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Biofit, Chapter 1: Modern Class II Cavity Preparations


Dr. David Clark introduces the modern Class II restoration which is a nonretentive, double serpentine, infinity edge preparation that is then injection molded with 3M’s Filtek One Bulk Fill composite.

 

Biofit, Chapter 2: The Five Steps to Success with the Biofit Matrix System


Dr. David Clark reviews the 5 steps necessary to achieve strong, broad contacts, and fracture resistant occlusal embrasures for Class II resin restorations using the Biofit Matrix System by Bioclear.

Following some Twitter buzz, one news outlet examined whether brushing teeth makes people hungry or lose their desire to eat – find out what was revealed about tooth brushing and hunger. Also, learn about a recent ProHEALTH-sponsored health fair, and what the organizers had to say to the public about oral health. And finally, this week, the AACD 2017 Meeting is in full swing in Vegas. Hear about what the organization has planned for attendees.

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Virtual Reality As Actual Reality for Surgery Students

Researchers in the United Kingdom are working on virtual reality education to train surgeons in medical and dental schools. Watch now to find out how the technology works, and what the advantages are for tomorrow’s maxillofacial surgeons. April is Oral Cancer Awareness Month, and Dentistry Today is offering many perspectives to get all dental professionals involved in diagnosing and treating this disease. Our last story this week focuses on a group of young girl scouts who just may be the dental professionals of the future.

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The first 1,000 days after conception strongly influence life expectancy and susceptibility to chronic diseases, according to the University of Washington (UW) School of Dentistry. For example, low birthweight often is used to identify early life stress and indicate poor nutrition during pregnancy. Now, researchers at the university report that an asymmetric lower face can capture early life stresses that occur after birth.

“Asymmetries in the skull and teeth have been used for decades by anthropologists to mark environmental stress, but they have only rarely been used in living populations,” said Philippe Hujoel, DDS, PhD, MSD, MS, a professor at the UW School of Dentistry. “Such lower-face asymmetries can be assessed by looking at the dental bite in the permanent teeth, an exam that can be completed in seconds and with more certainty than a mother’s recall of birthweight and more ease than a search for a birth certificate.”  

In a crooked or asymmetric bite, the teeth bite backward or forward on one side of the face and normally on the other side. Backward-biting asymmetries, the most common lower-face asymmetry in the United States, fluctuate randomly between the left and right sides of the face. Such randomness is evidence for early life stress, said Hujoel, who also is an adjunct professor of epidemiology at the UW School of Public Health.

Crooked teeth, overbites, and underbites are different from asymmetric bites, Hujoel added. These conditions can be associated with asymmetric and symmetric bites, the latter of which is largely a reflection of genetics, not environmental stress, Hujoel explained 

The researchers examined data gathered from 1966 to 1970 in a sample of 6,654 subjects aged 12 to 17 years involved in a National Health Examination Survey. The study found that one in 4 adolescents had lower-face asymmetries.

“Lower-face asymmetries were common in a generation that became typified by an epidemic of diabetes and obesity in adulthood,” said Hujoel.

The researchers had to look back 4 decades for data because in the 1970s, dental researchers in charge of designing US surveys began to disregard the value of diagnosing facial asymmetry and stopped taking those measurements.

“From a biological perspective, this decision resulted in an inability to reliably track trends in the United States,” said Hujoel. “We don’t have current information on the prevalence of lower-face asymmetries in the US population.”

The researchers noted that further work is needed to identify whether lower-face asymmetries are predictive of chronic diseases in living populations in the same way that skull asymmetries have been associated with degenerative diseases in long-deceased populations.

The study, “Lower Face Asymmetry as a Marker for Developmental Instability,” was published by the American Journal of Human Biology.

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Researchers from multiple universities and medical facilities will participate in a national study to determine whether medical devices used in the home can diagnose sleep apnea that often develops after traumatic brain injuries (TBIs). The $2.68 million study will compare the accuracy of formal laboratory screening versus wristwatch-like sensors that TBI patients will wear to measure sleep patterns.

The researchers want to know if wrist actigraphs, if proven comparable to full-scale polysomnography commonly used in sleep labs, would offer a reliable, accessible method to diagnose sleep apnea and lead to earlier treatment. The disorder often goes undiagnosed, which for TBI patients can be a crucial setback in recovery, according to the researchers.

