Optimizing radiation safety in dentistry: Clinical recommendations and regulatory considerations.

BACKGROUND: The value of dental radiographs to oral health care decision making must be balanced with radiation safety to minimize patient exposure and occupational risk of oral health care providers. This review summarizes recommendations and regulatory guidance regarding dental radiography and cone-beam computed tomography. An expert panel presents recommendations on radiation safety, appropriate imaging practices, and reducing radiation exposure. TYPES OF STUDIES REVIEWED: A systematic search run in Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews identified relevant topical systematic reviews, organizational guidelines, and regulatory reviews published in the peer-reviewed literature since 2010. A supplemental search of the gray literature (eg, technical reports, standards, and regulations) identified topical nonindexed publications. Inclusion criteria required relevance to primary oral health care (ie, general or pediatric dentistry). RESULTS: A total of 95 articles, guidance documents, and regulations met the inclusion criteria. Resources were characterized as applicable to all modalities, operator and occupational protection, dose reduction and optimization, and quality assurance and control. PRACTICAL IMPLICATIONS: Understanding factors affecting imaging safety and applying fundamental principles of radiation protection consistent with federal, state, and local requirements are essential for limiting patient ionizing radiation exposure, in conjunction with implementing optimal imaging procedures to support prudent use of dental radiographs and cone-beam computed tomographic imaging. The regulatory guidance and best practice recommendations summarized in this article should be followed by dentists and other oral health care providers.

Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association.

BACKGROUND: An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth. TYPES OF STUDIES REVIEWED: The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations. RESULTS: The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios. PRACTICAL IMPLICATIONS: The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

Barriers to oral health care for transgender and gender nonbinary populations.

BACKGROUND: Despite health disparities and barriers to medical care being well documented in the literature, transgender and gender nonbinary (TGNB) people's experiences and expectations with regard to oral health care remain understudied. The authors examined gender identity-related factors influencing experiences in the dental setting, aspects of subjective oral health, and avoidance of oral health care. METHODS: One-hundred eighteen TGNB people aged 13 through 70 years completed a 32-item questionnaire designed for this study. Data analysis relied on descriptive methods and bivariate comparisons using a conventional P < .05 statistical significance criterion. Qualitative description analysis was used to identify emerging themes from responses to an open-ended question. RESULTS: One-third of participants reported misgendering (that is, had been addressed by their incorrect name and pronouns in the dental setting). Although refusal of oral health care was rare in this sample of TGNB participants, more than one-half felt that their usual source of oral health care was not equipped to provide gender-appropriate care. Participants' avoidance due to gender identity was significantly associated with measures of self-reported suboptimal oral health. Common themes related to participants' oral health care experiences included gender insensitivity, awkward interactions, avoidance of care, and lack of gender-affirming providers. CONCLUSIONS: Discrepancies between TGNB patients' expectations and actual experiences suggest that their needs are often unmet in the dental setting, possibly contributing to gender identity-associated dental avoidance and oral health disparities. PRACTICAL IMPLICATIONS: Although these results need to be verified in larger and more diverse samples, they provide actionable information for improvement to this population's oral health and management.

Direct materials for restoring caries lesions: Systematic review and meta-analysis-a report of the American Dental Association Council on Scientific Affairs.

BACKGROUND: The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth. TYPE OF STUDIES REVIEWED: The authors included parallel and split-mouth randomized controlled trials comparing the effectiveness of direct restorative materials commercially available in the United States placed in vital, nonendodontically treated primary and permanent teeth. Pairs of reviewers independently conducted study selection, data extraction, and assessments of risk of bias and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The authors conducted pair-wise meta-analyses to summarize the evidence and calculated measures of association and their 95% CIs. RESULTS: Thirty-eight randomized controlled trials were eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass isomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Owing to a relatively low event rate across various outcomes indicating restoration failure, there was limited evidence to support important differences between direct restorative materials used in practice.

Teledentistry Implementation in a Private Pediatric Dental Practice During the COVID-19 Pandemic.

Purpose: (1) Implementation of teledentistry in a private pediatric practice during COVID-19 pandemic, (2) Evaluate dental care that was assessed and managed during the COVID-19 pandemic. Methods: Urgent dental care provided during the recommended deferment of elective dentistry (3/16/20-5/17/20) was documented. Encounters were documented by type and management (conventional vs. teledentistry). Results were summarized using descriptive statistics. Associations were compared with Chi-squared or Fisher's exact test. Results: There were 137 emergency patient encounters during the study period. The types were: orthodontics (32 percent), caries (22 percent), eruption concerns (18 percent), trauma (16 percent), "other" (12 percent) (i.e., ankyloglossia, aphthous ulcers). Almost half (48 percent) were managed with teledentistry. The highest utilization of conventional dentistry was caries (70 percent), and for teledentistry was "Other" (75 percent) and eruption concerns (60 percent). Conclusion: Nearly half of emergency encounters in this sample were managed with teledentistry. Teledentistry was a necessary modality of care during the beginning of the COVID-19 pandemic and has uses and implications beyond the triage of acute dental emergencies.

