Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age.

OBJECTIVE: This paper analyzes reports to the American Association of Poison Control Centers (AAPCC) of suspected overingestion of fluoride by children younger than 6 years of age between 1989 and 1994, and estimates the probably toxic amounts of various home-use fluoride products in children younger than 6 years of age. METHODS: Annual incidence rates of reported fluoride exposures attributed to dietary supplements, toothpaste, and rinses were calculated. Probably toxic amounts of each product were calculated using the frequently cited dose of 5 mg/kg. RESULTS: Children younger than 6 years of age accounted for more than 80 percent of reports of suspected overingestion. While the outcomes were generally not serious, several hundred children were treated at health care facilities each year. A 10 kg child who ingests 50 mg fluoride (10.1 g 1.1% NaF gel; 32.7 g 0.63% SnF2 gel; 33.3 g 1,500 ppm F toothpaste; 50 g 1,000 ppm F toothpaste; and 221 mL 0.05% NaF rinse) will have ingested a probably toxic dose. CONCLUSIONS: Overingestion of fluoride products in the home is preventable. Dentists and other health care providers should educate parents and child care providers about the importance of keeping fluoride products out of reach of children. Manufacturers should be encouraged by the ADA and the FDA to use child-resistant packaging for all fluoride products intended for use in the home.

The prevalence of recurrent herpes labialis during an army hot weather exercise.

A survey was performed on 1,062 of 2,500 (42%) Army personnel participating in a desert training exercise at Fort Irwin, California, in September 1983. The prevalence of recurrent herpes labialis (RHL) and chapped lips was observed during the third week of a four-week training period. Complexion, sex, lip protectant use, age, and time spent outdoors were obtained by observation and interview. Recurrent herpes labialis was found in 46 subjects (4%). Stratified analysis and stepwise logistic regression were used to identify risk factors associated with RHL and to determine the prevalence odds ratios (POR). Risk factors with statistically significant associations with RHL were lip protectant use (POR = 0.19), chapped lips (POR = 2.87), being female (POR = 5.00), and light complexion (POR = 2.48). These findings strongly support the use of lip protectants during prolonged exposure to hot, dry climates as a prophylaxis against recurrent herpes labialis. Additional studies should focus on excitatory factors of RHL; and clinical trials of the efficacy of the lip protectants to protect against RHL and chapped lips should be undertaken.

Dental public health for the 21st century: implications for specialty education and practice.

A panel of public health practitioners sponsored by the Health Resources and Services Administration met December 6-8, 1994, to examine current roles and responsibilities for dental public health workers and to recommend changes in education and training to meet challenges posed by an evolving health care system. Overall, at least the same number, if not more, dental public health personnel will be needed in the future. While some new roles were identified, the panel felt that only small numbers of personnel will be needed to fill these new roles. Not all of these roles necessarily require a dental degree. The panel felt that a need exists for more academicians for dental schools, schools of public health, dental public health residencies, and dental hygiene programs; oral epidemiologists and health services researchers; health educators; and specialists in utilization review/outcomes assessment, dental informatics, nutrition, program evaluation, and prevention. To meet these personnel needs: (1) dental public health residency programs should be structured to meet the educational needs of working public health dentists with MPH degrees through on-the-job residency programs; (2) the standards for advanced specialty education programs in dental public health should be made sufficiently flexible to include dentists who have advanced education and the requisite core public health courses; (3) flexible MPH degree programs must be available because of the rising debt of dental students and the decreased numbers of graduating dentists; (4) loan repayment should be available for dentists who have pursued public health training and are working in state or local health departments; and (5) standards for advanced education in dental public health should be developed for dental hygienists.

Perceived needs for dental continuing education within the Army dental care system.

Results of a worldwide survey examining the perceived needs for continuing education (CE) among Army general dentists and their supervisors are presented. Responses from 255 supervisors and 528 dentists were available for analysis. There was overall lack of agreement between supervisors and dentists concerning CE preferences; supervisors selected risk or clinic management topics and dentists chose patient care topics. Years of practice, practice location, and advanced general dentistry program participation strongly influenced dentists' perceived needs. Results suggest that in evaluating or planning for CE programs, differences in perceived needs between various groups within the dental care system must be considered.

Treatment needs and treatment time for soldiers in dental fitness class 2.

A systematic random sample of 962 dental records of soldiers in class 2 was reviewed by six general dentists and their estimates of periodontal and non-periodontal treatment time were recorded. The majority (88.9%) required some treatment. Periodontal treatment time ranged from 0 to 18 hours with a median and mode of 0 hours, a mean of 1.18 hours, and a standard deviation of 2.96 hours. Non-periodontal treatment time ranged from 0 to 58 hours with a median of 3 hours, a mode of 0 hours, a mean of 4.51 hours, and a standard deviation of 5.11 hours. When consultation time is included, the total time was 5.89 hours per soldier.

