It’s Every Kid Healthy Week, and oral health is key to overall health. Yet some states do a better job of supporting pediatric oral health than others, according to WalletHub’s 2017 Best & Worst States for Children’s Health Care, which compared the 50 states and the District of Columbia across 28 metrics on a 100-point scale each.
Iowa topped the overall list in terms of oral health, followed by West Virginia, Illinois, Rhode Island, Vermont, Kentucky, Massachusetts, Michigan, New York, and New Hampshire. Nevada was at the bottom of the list, preceded by California, Hawaii, Florida, New Jersey, Louisiana, Arkansas, Wyoming, Alabama, and New Mexico.
By the individual metrics, the report notes that Vermont has the highest percentage of children between the ages of one and 17 years with excellent or very good teeth, followed by New Hampshire, Maine and North Dakota (tie), and Massachusetts and South Dakota (tie). Nevada had the lowest share, preceded by New Mexico, California, Arizona, and Texas.
Vermont also has the highest share of children who have had both medical and dental preventive-care visits in the past 12 months at 81.4%, followed by Connecticut, New Hampshire, Massachusetts, and the District of Columbia. Nevada had the lowest share of children who have had both medical and dental preventive-care visits in the previous year, at 56.0%.
And, Michigan has the highest share of dentists participating in Medicaid for child dental services at 91.7%. That’s 4.5 times more than Ohio, which had the lowest share of dentists participating in Medicaid for child dental services at 20.4%.
Other metrics related to oral health included the share of children aged zero to 17 years lacking access to fluoridated water; the presence of a state oral health plan; the presence of school-based dental sealant programs; dental treatment costs; the presence of a state mandate for dental-health screening; and dentists per capita.
Severe periodontitis as defined by standard periodontology criteria strongly predicts higher all-cause mortality among patients with irreversible scarring of the liver, or cirrhosis, according to an international team of researchers. Presented at the International Liver Congress 2017 in Amsterdam, the study enrolled 184 consecutive patients with cirrhosis who received oral health assessments and were followed for an average of a year.
“Periodontitis may act as a persistent source of oral bacterial translocation, causing inflammation and increasing cirrhosis complications,” said Lea Ladegaard Grønkjaer, PhD, RN, of the Aarhus University Hospital in Denmark and lead author of the study. “As it can be treated successfully, however, we hope that our findings motivate more trials on this subject.”
When the study began, 44% of the patients had severe periodontitis. Nearly half of the included patients died during the follow-up. The association of periodontitis with mortality was adjusted for age, gender, cirrhosis etiology, Child-Pugh score, Model of End-Stage Liver Disease score, smoker status, present alcohol use, co-morbidity, and nutritional risk score. Mortality was mostly attributable to complications of cirrhosis.
In Europe, the researchers noted, cirrhosis is responsible for 1% to 2% of all deaths and is the leading cause of liver transplantation. Meanwhile, more than 35% of the European adult population has periodontitis, with 10% to 15% having severe forms of the disease. Previous studies have suggested that periodontitis is involved in the progression of liver diseases and that it has a negative impact on the clinical course after liver transplantation.
“This study demonstrates the association between gum disease and risk of death in patients with liver disease,” said Philip Newsome, PhD, of the Centre for Liver Research at the University of Birmingham in the United Kingdom and governing board member of the European Association for the Study of the Liver. “Further studies are now required to determine if improving gum care can improve outcomes in patients with liver cirrhosis.”
When you acquire a new piece of equipment to use in your practice, you are pumped about all of the features it has to offer. After all, you’re a dentist, and the features matter. But your patients don’t care so much about its features. In some cases, the features may go right over their heads.
What matters to your patients is how your new acquisitions benefit them. How do your patients benefit from selecting your practice over your corporate competitor down the street? The following are examples of how talking about benefits can help you attract new patients and keep your current patients coming back.
Say you get a new intraoral scanner. You’re excited about the technology and how precise it will allow you to be. But what does that matter to your patients? The way to get your patients excited is to share what that means to them: their appointment time is shorter, they won’t have to choke on goopy impression trays, and their finished product will fit correctly (which means not having to return to adjust the prosthesis). The mere fact that your scanner can save them time is a benefit that your patients can appreciate.