“Optimizing sleep is essential for neurorecovery after TBI,” said researcher Kathleen Bell, MD, of the O’Donnell Brain Institute at the University of Texas Southwestern Medical Center, and the Kimberly-Clark Distinguished Chair in Mobility Research.

Funding for the study comes from the Patient-Centered Outcomes Research Institute to further previous work from the multi-institutional team on how TBI affects sleeping patterns. The team previously examined sleep apnea incidence in consecutive admissions to inpatient brain injury rehabilitation and found that 50% of all brain injury admissions and 37% of people with TBI were diagnosed with sleep apnea.

Up to 3 million TBIs occur in the United States each year, the researchers report. But diagnosing the ensuing cases of sleep disorder has been a challenge because most TBI patients don’t realize they’re at higher risk and are unaware their sleep is being disrupted by snoring or other symptoms. The researchers aim to improve the diagnosis rate by demonstrating whether home-based technology can be just as effective as laboratory testing.

The wrist actigraphs, which primarily have been used informally by researchers to monitor sleep patterns, will be upgraded for the study with improved sleep-tracing abilities to determine whether they can be a viable alternative to full-scale polysomnography, which is conducted in a sleep lab by a technician.

“We know that you can identify disturbances in sleep with wrist actigraphs. What we don’t know is how effective these screening methods are stacked up against one another,” said Bell.  

The study will begin enrollment in May at 6 TBI Model System Research Centers across the country. Participants will be selected from inpatients enrolled in the TBI Model Systems.

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The Children’s Dental Group will reopen its Anaheim clinic for all patients on April 24. The clinic had been closed since December, when the Orange County Health Care Agency (OCHCA) found Mycobacterium in multiple samples taken from its water system. The OCHCA had ordered the installation of the water system after the practice’s previous setup had tested positive for Mycobacterium as well.

“We are pleased that we have met all of the conditions of OCHCA’s December 2016 order and that we may operate again in an exceptionally safe, child-friendly environment where high-quality care, patient satisfaction, and safety are at the forefront of our mission,” said Jerry Minsky, DDS, the company’s chief dental officer.

According to the OCHCA, the clinic was the source of 22 confirmed and 46 probable cases of infections affecting children between the ages of 2 and 11 years who had pulpotomies there between February 4 and August 20, 2016. All of these children have been hospitalized at some point, with treatments including long-term intravenous antibiotics, surgery to remove the infection, and, in some cases, tooth extractions and jaw reconstruction.

In response, the OCHCA sought certifications from the Dental Board of California, the Centers for Disease Control and Prevention, and other organizations and experts regarding the removal of all sources of bacteria potentially posing risk, compliance with the dental board’s accepted standards of practice, and the absence of bacterial levels that pose any risk before the clinic could reopen.

According to the Children’s Dental Group, the company has undergone several evaluations, analyses, audits, and tests related to the water systems, clinical care, and infection control and sterilization processes and procedures. It also has collaborated with scientists, clinicians, and other experts to enact infection control, sterilization, and safety practices beyond those required by dental industry standards, the company says. 

“We are pleased to do this in the interest of patient welfare, and we are confident that patients will be well protected by the extraordinary water safety systems, infection, control, and sterilization practices that have been adopted. Families can take comfort in the knowledge that the quality of care and safety practices at our clinic offer high levels of protection for our patients,” Minsky said.  

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The American Society for Radiation Oncology (ASTRO) has issued new clinical guidelines for the management of oropharyngeal cancer. The guidelines, “Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma: An ASTRO Evidence-Based Clinical Practice Guideline,” are available for free from Practical Radiation Oncology, ASTRO’s clinical practice journal.

Drawing on data from clinical trials and other prospective studies, the recommendations address the use of radiation therapy (RT), also known as radiotherapy, to treat tumors of the oropharynx in a variety of scenarios. The guidelines cover optimal radiation dose and fractionation schedules, the integration of chemotherapy with RT, and the role of induction chemotherapy.

Oropharyngeal squamous cell cancer (OPSCC) is rapidly becoming the most commonly diagnosed head and neck malignancy, reports ASTRO, which also notes that the demand for radiation oncologists to treat head and neck cancer will increase nearly 20% by 2020 compared to 2010.