Tooth Eruption and Early Childhood Caries: A Multisite Longitudinal Study.

Purpose: The purpose of this study was to assess the relationship between the number of teeth present at 12 months and decayed, missing, or filled surfaces (dmfs) at 30 and 48 months. Methods: Data are from a longitudinal, multisite study with clinical dental examinations conducted at 12, 30, and 48 months of age. Spearman correlation and chi-square tests assessed relationships between teeth present at 12 months and dmfs at 30 (n equals 1,062) and 48 months (n equals 985). Results: Spearman correlations were weak but significant for both 30- and 48-month time points (R equals 0.066, P=0.032; R equals 0.093, P=0.004, respectively). Mantel-Haenszel chi-square analyses of categories of teeth present at 12 months (zero, one to four, five to eight, and greater than or equal to nine) and categories of dmfs at 30 and 48 months (zero, one to two, three to five, six to 15, and greater than or equal to 16) revealed nonsignificant (P=0.326) relationship with 30-month dmfs but a significant (P=0.013) relationship with 48-month dmfs. Conclusion: Results suggest that early tooth eruption is weakly associated with an occurrence of early childhood caries.

Child Nutrition Patterns Are Associated with Primary Dentition Dental Caries.

Purpose: Diet is a well-established, modifiable factor influencing dental caries risk. However, evidence regarding its association with distinct clinical patterns of dental caries is lacking. The purpose of this study was to identify the association of child nutrition patterns with two distinct clinical presentations (subtypes) of childhood dental caries. Methods: The study sample comprised 120 children who were patients of a private pediatric dental practice: 30 ages one to three years (mean equals 2.2 years) with anterior carious lesions; 30 ages four to 12 years (mean equals six years) with posterior-only carious lesions; and 60 age-, gender-, and payment method-matched caries-free controls. Participants underwent dental examinations, and their guardians completed a 17-item nutrition frequency questionnaire. A latent profile analysis was used to define distinct dietary patterns and, subsequently, test their association with dental caries subtypes. Results: Dietary patterns were differentiated by consumption frequencies of water and cariogenic solid, soft, and liquid food items; a diet cluster characterized by frequent consumption of fruit juice, cereal bars, and daily vitamins was more common (P<0.05) among one- to three-year-old patients with anterior carious lesions compared to matched caries-free controls. Conclusions: These results affirm the key role of dietary patterns in childhood oral health and demonstrate the influence of fermentable carbohydrates on specific clinical subtypes of caries.

Influence of Temperament As a Risk Indicator for Early Childhood Caries.

Purpose: To evaluate the association between temperament and caries. Methods: A total of 408 primary caregiver-child pairs were followed for 36 months; they completed the Early Childhood Behavior Questionnaire Very Short-Form (ECBQ-VSF) at age four years. Demographic, behavioral, and clinical data were obtained at ages one, two-and-a-half, and four years, with caries experience assessed each time using the International Caries Detection and Assessment System (ICDAS). The ECBQ-VSF (36 items) was used to measure three child temperament domains: (1) surgency; (2) negative affect; and (3) effortful control. The associations between cavitated carious lesion experience by age four years (decayed, missing, and filled primary surfaces [dmfs] score greater than zero; d equals ICDAS score greater than or equal to three) and the three ECBQ-VSF temperament domains were analyzed using generalized estimating equation models. Results: Temperament domains predicted the number of carious surfaces (dmfs). After adjusting for covariates, every one-point increase in surgency and one-point increase in negative affect were associated with 77 percent and 31 percent increases in dmfs, respectively (P<0.05), and every one-point increase in effortful control was associated with a 39 percent decrease in dmfs (P<0.05). Conclusions: By age four years, children with higher levels of surgency and negative affect have a higher caries experience, whereas children with greater effortful control have a lower caries experience.

Fluoride Use in Caries Prevention in the Primary Care Setting.

Dental caries remains the most common chronic disease of childhood in the United States. Caries is a largely preventable condition, and fluoride has proven effectiveness in caries prevention. This clinical report aims to clarify the use of available fluoride modalities for caries prevention in the primary care setting and to assist pediatricians in using fluoride to achieve maximum protection against dental caries, while minimizing the likelihood of enamel fluorosis. Fluoride varnish application is now considered the standard of care in pediatric primary care. This report highlights administration, billing, and payment information regarding the fluoride varnish procedure.

Dental Caries Risk Varies Among Subgroups of Children with Special Health Care Needs.