The prevalence of chapped lips during an army hot weather exercise.

OBJECTIVES: To identify risk factors associated with chapped lips in soldiers during prolonged exposure to a hot, dry environment. METHODS: We examined 1,053 of 2,500 soldiers (42%) participating in a desert training exercise at Fort Irwin, California, in September 1983. We measured the prevalence of chapped lips during the third week of a 4-week training period. Our independent variables (complexion, sex, lip protectant use, age, and the prevalence of recurrent herpes labialis) were obtained by observation and interview. RESULTS: We found severe chapping in 150 (10%) and moderate chapping in 247 (23.5%) of the soldiers. Stepwise ordinal logistic regression was used to identify risk factors associated with chapped lips and to determine the prevalence odds ratios (OR). Risk factors with statistically significant associations with chapped lips were the presence of recurrent herpes labialis (OR = 2.88), very fair complexion (OR = 3.23), and fair complexion (OR = 1.58). CONCLUSIONS: Moderate to severe chapping occurred in approximately one-third of the soldiers. Lip protectants appeared to be relatively ineffective in the prevention and treatment of chapped lips but were associated with a lower prevalence of recurrent herpes labialis.

Carpal tunnel syndrome: effect on Army dental personnel.

The purpose of this study was 2-fold: (1) to determine the prevalence of hand problems, in particular carpal tunnel syndrome (CTS), among Army dental personnel; and (2) to identify dental professionals at risk. A 12-page survey was mailed to all U.S. Army military and civilian dental personnel. Of the 6,320 surveys mailed, 80.9% were returned completed. An analysis was performed identifying the prevalence of hand problems and CTS and noting differences between civilian and military dental personnel. Of the 5,115 surveys analyzed, 44.8% indicated hand problems and 25.4% were determined to indicate a high probability of CTS. Of the 18 dental job specialties, dental therapy assistants and dental hygienists had the highest prevalence of CTS, 73% and 57%, respectively. Army dental personnel are at greater risk of developing CTS than the general public, especially civilian dental personnel, who were female, older, and employed longer.

A comparison of dental fitness classification using different class 3 criteria.

Examinations were performed on 585 Army Reserve Component soldiers during their 2-week Annual Training at Fort Pickett, Virginia, from June through September 1991. Of the 585 soldiers examined, 338 (57.8%) were in class 3 using the current DoD criteria, while 272 (46.5%) were in class 3 using the previous criteria. Of 585 paired examinations, there was agreement between the two systems in 531 (90.8%) examinations. Over 96% of the disagreement represented patients put in class 2 under the old system who were put in class 3 under the new system. In the aggregate, there were 19.3% more soldiers put into class 3 under the new system. The major source of this difference was partially erupted or pericoronally involved third molars. The increase in the class 3 proportion is due to the lack of operational criteria in the old system. Data collected under the current system provide more detailed information for administrative epidemiologic purposes. Because of the additional clinical guidelines under the current DoD criteria, the inevitable differences should be considered when pre- and post-DoD instruction dental fitness classification data are compared for a population.

Restoring teeth that are endodontically treated through existing crowns. Part II: Survey of restorative materials commonly used.

OBJECTIVE: A survey was undertaken to categorize the materials used for the restoration of endodontic access openings through complete-coverage crowns after completion of nonsurgical root canal treatment. METHOD AND MATERIALS: The survey package consisted of a cover letter stating instructions, rationale, and purpose for the questionnaire, a questionnaire of 8 short-answer questions, and a stamped, self-addressed envelope. A randomized sample of active dentists (300 general practitioners, 300 prosthodontists, and 300 endodontists), was selected. Collected data were analyzed with the chi-square analysis. RESULTS: Most general practitioners (93%), endodontists (61%), and prosthodontists (75%) reported that they frequently or always permanently restore teeth after nonsurgical root canal treatment. Empress was the all-ceramic system used most commonly by prosthodontists (42%) and general practitioners (38%). A statistically significant difference in restorative material preference was found (P < 0.0001), depending on the type of crown used. CONCLUSION: Amalgam alone and in combination with bonding agents are materials of choice for restoration of access openings through all-metal complete crowns, while resin composite is the choice for all types of complete crowns involving porcelain. Endodontists preferred "other" materials.

Restoring teeth that are endodontically treated through existing crowns. Part I: Survey of pulpal status on access.