You’ve finally hired a new associate. Of course, you’ll want to share a brief biography with your patients so they’re not taken by surprise (where your associate went to school, how long your new employee has been practicing, etc). But ultimately, your patients care about how they can benefit from your new hire.
Will having an associate dentist allow you to extend your hours? Does your new associate have a different skill set like FastBraces or ClearCorrect certifications that will benefit the practice? It’s easier for your patients to get behind your choice to bring someone new on board if they know how it will make their lives easier.
If you move or expand your practice, that’s exciting, right? New signage, new business cards, new décor—all new! But what about this change matters to your patients? Change can be scary, so to get them excited, explain the benefits. Maybe your new office is more centrally located, or closer to a freeway. Or maybe it’s closer to a favorite shopping complex or eating establishment. Maybe the new décor will function to make your patients feel calm, thereby enhancing their overall experience when they visit for a treatment. If your patients understand how it benefits them, then they’ll be as excited as you to see the new place.
When you’re among other dental professionals, you can discuss the features of your equipment, people, or places to your heart’s content. When you’re reaching patients—especially through social networking, email, blogs, and your website—focus on the patient benefits. You’ll understand the payoff when they return again and again for treatments.
Drummer Rikki Rockett has a different outlook on life as he heads out on tour with his band Poison this spring. A year ago, he didn’t even know if he would survive while he was battling tongue cancer. But after participating in an immunotherapy clinical trial at the Moores Cancer Center, he was declared cancer-free in July 2016. And now he wants to give back.
“Without the doctors and staff at Moores Cancer Center, I can honestly say I don’t think I’d be here today, to say nothing about playing drums and going on tour again,” said Rockett. “I am incredibly grateful that I’ve got my life back and I’ll get to see my 2 children grow up.”
At American stops on Poison’s tour through June, fans will hear his story and watch a video about the Moores Cancer Center. Also, fans anywhere will be able to donate $10 to the center by texting “RIKKI” to 50555. Donations will directly support cancer immunotherapy, including research, clinical trials, and patient care.
Rather than directly targeting tumors as in traditional cancer therapies, immunotherapy boosts the body’s immune system to better enable it to attack cancer cells itself. Compared to traditional therapy, it has fewer side effects, it can specifically eradicate cancer cells anywhere in the body, and it’s effective against tumors that are resistant to chemotherapy and radiation.
“We are delighted that Rikki responded so well to immunotherapy. He had already been through a lot with chemotherapy and radiation treatment before he came to us, but his cancer recurred,” said Ezra Cohen, MD, co-head of the Solid Tumor Therapeutics Research Program, associate director of Translational Sciences, and one of Rockett’s oncologists at the center.
“While this approach is still in the early stages and isn’t right for everyone, with Rikki’s support we hope to make immunotherapy available to more patients before they have to go through everything he did,” said Cohen.
Rockett’s clinical trial is testing a combination of 2 immunotherapy drugs that remove the defenses cancers use to hide from the immune system. The first is Keytruda, a drug approved by the Food and Drug Administration for some cancers but only recently approved for Rockett’s type of oral cancer. The second experimental drug is called epacadostat.
“My hope is that by talking to other cancer patients, I might be able to lessen their pain and suffering,” said Rockett. “I know from experience that chemotherapy and radiation are not fun. If I can help anyone else, it would help give reason to what I went through.”
April is Oral Cancer Awareness Month, and dentistrytoday.com will be celebrating the event with blogs, news stories, and other features all spotlighting the disease. #OralCancerAwareness
Oral cancer is a deadly disease affecting nearly 750,000 people worldwide with nearly 300,000 new cases diagnosed yearly and an annual mortality rate of 145,000. It is a disease of varying clinical presentation with risk based on ethnicity, geography, and habits with an underlying genetic predisposition. Oral cancer can arise de novo from normal appearing oral mucosa, but is also commonly preceded by oral mucosal lesions of varying degrees of malignant potential known collectively as oral potentially malignant disorders (OPMDs).
Given that a general dental practitioner is more likely to encounter OPMDs such as leukoplakia in daily practice compared to oral cancer, it is advisable to assess all high-risk patients clinically as part of a comprehensive head and neck cancer examination and risk assessment.
