about the erosive outcome. However, the published studies vary considerably regarding the erosive parameters used, and few of these studies have been validated. On the other hand, relevant in situ/in vivo studies are available that have studied the effect of salivary pellicle and preventive treatments on initial erosion, as well as the changes in salivary pH following exposure to acid solutions. Guidelines for good methodology in modelling initial erosion are proposed.

APF and dentifrice effect on root dentin demineralization and biofilm.

Because dentin is more caries-susceptible than enamel, its demineralization may be more influenced by additional fluoride (F). We hypothesized that a combination of professional F, applied as acidulated phosphate F (APF), and use of 1100-ppm-F dentifrice would provide additional protection for dentin compared with 1100-ppm-F alone. Twelve adult volunteers wore palatal appliances containing root dentin slabs, which were subjected, during 4 experimental phases of 7 days each, to biofilm accumulation and sucrose exposure 8x/day. The volunteers were randomly assigned to the following treatments: placebo dentifrice (PD), 1100-ppm-F dentifrice (FD), APF + PD, and APF+FD. APF gel (1.23% F) was applied to the slabs once at the beginning of the experimental phase, and the dentifrices were used 3x/day. APF and FD increased F concentration in biofilm fluid and reduced root dentin demineralization, presenting an additive effect. Analysis of the data suggests that the combination of APF gel application and daily regular use of 1100-ppm-F dentifrice may provide additional protection against root caries compared with the dentifrice alone.

No calcium-fluoride-like deposits detected in plaque shortly after a sodium fluoride mouthrinse.

Plaque 'calcium-fluoride-like' (CaF(2)-like) and fluoride deposits held by biological/bacterial calcium fluoride (Ca-F) bonds appear to be the source of cariostatic concentrations of fluoride in plaque fluid. The aim of this study was to quantify the amounts of plaque fluoride held in these reservoirs after a sodium fluoride rinse. 30 and 60 min after a 228 microg/g fluoride rinse, plaque samples were collected from 11 volunteers. Each sample was homogenized, split into 2 aliquots (aliquots 1 and 2), centrifuged, and the recovered plaque fluid combined and analyzed using microelectrodes. The plaque mass from aliquot 1 was retained. The plaque mass from aliquot 2 was extracted several times with a solution having the same fluoride, calcium and pH as the plaque fluid in order to extract the plaque CaF(2)-like deposits. The total fluoride in both aliquots was then determined. In a second experiment, the extraction completeness was examined by applying the above procedure to in vitro precipitates containing known amounts of CaF(2)-like deposits. Nearly identical fluoride concentrations were found in both plaque aliquots. The extraction of the CaF(2)-like precipitates formed in vitro removed more than 80% of these deposits. The results suggest that either CaF(2)-like deposits were not formed in plaque or, if these deposits had been formed, they were rapidly lost. The inability to form persistent amounts of CaF(2)-like deposits in plaque may account for the relatively rapid loss of plaque fluid fluoride after the use of conventional fluoride dentifrices or rinses.

Kinetics of monofluorophosphate hydrolysis in a bacterial test plaque in situ.

Models to evaluate the anticaries potential of fluoride (F) formulations containing monofluorophosphate (MFP) should consider the release of F ion to the oral environment by its enzymatic hydrolysis. This was tested in situ, using a test plaque of a strain of Streptococcus mutans which presents high MFPase activity at pH 5.0. The test plaque was exposed to non-F or MFP (1,450 microg F/g) dentifrices and the fluid phase of the plaque was analyzed after 15, 30, 45 and 75 min. MFP concentration in the plaque fluid decreased over time after exposure to MFP dentifrice, but F ion reached 134.9 +/- 32.0 microM at 15 min and decreased significantly only at 75 min, suggesting continuous MFP hydrolysis by the test plaque.

Mechanism of fluoride dentifrice effect on enamel demineralization.