Also, the profile of the typical OPSCC patient has changed. From 1988 to 2004, the rates of OPSCC related to human papillomavirus (HPV) rose more than 200% while the rates of HPV-negative disease dropped by half, according to ASTRO. Meanwhile, the estimated risk of death for HPV-positive OPSCC patients is 50% lower than for those with HPV-negative disease, largely due to the more favorable biology of HPV-driven disease and because those patients tend to be younger and healthier when diagnosed.

“Advances in treatment planning and technology, as well as a shift in the ‘typical’ oropharyngeal cancer patient over the past several decades, have led to a significant improvement in treatment outcomes for these patients,” said David J. Sher, MD, MPH, co-chair of the task force that wrote the guidelines and a radiation oncologist at the University of Texas Southwestern in Dallas.

“Despite these advances, however, treatment in this sensitive and complex region of the head and neck often leads to short-term, long-term, and potentially lifelong side effects, which become even more salient as this patient population trends younger,” said Sher.

“Radiation therapy is the most commonly used curative option for the primary treatment of oropharynx tumors,” said Avraham Eisburch, MD, co-chair of the task force and a radiation oncologist at the University of Michigan in Ann Arbor. “We developed the current guidelines to address critical topics facing radiation oncologists who treat oropharyngeal cancer, including when to use chemotherapy, as well as appropriate dose and fractionation schedules for definitive and postsurgical RT settings.”

The guidelines first address the addition of chemotherapy to curative RT for oropharyngeal cancer, recommending concurrent chemoradiation for patients with stages III or IV disease with large-volume tumors, but not for patients with stages I or II disease. They also provide guidance for the use of radiation and chemoradiation following primary surgery for OPSCC. And, they outline optimal dosing and fractionation schedules based on treatment approach, disease profile, and risk of recurrence.

Furthermore, the guidelines address the role of induction chemotherapy (IC) in treating OPSCC, examining the 3 existing published randomized trials examining IC followed by chemoradiation for the disease. None of these trials found an improvement in overall survival, yet all found increased toxicity following IC, so the guidelines strongly recommend that IC should not be delivered routinely to patients with OPSCC.

The guideline was based on a systematic literature review of studies published from January 1990 to December 2014. The 119 articles that met inclusion criteria were abstracted into evidence tables and evaluated by a 16-member task force of experts in oropharyngeal cancer. The Clinical Practice Statement was approved by ASTRO’s board of directors following a 6-week period of public comment. It has been endorsed by the European Society for Radiotherapy and Oncology and the American Society of Clinical Oncology.

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The oral cavity can reveal signs of malnutrition. Healthcare practitioners just need to know what these signs look like. That was the focus of a recent workshop hosted by the East Carolina University (ECU) School of Dental Medicine for dietetic interns and master’s students in ECU’s Department of Nutrition Science.

“Today’s workshop is a first for dental and nutrition science faculty collaboration,” said Geralyn Crain, DDS, PhD, a dental faculty member and interim assistant vice chancellor for interprofessional collaboration for the ECU Division of Health Sciences. “I’d like to see the dental and nutrition science areas become regular partners.”

Dental faculty members Nisha Ganesh, DDS, and Troy Sluder, DDS, shared a presentation on building an interprofessional oral health team. They illustrated normal structures in the oral cavity, demonstrated how to perform oral exams, and helped workshop participants perform oral exams on each other.

Next, the dental school’s pathologist, Bobby Collins, DDS, MS, discussed the oral manifestations of nutrition deficiency to help students recognize oral abnormalities that require nutritional and medical interventions. Plus, Sylvia Escott-Stump, MA, RDN, LDN, director of ECU’s dietetic internship program, noted that malnutrition also includes over-nutrition and obesity.

“What people assume, including some doctors, is that people who are overweight are well nourished, though their diet might be terrible, like eating all fats or all sugars,” said Escott-Stump. “So nutritionists need to be able to recognize signs of malnutrition, which can often be detected in the mouth and eyes.”

Crain and a leadership team from across ECU’s health sciences division are exploring ways to promote and support interprofessional practice, learning, research, and service throughout the division as part of a growing trend toward a patient-centered, collaborative approach to healthcare.

“There is no fence blocking inflammation caused by periodontal disease—that is, the effects of diseases of the gums and bone structure around the teeth—from spreading to other organs of the body. There is growing evidence in the connection between the inflammation caused by periodontal disease and heart disease, low neonatal birthweight and preterm delivery, and other disorders,” said Crain.