Purpose: Currently, caries risk assessment tools consider all children with special health care needs in tandem. The purpose of this study was to test this assumption by examining caries risk among and within five distinct groups of children, most with special health care needs (CSHCN): (1) autism (ASD); (2) congenital heart disease (CHD); (3) cerebral palsy (CP); (4) Down syndrome (DS); and (5) a control (non-CSHCN) group. Methods: A retrospective longitudinal cohort of 150 patients (30 per group) from a private pediatric dental practice was assembled, and information on caries diagnoses and 21 postulated caries risk factors from clinical records was extracted. Bivariate tests and multivariable Poisson regression modeling were used to estimate the caries incidence rate (IR), ratio (IRR), and 95 percent confidence interval (CI). Results: CSHCN had a higher caries burden and caries risk (IR equals 0.049 per person per year) compared to the control group (IR equals 0.033). Caries risk was nearly double among CHD (IRR equals 1.9 [95 percent CI equals 0.72 to 5.2] versus controls) compared to DS (IRR equals 1.04 [95 percent CI equals 0.38 to 2.9]). Visible cavities or fillings was the only significant risk factor, yet it did not alter the between-CSHCN group (i.e., CHD greater than DS, controls) caries risk heterogeneity. Conclusions: Children with special health care needs comprise a heterogeneous group that must be treated in a precise, diagnosis-specific manner in caries risk assessment. Caries experience in the primary dentition was the only significant predictor of permanent dentition caries incidence. (Pediatr Dent 2019;41(5):378-84).

Personalized Dental Caries Management in Children.

This article reviews dental caries management in children. The goal is to help clinicians recognize common patterns of dental caries in primary dentition and make appropriate decisions regarding management of carious lesions in children, taking into account the best available evidence, clinician expertise and experience, and a child's treatment needs, age, medical history, and ability to tolerate treatment as well as caregiver preferences. It also is important to protect the developing psyche of the child, stabilize or restore the dentition to health and natural esthetics when possible, and maintain space for the eruption of the future permanent dentition.

Management of After-Hours Pediatric Dental Emergencies Among Pediatric and General Dentists.

Purpose: Assess how pediatric dentists (PD) and general practitioners (GP) manage after-hours pediatric dental emergencies according to perceived urgency. Methods: A survey was e-mailed to PD and GP in North Carolina. Participants responded to management of 18 cases (primary and permanent dentition) according to perceived urgency. Repeated-measures logistic regression was used to analyze factors influencing perception of clinical scenarios. Results: Response rates for PD and GP were 45.5% and 36.3%, respectively. Perceived urgency varied by clinical scenarios, dentition (primary vs. permanent), and practitioner (PD vs. GP) (P<.001). Practitioners with fewer years in practice or seeing fewer pediatric patients managed more cases as urgent. Traumatic injuries in primary dentition (intrusion, pulp exposure, palatal displacement, avulsion) were managed as more urgent by GP than PD (P<.001). Emergencies related to infection and permanent dentition were perceived similarly by PD and GP. Conclusions: Clinical scenarios highlighted disagreement in the management of after-hours pediatric dental emergencies between GP and PD, especially trauma in primary dentition. General practitioners tended to refer to an ED or see urgently, and PD tended to defer care. By identifying needs for improved education in dental trauma management, we can increase utilization of the dental home, avoiding use of overburdened EDs.

Looking beyond the exome: a phenotype-first approach to molecular diagnostic resolution in rare and undiagnosed diseases.

PurposeTo describe examples of missed pathogenic variants on whole-exome sequencing (WES) and the importance of deep phenotyping for further diagnostic testing.MethodsGuided by phenotypic information, three children with negative WES underwent targeted single-gene testing.ResultsIndividual 1 had a clinical diagnosis consistent with infantile systemic hyalinosis, although WES and a next-generation sequencing (NGS)-based ANTXR2 test were negative. Sanger sequencing of ANTXR2 revealed a homozygous single base pair insertion, previously missed by the WES variant caller software. Individual 2 had neurodevelopmental regression and cerebellar atrophy, with no diagnosis on WES. New clinical findings prompted Sanger sequencing and copy number testing of PLA2G6. A novel homozygous deletion of the noncoding exon 1 (not included in the WES capture kit) was detected, with extension into the promoter, confirming the clinical suspicion of infantile neuroaxonal dystrophy. Individual 3 had progressive ataxia, spasticity, and magnetic resonance image changes of vanishing white matter leukoencephalopathy. An NGS leukodystrophy gene panel and WES showed a heterozygous pathogenic variant in EIF2B5; no deletions/duplications were detected. Sanger sequencing of EIF2B5 showed a frameshift indel, probably missed owing to failure of alignment.ConclusionThese cases illustrate potential pitfalls of WES/NGS testing and the importance of phenotype-guided molecular testing in yielding diagnoses.

Dental Emergency Practice Characteristics Among North Carolina Pediatric and General Dentists.