OPMDs have previously been known as premalignant lesions and include such entities as leukoplakia, erythroplakia, erythroleukoplakia, submucosa fibrosis, discoid lupus erythematosus, chronic hyperplastic candidosis, and more recently oral lichen planus. Although these conditions have differing etiologies, some better understood than others, they have a common underlying clinical presentation. They typically all appear clinically as red or white patches of the oral mucosa, with either a homogeneous consistent pattern or a nonhomogeneous pattern that is inconsistent in color, appearance, or texture from one area of the lesion to another.
Clinicians may have difficulty making accurate diagnoses for such lesions, but this has been shown not to affect outcomes, as long as clinicians can designate these lesions as homogeneous or nonhomogeneous. Keratotic, traumatic, reactive lesions have minimal potential to transform to malignancy, and they can often be diagnosed clinically and may not require biopsy or histopathological assessment. These lesions are benign and not designated as OPMD.
OPMD often are difficult to distinguish clinically. They require biopsy and histopathological assessment to offer a more definitive diagnosis, but also to investigate the presence of oral epithelial dysplasia (OED). The presence of OED on histology increases the likelihood that an OPMD may transform at some stage to oral cancer. Although there are discrepancies in the literature about the usefulness of OED in predicting oral cancer formation, and even more disagreement about the importance of OED grading in this regard, OED is still the best predictive indicator of malignant transformation.
A significant amount of work is being carried out globally to unravel molecular diagnostic, prognostic, and predictive biomarkers of oral cancer and precancer utilizing various tissue, cellular, and fluid samples. But until these have proven their clinical utility, OED on histopathological samples remains the chief indicator for treatment, clinical review, and malignant transformation.
Risk factors are easily divided into patient risk factors and lesion risk factors. Lesion risk factors are related to the clinical appearance of the lesion and should be assessed with careful clinical examination under good illumination, preferably with white light, and are significantly enhanced with magnification with the use of loupes. Common clinical features to watch out for include the clinical type, site, size, multifocality, and duration of lesions.
Lesion Risk Factors
Type—Nonhomogeneous leukoplakia, which can contain nodular and/or red areas, are associated with a 4 to 7 times greater risk of malignant transformation. Any area of chronic ulceration that does not heal within 2 weeks should also be considered a suspicious oral lesion until proven otherwise.
Site—The site of OPMD impacts on the risk of progression to malignancy and should be factored into any treatment decision. Leukoplakia that presents on the lateral border of the tongue, on the floor of mouth, or on the retromolar/soft palate region are associated with the highest risk of malignant transformation. The lateral border of the tongue has also been correlated with a higher risk of malignant transformation of dysplastic lesions compared to those affecting other intraoral subsites.
Size—The risk of progression to malignancy has been reported to be significantly higher in leukoplakia larger than 200 mm2. The same holds true for OED, with lesions greater than 200 mm2 being 3 times more likely to undergo malignant transformation compared to smaller lesions. These lesions are also more difficult to manage because of their size and resultant morbidity for patients, especially if they cross anatomic boundaries.
Multifocality—Widespread oral leukoplakia appear to exhibit a higher potential for the development of oral cancer than do localized lesions. As is the case with large lesions, multifocal lesions are more difficult to manage surgically. In the case of extensive lesions, close follow-up with regular biopsies may constitute the necessary compromise. Lesions such as oral lichen planus that typically are multifocal present a true challenge in long-term management, especially in relation to monitoring for malignant transformation, particularly given the mixed red and white appearance of these lesions in most cases.
Duration—OPMDs are by their nature chronic conditions and carry increased risk of malignant transformation, particularly in the first 5 years after diagnosis. The rate of malignant transformation may decrease after this period, but the risk does not completely disappear, with some lesions undergoing transformation even 16 years after follow-up.
Patient Risk Factors
High-risk patients for developing oral cancer include older males (older than 60 years) with a history of smoking and alcohol consumption, patients with a family history of upper aero-digestive cancer, and those with OPMD (leukoplakia, erythroplakia, oral lichen planus, discoid lupus erythematosus, chronic hyperplastic candidosis) particularly involving the lateral border of the tongue or floor of the mouth. High-risk patients for malignant transformation of oral leukoplakia (the most common OPML) include nonsmoking older females (older than 60 years) who present with a nonhomogeneous, multifocal lesion larger than 200 mm2 present on the lateral border of the tongue or floor of the mouth that has been present for less than 5 years or demonstrates oral epithelial dysplasia on biopsy.