OBJECTIVE: The purpose of this study was to identify the pulpal findings encountered by practitioners when accessing complete-coverage crowns that require nonsurgical root canal treatment and the relevance of coronal leakage to the success of the RTC. METHOD AND MATERIALS: The survey package consisted of a cover letter stating the instructions, rationale, and purpose for the questionnaire, a questionnaire with 8 short-answer questions, and a stamped, self-addressed envelope. A randomized sample of active dentists (300 general practitioners, 300 prosthodontists, and 300 endodontists) was selected. Collected data were analyzed with the chi-square test. RESULTS: A 60% response rate was obtained. Statistically significant differences were found among the practitioner groups, depending on the question. General practitioners and endodontists obtain access through crowns and maintain these crowns as final restoration significantly more often than do prosthodontists. Practitioners responded that teeth with complete crowns require nonsurgical root canal treatment after 5 to 10 years. CONCLUSION: Respondents believe that leakage must be addressed when endodontic access cavities in artificial crowns are restored after nonsurgical root canal treatment. General practitioners perform nonsurgical root canal treatment more frequently than do prosthodontists. Practitioners indicated that when teeth with complete crowns require nonsurgical root canal treatment, treatment is most often performed 5 to 10 years after placement of the crown.

Orofacial injuries in youth soccer.

PURPOSE: The purpose of this study was to estimate the incidence of orofacial injuries in youth soccer in the 1995 fall and 1996 spring seasons for eight Dallas, Texas metropolitan area YMCA youth soccer leagues. METHOD: Surveys requesting orofacial injury as well as game and practice information were sent to all soccer coaches of children 3 to 12 years of age in eight cooperating YMCA leagues in the Dallas metropolitan area. RESULTS: The incidence of orofacial injury was low. In 47,772 hours of games and practice only 17 orofacial injuries were reported by the 122 coaches who responded. All reported injuries were to soft tissue and none required professional attention. CONCLUSION: The reported incidence of orofacial injury was very low suggesting that at the age and skill levels represented by these YMCA teams, soccer appears to be relatively safe to the maxillofacial complex.

Acute ethanol toxicity from ingesting mouthwash in children younger than 6-years of age.

The purpose of our study was to analyze reports of the American Association of Poison Control Centers (AAPCC) of suspected overingestion of ethanol from mouthrinses by children younger than 6 years of age between 1989 and 1994. Annual incidence rates of reported ethanol exposures attributed to mouthrinses were calculated. Lethal and toxic amounts of several mouthrinses were calculated using peak blood ethanol concentrations of 500 and 50 mg per 100 mL, respectively. In 1994, there were 2937 calls reported by poison control centers related to ethanol-containing mouthrinses, an estimated incidence of 168 reported exposures per 100,000 children younger than 6 years of age. A 15-kg child who ingests 212 mL (7.2 oz.) of Listerine (26.9% ethanol) ingests 57 mL (1.9 oz.) of ethanol, which is potentially lethal. Approximately one-tenth that amount of ethanol can produce a toxic reaction. Physicians, dentists, and other health care providers should inform parents of the dangers associated with accidental ingestion of mouthrinse and encourage them to keep mouthrinse out of the reach of children. The Food and Drug Administration (FDA) should require readily visible warning labels and child-resistant caps for containers with potentially toxic volumes of ethanol. The American Dental Association (ADA) should re-evaluate its acceptance criteria for advertising cosmetic mouthrinses in its publications and consider including child-resistant caps and warning labeling.

The average daily dose of fluoride: a model based on fluid consumption.

The quantity of fluoride needed to prevent caries but avoid dental fluorosis is unknown. To estimate the desired daily dose of fluoride, we analyzed fluid consumption data from a stratified random sample of 7,345 children studied during the 1977-78 US Department of Agriculture Nationwide Food Consumption Survey and applied it to Dean's observations of optimally fluoridated communities in the 1940s. The average daily fluoride intake per kilogram body weight from optimally fluoridated tap water was highest (0.080 mg/kg/d) from 7 to 9 months of age, and declined linearly to 0.034 mg/kg/d at 12.5 to 13 years of age. The mean was 0.068 +/- 0.008 mg/kg/d from birth to age 7 years, and 0.042 +/- 0.006 mg/kg/d from age 7 to 13 years. The American Academy of Pediatrics supplementation schedule delivers fluoride dosage rates that are below our findings of the average daily dose of fluoride after the third month of life, although the two curves are within 0.006-0.013 mg/kg/d from 3 months to 16 years of age. While supplementation alone does not exceed the average daily dose of fluoride, the cumulative effects of fluoride from tap water, processed foods, ingested toothpaste, and dental treatments after the third birthday should be evaluated for their role in the increased prevalence of fluorosis.