Although the anticaries effect of fluoride (F) dentifrices is clearly established, the relative importance of F taken up by dental plaque not removed by brushing and of F products (CaF(2)-like) formed on totally cleaned enamel for the subsequent inhibition of demineralization is not known. Both effects were evaluated using conventional (1,100 microg F/g) and low-F concentration (500 microg F/g) dentifrices in a randomized, crossover, double-blind in situ study. Enamel blocks not treated or pretreated with the dentifrices to form CaF(2)-like deposits were mounted in palatal appliances in contact with a Streptococcus mutans test plaque. Volunteers brushed with non-F (negative control), low-F or conventional dentifrices and inserted the appliance in the mouth. F concentration in the fluid and solid phases of the test plaque was determined after 30 min, and a rinse with 20% sucrose solution was performed. After additional 45 min, plaque was collected and the loss of surface hardness at different test-plaque depths was measured. CaF(2)-like deposition on enamel and F taken up by plaque due to the use of F dentifrices were able to significantly increase F concentration in the fluid phase of the test plaque, but only the latter significantly reduced the loss of hardness because of the 20-30 times higher F concentration. Also, significant differences between the low-F and conventional dentifrices were observed for F on enamel, in plaque and on the subsequent loss of hardness. The results suggest that uptake of F by dental plaque not removed by brushing may be the main cause of the anticaries effect of F dentifrices.

Fluoride release from CaF2 and enamel demineralization.

The anticaries effect of professional fluoride (F) application has been attributed to calcium-fluoride-like deposits (CaF(2)) formed on enamel, but this has not been clearly demonstrated. We hypothesized that CaF(2) formed on plaque-free enamel by F application would reduce enamel demineralization due to the increase of F availability in fluid of subsequently formed plaque. We created distinct levels of CaF(2) on enamel to evaluate a dose-response effect. Enamel blocks were mounted in contact with a S. mutans test plaque and used in situ by 10 volunteers. F released to the fluid phase of this substrate ("plaque fluid") was measured before a cariogenic challenge. "Plaque fluid" F concentration was highly correlated to the enamel CaF(2) concentration (r = 0.96, p < 0.001) and to consequent enamel demineralization (r = -0.75, p < 0.001). The results suggest that F released to plaque fluid from CaF(2) formed on enamel may play a significant role in the anticaries effect of professionally applied F agents.

Effect of starch and sucrose on dental biofilm formation and on root dentine demineralization.

The cariogenicity of starch alone or in combination with sucrose is controversial and the effect on dentine demineralization and on the dental biofilm formed has not been explored under controlled conditions. A crossover, single-blind study was conducted in four steps of 14 days each, during which 11 volunteers wore palatal appliance containing 10 slabs of root dentine to which the following treatments were applied extraorally: 2% starch gel-like solution (starch group); 10% sucrose solution (sucrose group); a solution containing 2% starch and 10% sucrose (starch + sucrose group), or 2% starch solution followed by 10% sucrose solution (starch --> sucrose group). On the 14th day of each phase the biofilms were collected for biochemical and microbiological analyses, and dentine demineralization was assessed by hardness. A higher demineralization was found in dentine exposed to sucrose and starch sucrose combinations than to starch alone (p < 0.01), but the sucrose-containing groups did not differ significantly from each other (p > 0.05). The concentrations of soluble and insoluble extracellular polysaccharides (EPS), and the proportion of insoluble EPS, were lower in the biofilm formed in presence of starch (p < 0.01) than in those formed in the presence of sucrose or sucrose/starch combinations; however, no significant difference was observed among the groups containing sucrose (p > 0.05). RNA was successfully isolated and purified from in situ biofilms and only biofilms formed in response to sucrose and starch/sucrose combinations showed detectable levels of gtfB and gtfC mRNA. The findings suggest that the combination of starch with sucrose may not be more cariogenic to dentine than sucrose alone.

Effect of microleakage and fluoride on enamel-dentine demineralization around restorations.

There is no consensus about an association between microleakage and secondary caries, especially considering the presence of fluoride (F) at the tooth/restoration interface. Thus, a randomized, double-blind, crossover study was carried out to evaluate in situ the effect of microleakage on caries around enamel-dentine restorations in the presence of F from dental materials or dentifrice, either alone or in combination. In 4 phases of 14 days each, 14 volunteers wore palatal devices containing dental slabs restored with composite resin (CR) or resin-modified glass ionomer cement (GI). Restorations were made without leakage (L-), following the recommended adhesive procedures, or with leakage (L+), in the absence of adhesive procedures. Plaque-like biofilm (PLB) was left to accumulate on the restored slabs, which were exposed extraorally to a 20% sucrose solution 10x/day. The volunteers used a non-F (NF) or an F (FD) dentifrice 3x/day, depending on the experimental phase. No differences were found between L+ or L- restorations (p > 0.05). Higher demineralization in both enamel and dentine around CR restorations was observed under NF (p < 0.05). F concentration was higher in the fluid of PLB exposed to FD or formed onto GI restoration (p < 0.05). These results suggest that while microleakage does not affect caries development, GI or FD may maintain increased F levels in the PLB, thereby decreasing caries progression.