In addition, rare inherited conditions such as xeroderma pigmentosum and Fanconi’s anemia carry an increased incidence of oral cancer. Immuno-deficiency due to the prolonged use of immunosuppressive drugs or due to an underlying HIV infection may increase risk. And, oral cancer has been reported in patients suffering from chronic Graft Versus Host Disease after haematopoietic stem cell transplantation.
Disclosure: Dr. Farah has no disclosures in relation to this article.
Even though tooth decay is the most common chronic disease among children and teenagers, according to the Centers for Disease Control and Prevention (CDC), many of these kids don’t receive dental sealants. In fact, the Pew Charitable Trusts reports that only 11 states have school-based dental sealant programs in most of their high-need schools.
In response, the Sealant Work Group (SWG) from the Children’s Dental Health Project has issued a report and other resources to strengthen the ability of school-based sealant programs (SSPs) to reach more children, especially those most at risk for cavities. The SWG’s 16 recommendations include the following:
- State health departments should develop certification standards for SSPs that strengthen accountability and bolster school official’s confidence that a sealant program is delivering quality oral health services in an efficient, safe, and ethical manner.
- SSPs should collect, analyze, and report specific types of data outlined by the SWG. Doing so ensures quality control and enables programs to demonstrate their impact in improving health, demonstrating why SSPs are an investment that pays off.
- States can facilitate the expansion of SSPs by simplifying the Medicaid application and credentialing process for all licensed dental professionals. Managed care organizations should be required to abide by the same payment and contracting requirements that govern the state Medicaid program.
- SSPs should develop a communication plan that identifies the messages, communication vehicles, and other details to guide their efforts to engage school staff, families, children, and the community. Raising awareness of oral health and explaining what sealants are can help improve parental consent rates.
- State Medicaid agencies should adopt new reimbursement codes for case management services and educate dental providers on how to use these codes appropriately. Case management can help ensure that children with urgent dental needs get the treatment they need.
“From the beginning, our mission was to offer recommendations that can help good sealant programs become great sealant programs,” said Matt Crespin, chair of the SWG. “We truly believe these recommendations can serve as a roadmap to guide both states and sealant programs to reach more children.”
According to the CDC, using school-based programs to provide sealants to about 7 million low-income children who lack them could save up to $300 million in dental treatment costs. Also, an SSP serving 1,000 children would prevent the need for 485 dental fillings.
“By improving their data collection and analysis, local sealant programs are likely to have a powerful story to tell about the impact they’re having,” said Crispin.
Every day, water used during routine dental procedures exposes patients to millions of micro-organisms. Treated city water typically enters a dental office with very few viable bacteria present. But by the time that water runs through pipes, tubing, and dental delivery systems, micro-organisms have been given the opportunity—and sometimes, prime conditions—to grow exponentially in dental unit waterlines.
The design and typical usage behaviors associated with dental delivery systems are major contributors to bacterial growth. Small-diameter waterlines, low flow rates, long periods of stagnation, waterline termination (dead legs), and even occasional “suck back” from patients all contribute to creating an ideal environment for microbial growth.
The microbiological quality of water used in the dental industry is quantified by heterotrophic plate count (HPC). This time-tested method of gauging water quality dates to the 19th century, and it provides a good general measure of how well a water system is being maintained by counting the number of colony-forming units (CFU) of bacteria that a water sample contains.
HPC testing counts environmental bacteria that are generally not harmful, and therefore this method provides only an indirect indication of water quality. But because HPC testing does give a representative perspective on how well a water system has been maintained, both the Centers for Disease Control and Prevention (CDC) and the ADA have set guidelines for the dental industry based on HPC counts. The CDC and ADA both recommend that water used in nonsurgical dental procedures contains fewer than 500 CFU/mL.
As previously mentioned, municipal water generally arrives at a practice with very low levels of viable bacteria. But the pipes, tubing, and dental unit waterlines in the facility narrow progressively to create increasingly higher surface-to-water ratios that contribute to the growth of any micro-organisms present. Incidentally, this increasingly smaller-diameter tubing also allows cold water from the municipal supply to warm to room temperature more quickly, helping to incubate any living organisms.
Narrow tubing creates what’s known as laminar flow in the waterline. Laminar flow refers to water’s tendency to flow freely in the center of tubing, while allowing the flow along the outside of the tubing to remain relatively stagnant. This flow stagnation enables micro-organisms to grow virtually undisturbed along the edges of the tubing, which can lead to the development of biofilm.