Louisiana dentists' attitudes toward the dental Medicaid program.

PURPOSE: This study was performed to determine factors associated with Louisiana dentists' participation in the Dental Medicaid Program. METHODS: Surveys were mailed to all pediatric and general dentists as reported by the Louisiana State Board of Licensing. A second mailing was made to non-respondents. RESULTS: Surveys from 956 of 1,926 dentists (50%) were returned. Of 607 general dentists and 40 pediatric dentists who treated dental Medicaid-enrolled children in the past year, 269 (44%) and 18 (45%), respectively, treated all Medicaid-enrolled children. Newly graduated dentists were more likely to be actively enrolled than their more established counterparts (chi 2 = 10.67; p = 0.01). Medicaid reimbursement levels were viewed as "much less" than private fees by 62%, "less" by 33% and "the same" by 4% of the respondents. Broken appointments were the most prevalent reported problem (80%), followed by low fees (61%), patient non-compliance (59%), unreasonable denial of payments (57%), slow payment (44%), and complicated paperwork (42%). With the exception of the perceived importance of Medicaid reimbursement levels, active and inactive general and pediatric dentists' perceptions of the importance of Medicaid issues were not significantly different. These findings indicated that significantly more Medicaid-active general dentists who allocated 10% of their office visits to Medicaid-eligible children felt that slow payment (p = 0.002) and complicated paperwork (p < 0.001) were more important problems than general dentists who allocated less time to Medicaid-eligible children. CONCLUSIONS: Louisiana dentists' sources of dissatisfaction with Medicaid are similar to those of dentists in other states. Some of the issues are programmatic and are within the power of the dental Medicaid director and state legislature to address. Patient-related issues such as frequent broken appointments may be addressed by assigning case managers to Medicaid beneficiaries.

Potential effects of opportunity cost on dental school patients.

Predoctoral clinic fees are set below those of private practices to attract patients. Treatment in a predoctoral clinic requires more and longer appointments and patients spend more time waiting to be seen than in a private practice. This time has a value that economists call opportunity cost, the value of the next best alternative (the hourly wage for an employed patient). A model comparing total cost (fee plus opportunity cost) of treatment in dental schools and private practices for insured and uninsured patients is presented. As patient income increases, the total cost of some treatment plans becomes higher in dental schools than in private practices. To insured patients, however, the out-of-pocket cost of a treatment plan depends on copayments rather than fees. This makes predoctoral clinics less competitive. Considering opportunity cost further increases dental schools' lack of competitiveness. For insured patients, more treatment plans will have a lower total cost in private practice. Clinic directors must realize that if opportunity costs are not reduced, the market may dictate that fees be lowered to remain competitive with private practitioners. They are in competition for patients based on total cost, and efficiencies that reduce opportunity cost may increase revenue and attract patients.

Provision of free and discounted dental services to selected populations: a survey of attitudes and practices of dentists attending the 1996 Dallas Midwinter Meeting.

An attitudes and practices survey of dentists attending the Dallas Midwinter Meeting in January 1996 in Dallas was conducted as a collaborative effort between the Dallas County Dental Society and the Baylor College of Dentistry. The survey was developed to help determine participating dentists' attitudes and practices in the area of provision of dental services on a discounted or free basis to disadvantaged patient groups. A total of 225 dentists responded to the survey. Of these surveyed dentists, 213 (94.6%) were in private practice and 199 (88.4%) described themselves as general dentists. A considerable amount of charitable dental services, discounted and free, was reported to be provided by the group of respondent dentists. A total of 152 (67.6%) of the dentists surveyed reported providing discounted or free care to elderly patients with low income, 125 (55.6%) provided such care to low-income patients without age restriction, and 137 (60.9%) cared for patients of record with temporary financial hardship. In other patient categories, 79 (35.1%) of the dentists provided free/discounted services to handicapped persons and 47 (20.9%) provided care to homebound patients. These findings concerning charitable practices by dentists were similar to those found in a comparable survey conducted by the American Dental Association in 1994. Dentists were fairly evenly split as to their preference where to volunteer services. Of the total respondents, 84 (40.6%) preferred providing services in their own office and 91 (44.0%) preferred to do so at a community health clinic that hosted volunteers.

Consumer satisfaction with dental care: where have we been, where are we going?

This paper reviews research developments in the area of dental patient satisfaction over the past three decades, contrasts these with comparable developments in medicine, and suggests directions for future work in the dental arena. The conclusion of the review is that developments in managed care in medicine have stimulated a level of effort in patient satisfaction measures that have gone well beyond that in managed dental care. Analogous work in dentistry is needed as managed dental care plans grow in number.