PURPOSE: The purpose of this study was to assess after-hours practice characteristics of pediatric dentists (PDs) and general dentists (GDs) and determine how patients-of-record obtain after-hours emergency dental care. METHODS: A 29-item survey was electronically distributed to PDs and GDs in North Carolina in September 2014. Demographics and after-hours emergency practice characteristics were assessed. Survey respondents were subsequently called after-hours to validate reported after-hours emergency protocol. Descriptive and bivariate statistics compared responses from PDs and GDs. Concordance between survey and telephone responses was analyzed. RESULTS: Eighty-six (46 percent) PDs and 1,199 (36 percent) GDs completed the survey; 86 (100 percent) and 1,015 (85 percent) met inclusion criteria, respectively. Most dentists allowed patients to reach them via pager/cell phone after-hours (82.1 percent of PDs, 72.8 percent of GDs; P=0.04). More PDs than GDs had established after-hours emergency protocols (95.3 percent versus 56.7 percent, P<0.001), practiced in a group (71.1 percent versus 40.9 percent, P<0.001), and shared call (64.0 percent versus 30.1 percent, P<0.001). Telephone and survey responses significantly differed for GDs (P<0.001) but not PDs (P=0.14). CONCLUSIONS: After-hours emergency care is an important component of a comprehensive dental home. More pediatric dentists than general dentists provided after-hours emergency dental care. Survey and telephone responses were more consistent and favorable for PDs than GDs. This highlights gaps in emergency dental practice and breakdown of the dental home.

De Novo Truncating Variants in ASXL2 Are Associated with a Unique and Recognizable Clinical Phenotype.

The ASXL genes (ASXL1, ASXL2, and ASXL3) participate in body patterning during embryogenesis and encode proteins involved in epigenetic regulation and assembly of transcription factors to specific genomic loci. Germline de novo truncating variants in ASXL1 and ASXL3 have been respectively implicated in causing Bohring-Opitz and Bainbridge-Ropers syndromes, which result in overlapping features of severe intellectual disability and dysmorphic features. ASXL2 has not yet been associated with a human Mendelian disorder. In this study, we performed whole-exome sequencing in six unrelated probands with developmental delay, macrocephaly, and dysmorphic features. All six had de novo truncating variants in ASXL2. A careful review enabled the recognition of a specific phenotype consisting of macrocephaly, prominent eyes, arched eyebrows, hypertelorism, a glabellar nevus flammeus, neonatal feeding difficulties, hypotonia, and developmental disabilities. Although overlapping features with Bohring-Opitz and Bainbridge-Ropers syndromes exist, features that distinguish the ASXL2-associated condition from ASXL1- and ASXL3-related disorders are macrocephaly, absence of growth retardation, and more variability in the degree of intellectual disabilities. We were also able to demonstrate with mRNA studies that these variants are likely to exert a dominant-negative effect, given that both alleles are expressed in blood and the mutated ASXL2 transcripts escape nonsense-mediated decay. In conclusion, de novo truncating variants in ASXL2 underlie a neurodevelopmental syndrome with a clinically recognizable phenotype. This report expands the germline disorders that are linked to the ASXL genes.

A policy review of after-hours emergency dental care responsibilities.

OBJECTIVES: To examine professional guidelines and/or requirements of state and national dental organizations regarding the responsibility of dentists for after-hours emergency care. METHODS: Guidelines of national dental professional organizations, specialties, and all 50 state dental boards were examined for language pertaining to after-hours emergency care. Guidelines were categorized as: a) no guidelines; b) deferral to American Dental Association (ADA) guidelines; c) specific guidelines outlined. RESULTS: Most states and national guidelines were similar to the ADA: dentists are obliged to make reasonable arrangements for the emergency dental care of patients of-record and not-of-record. Oral surgery maintains the most stringent guidelines of all specialties. Results of the 50 states reviewed: no guidelines-16 states (32 percent), deferral to ADA guidelines-21 states (42 percent), and specific guidelines outlined-13 states (26 percent). CONCLUSIONS: Current after-hours emergency guidelines are nonspecific and open to interpretation. Variability between state guidelines likely contribute to unnecessary hospital emergency visits and increased healthcare costs, undermining the goal of establishing and maintaining dental homes.

Coordinated Pediatric and Periodontal Dental Care of a Child with Down syndrome.

The purpose of this report was to describe the management of an eight-year-old Bulgarian male with Down syndrome presenting with periodontitis as a manifestation of systemic disease in the early mixed dentition. Treatment involved full-mouth mechanical debridement and extraction of hopeless teeth under general anesthesia followed by systemic antibiotics and chemical adjunctive therapy. Microbial culture and sensitivity testing aided in diagnosis and guided treatment decisions. This case report demonstrates a multidisciplinary approach in the management of aggressive periodontal disease in an internationally adopted pediatric patient with special health care needs.