Biofilm is essentially a stubborn layer of bacteria that grows on the inside surface of tubing. Biofilm also is “smart.” Once it develops, it can use a process called quorum sensing to protect itself from chemicals or other threats in the water, which makes it difficult to kill. Quorum sensing is a complex process that enables bacteria to send signals downstream to other bacteria to warn of threats such as antimicrobials or antibiotics. Downstream bacteria can actually respond by changing its DNA to protect itself.
Questions to Ask
Conditions relatively unique to dental environments can contribute to microbiological growth. Once established, micro-organisms can develop into biofilms that are difficult to kill and control. Next, we must answer a couple of questions that are vitally important to understand: how much of a “threat” does this microbiological contamination really pose, and what should practitioners do about it?
To answer the first question we must distinguish between common (and typically harmless) types of environmental bacteria and more serious types of pathogenic micro-organisms. Pathogenic or disease-causing micro-organisms found in water include bacteria such as Escherichia coli and Salmonella, viruses such as norovirus and rotaviruses, and protozoans such as Giardia and Cryptosporidium.
The good news is that city water facilities typically manage pathogenic microbial contamination fairly easily. But remember that dental unit waterlines can provide the perfect environment for microbial growth. Even a single micro-organism that survives filtration or chemical treatment has the potential to grow exponentially in a dental waterline. Also, typically harmless types of bacteria—when present in large numbers—can have negative effects on young children and immunocompromised individuals.
In the News
A recent and terribly unfortunate example of this reality occurred in September 2016, when dozens of children were hospitalized after undergoing pulpotomy procedures at a facility in Anaheim, Calif. These children were diagnosed with severe infections of the mouth and jaw from an environmental bacterium called Mycobacterium abscessus. The children had to receive antibiotics intravenously for several months, and many lost adult teeth as a result of the infection. Ultimately, approximately 500 patients were required to return for evaluations.
Although the first instinct in a situation like this is to blame the infection on a disregard for sanitation and surgical protocols, which very well might have been the case, we must remember that even following guidelines to a tee does not guarantee zero risk of infection. I share this example—and unfortunately, there are more like it—only to underscore the potential seriousness of the issue of microbial contamination in dental waterlines.
What Should You Do?
Dental practitioners should follow the protocols outlined by the CDC and various dental organizations for flushing all water-bearing lines for at least 2 minutes at the beginning of each workday and for at least 20 seconds in between patients. Beyond this, due to the nature and complex design of dental delivery units, the periodic use of waterline cleaners and antimicrobials is extremely important for proper waterline care.
For more information, visit dentalwatertesting.com/protocols.
Disclosure: Mr. Chandler is the author of The Book on Dental Water and the president of Vista Research Group, which manufactures several products designed to meet the water treatment, purification, and processing needs of dental practices.
There’s no better time to enter the field of dental sleep medicine. As obstructive sleep apnea (OSA) continues to affect millions of American adults, sleep physicians and patients across the country are increasingly seeking qualified dentists who can provide oral appliance therapy to help treat this condition.
Not only is OSA prevalent and under-diagnosed, but only about half of patients adhere to the traditional treatment, continuous positive airway pressure (CPAP) therapy. Providing custom-fit oral appliances can put your patients on the path to better sleep and help improve overall health, while positioning your practice to increase its patient roster and revenue.
For continuing education (CE) that can help you break into the field of dental sleep medicine, the American Academy of Dental Sleep Medicine (AADSM) offers opportunities that are:
- Recognized – All AADSM courses are recognized by the ADA Continuing Education Recognition Program (CERP) and put you on the path to being a Qualified Dentist.
- Respected – The AADSM’s reputable education options lead the field, are backed by 25 years of proven success for growing dental practices, and are respected by sleep physicians looking for dentists to help treat OSA with oral appliance therapy.
- Rewarding – AADSM’s tailored instructional approach will give dentists of all experience levels the credibility and tools to unlock immediate opportunities in dental sleep medicine to grow their business and effectively improve their patients’ health.
If you’re seeking best-in-class CE in the field of dental sleep medicine, look no further than the educational opportunities provided by the AADSM – the only non-profit professional association dedicated exclusively to dental sleep medicine. To learn more, visit www.AADSM.org.