There is a current trend among primary care doctors to include an examination of the oral cavity as part of the routine exam that evaluates a patient’s head, ears, eyes, nose, and throat, Crain said.

Under Crain’s leadership, students in the accelerated second-degree bachelor of science in nursing program have helped screen patients for the dental school’s clinics. Also, general dentistry practice residents have instructed nurse-midwifery students in oral health screenings and examinations. And, dental students have helped to establish a prenatal oral health program in collaboration with the ECU Brody School of Medicine’s obstetrics and gynecology clinic.

“The learning between professions needs to go both ways,” said Crain. “For example, we are exploring ways to incorporate more nutrition science education into the dental school curriculum and clinics, and we’ll look to our nutrition science colleagues at ECU for partnership. There are so many ways that the health sciences can collaborate that will lead to reduced healthcare costs and enhanced patient outcomes.”

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Dental anxiety is common, though it is considered a phobia when it has a marked impact on the patient’s well-being. For example, people with dental phobia are more likely to have active caries and missing teeth, according to the King’s College London Dental Institute. These people also report that their quality of life, as related to their oral health, is poor.

The study analyzed the data set from the Adult Dental Health Survey to look into the common oral health conditions of those with dental phobia. The data comprised 10,900 participants, with 1,367 identified as phobic. Of these, 344 were male, and 1,023 were female. The results showed that those who were dental phobic were more likely to have caries and one or more missing teeth than those who were nonphobic.

The researchers suggest that the greater rates of decay and missing teeth were because many people with dental phobia avoid seeing a dentist regularly to address oral conditions that are preventable and chronic. Once a visit has been made, the phobic patient also might prefer a short-term solution instead of a long-term care plan, such as extraction.

“The correlation between those with missing teeth and dental phobia could be the result of treatment decisions made when the individual with dental phobia finally seeks treatment. Both patient and practitioner may favor extraction of the tooth rather than booking a number of appointments to complete a restoration,” said Tim Newton, PhD, of the King’s College London Dental Institute.

The study also explored how dental phobia can affect these patients’ quality of life, impacting their physiological, psychological, social, and emotional well-being. These patients showed higher levels of impact in these areas, even when levels of dental disease were controlled.

“Other research has shown that individuals with dental phobia express negative feelings such as sadness, tiredness, discouragement and general anxiety, less vitality, and more exhaustion,” said Ellie Heidari, BDS, MSc, MA, lead author of the study. “Embarrassment at their poor teeth will prevent them from smiling and showing their teeth.”

Meanwhile, the researchers noted the significant difference in the numbers of males and females identified as phobic. While the reasons behind these difference remain unclear, the researchers said, they did speculate that it may be due to the reluctance of males to report extreme fears during the self-reporting process. Or, the researchers said, biological factors such as high levels of cortical arousal, which lead to heightened awareness and vigilance in regards to fear-related stimuli, may be at play.

Overall, the findings have additional implications for preventive services for those with dental phobia. By providing these patients with a detailed at-home oral healthcare plan, dental practitioners could help reduce acute conditions with preventive care. The Dental Institute is now developing a preventive program for those with dental phobia, focusing on what can be done to help them avoid acute conditions.

The study, “The Oral Health of Individuals with Dental Phobia: A Multivariate Analysis of the Adult Dental Health Survey, 2009,” was published in the British Dental Journal.

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More than 49,750 people in the United States will be diagnosed with oral cancer this year, according to Vigilant Biosciences. Yet 62% of adults in the US know very little or nothing at all about the disease—including cancer of the oral cavity, tongue, larynx, and pharynx—and only 29% report being screened for oral cancer at their last dental checkup, according to a survey conducted by the company in collaboration with the Head and Neck Cancer Alliance, Oral Cancer Foundation, and Support for People with Oral and Head and Neck Cancer (SPOHNC).

Released in support of Oral Cancer Awareness Month, the online survey polled more than 500 adults in the United States between the ages of 18 and 75 years on their knowledge and perceptions of oral cancer and oral cancer screenings. It found that more than 77% of adults in the United States want to learn more about how to reduce their risk for oral cancer and are interested in simple screening tools that test for early indicators of oral cancer.   

The survey also revealed how little US adults know about the various risk factors for oral cancer, particularly the connection between oral cancer and oral human papillomavirus (HPV). While the Centers for Disease Control and Prevention report that up to 70% of oropharyngeal cancers may be associated with HPV, the survey found that 59% of adults in the United States are not aware that HPV is a risk factor for oral cancer.

“Oral, head, and neck cancer—particularly HPV-related—is increasing at an alarming rate and, given that the symptoms are hard to identify, many people are not diagnosed until the cancer has progressed to a late stage,” said Holly Boykin, executive director of the Head and Neck Cancer Alliance. “Early detection is critical and may impact the complexity of the treatment of these cancers. By working together with other advocacy organizations and the medical and dental community, we can help save lives through early detection and a commitment to raising awareness about these cancers.”

While 29% of those surveyed recall being screened for oral cancer at their last dental checkup, 81% would like to be screened at every checkup. Also, 79% would like the option of being screened for oral cancer with a simple test that collects samples via a saline rinse and flags early indicators of oral cancer. And, only 5% have ever requested an oral cancer exam from a dental or medical professional. Of those who have not, most did not know that they should or had never thought about it. 

Meanwhile, tobacco use and alcohol consumption are associated with the highest risks for developing oral cancer. While most survey respondents recognized tobacco use as a leading risk factor for oral cancer, many were not aware of additional risk factors, such as certain types of the HPV virus. Of those diagnosed with HPV, only 36% considered themselves at risk for oral cancer. Less than 5% of those surveyed had discussed the relationship between HPV and oral cancer with their dental professional. And, only 20% said their dental professional spoke with them about risk factors for oral cancer at their last appointment.

Perhaps most significantly, respondents underestimated the death rate for oral cancer. Only 17% of those surveyed were aware that 40% of people diagnosed with oral cancer die within 5 years, due to late-stage diagnosis, with most believing the 5-year survival rate to be much higher. Early detection in stage I or II yields survival rates of up to 90%. If diagnosed with oral cancer, 69% of respondents would seek out a support network via email, phone, online, or in person, and more than 36% of respondents would be interested in all these supports.

“Patients diagnosed with this disease can find support, hope, and encouragement through SPOHNC’s many resources and programs specifically designed for this patient population,” said Mary Ann Caputo, executive director of SPOHNC. “SPOHNC’s long history of more than 25 years understands the importance of the value of its programs and resources to this patient population. Any steps to raise awareness of oral, head, and neck cancer will help to increase the survival rate and quality of life from earlier intervention.”

“Our survey this year found that these is still much work to be done around increasing awareness of oral cancer and oral cancer risk, particularly around the various risk factors for oral cancer,” said Matthew H. J. Kim, founder, chairman, and CEO of Vigilant Biosciences. “Working together with medical and dental health professionals, as well as industry advocacy groups, we can reduce the number of late stage diagnoses by educating consumers at risk and developing simple, accurate, and cost-effective tools that can help detect oral cancer in its early stages, before it’s too late.”

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Henry Schein has donated more than $80,000 in health supplies and equipment to the Children’s Aid Society to support 5 health centers located in high-need communities throughout New York City. The donation included hearing test kits, HIV test kits, dental radiography equipment, and other healthcare supplies. Three of the health centers are located in Manhattan, with one in Staten Island, and the other in the Bronx.

“We are extremely grateful to Henry Schein for its generous donation to our healthcare centers, which ensure children and youth have access to high-quality medical, dental, and mental health services,” said Children’s Aid Society president and CEO Phoebe Boyer. “These supplies and equipment will surely enrich our health services in our school- and community-based health centers in some of New York City’s most under-resourced communities, offering critical improvements to our service delivery.”

The Children’s Aid Society addresses the needs of underserved children and their families at more than 40 locations in New York City and Westchester County, providing children with access to healthcare, academic support, extracurricular activities, and college and job preparatory training programs. It also provides a range of family services, including prenatal counseling, housing assistance, and domestic violence counseling.

“We at Henry Schein are pleased to support the Children’s Aid Society in its efforts to expand access to medical and oral healthcare for underserved children and families throughout New York City,” said Stanley M. Bergman, chairman of the board and CEO of Henry Schein. “This donation does more than help this organization grow its capacity to provide a range of health services. It enhances its ability to help create healthier, happier, and stronger communities.”

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