Patients see plenty of needles when they’re at the dentist’s office. But they may be seeing more, as some dentists explore the use of acupuncture in their work to address dry mouth, dental anxiety, gag reflexes, and even orofacial and postoperative pain. The treatment has evolved throughout the millennia from ancient mysticism to a more modern approach known as battlefield acupuncture (BFA).
“In traditional Chinese acupuncture, placing needles in specific locations of the body would cause a disruption of the bodily energy known as Qi. This in turn helps break down any blockades, allowing normal currents of Qi. These currents flow in 12 pathways known as meridians, 6 yin and 6 yang,” said Tyler Rallison, DMD, a US Air Force captain who discussed the subject during the 2017 Hinman Dental Meeting Table Clinics in Atlanta on March 23.
“In modern Western acupuncture, it’s believed that the placement of the needles in specific locations on the body releases autogenous molecules. These molecules are believed to work directly on the signals of the peripheral and central nervous systems. This aids in pain reduction and increases blood flow. The effectiveness may be affected by the location and the depth as well as what type of application you want to apply to those needles,” Rallison said.
Modern acupuncture uses hundreds of points on the body to effect treatment. In 2001, however, Col. Richard Niemtzow, MD, PhD, of the Air Force developed the abbreviated BFA technique. Practitioners inject a series of just 5 needles that are about the size of a pencil point—each known as auricular semi-permanent (ASP) needles—into the cingulate gyrus, the thalamus, the omega 2, point zero, and the shenmen, all located on the ear. The injections produce only minor transient discomfort.
“Niemtzow recommends placing the ASP needles in a specific sequence and then stopping at a point when the patient reports adequate pain relief,” said Rallison. “The first part would be the cingulate gyrus. You place that point. You have patients stand up, walk a short distance, come back, and report their pain. Then you go to the other ear, place the same point, and do the same thing. And you’ll go through that with each point.”
The needles are designed to stay where they have been injected for 2 to 4 days before falling out on their own. Niemtzow initially developed the procedure so it could be used on the battlefield when the use of western pain medications wasn’t advisable. Since then, it has been used to assist in the relief of both acute and chronic pain throughout the body, including facial pain, neck pain, and fibromyalgia, in addition to nausea and vomiting.
As for dentistry, in 2005, Morganstein found that regular acupuncture could increase salivary flow in patients who had received head and neck radiation due to cancer. In 2007, Karst et al showed a significant reduction in dental anxiety with acupuncture compared to midazolam and placebo treatments. And in 2010, Sari and Sari demonstrated a 58.9% gag reflex reduction using laser-stimulated acupuncture.
When it comes to pain, Lao et al concluded in 1999 that Chinese acupuncture could reduce postoperative dental pain in third molar extractions compared to a placebo. And in 2014, de Cassia Faglioni Boleta-Ceranto et al demonstrated a reduction in post-adjustment orthodontic pain. Rallison noted further areas where BFA could be employed in general dentistry.
“It could be used for something as simple as anxiety and nausea. It could be something xerostomic. Oral surgeons may use it for postoperative pain. Prophylactic pain. And that’s usually with orthognathic surgery, extractions, trauma, and cancer patients. Endodontists may utilize it for trauma cases. The orofacial pain specialists in the Air Force are currently utilizing this for most of our temporomandibular joint (TMJ) disorder cases,” Rallison said.
Furthermore, periodontists may be able to use it in their osseo or grafting surgeries, while orthodontists may use it for separator or even band placements, Rallison said. However, he added, usage in the civilian sector will depend on state laws for scopes of practice and on insurance codings and reimbursements. For example, Aetna and Cigna currently reimburse for acupuncture in treating TMJ and post-op dental pain.
One of the primary benefits of BFA, Rallison noted, is its potential for reducing drug dependency, potentially eliminating the need for opioids and serving as an adjunct to other drug therapies. Also, costs are minimal. ASP needles cost between 50 cents and a dollar each. Effects last for a month to 2 months, and usage is repeatable. BFA is especially recommended for patients who already are being treated by a pain specialist, Rallison said.
As with any treatment, there are risks, which include discomfort or pain, broken needles, inflammation or infection at the injection site, bleeding or bruising at the injection site, and nausea or dizziness. Also, contraindications include pregnancy, as acupuncture may induce labor, plus aversion to needles, active ear infections, bleeding disorders, coagulation medication, and new, acute pain in the area.
Resources are available for dentists who would like to learn more. For example, battlefieldacupuncture.net provides information online and seminars in person. The Defense and Veterans Center for Integrative Pain Management also offers information and training. And, Niemtzow provides webinars and weekend clinics on his technique as well. Still, Rallison admitted there is skepticism.
“That’s the biggest controversy with acupuncture. You’ve got people saying it doesn’t work because you can’t prove it. And it’s very true. You can’t prove it,” Rallison said. “But you’ve got patients who say it works, and that’s the biggest benefit. If the patient says it works? Then you’ve done your job. You may not know why it’s working, but it’s working.”
Dentists often have a choice in posterior restorations: quick application or aesthetics. But 3M’s Filtek One Bulk Fill Restorative aims to bridge both demands with one-step placement that preserves opacity, with 5 different available shades. The material does not compromise when it comes to strength either, according to the company.
“We’re trying to simplify posterior restoration placement for the dentist,” said Dan Krueger, a technical service specialist with 3M. “Traditionally, if you have a 4- or 5-mm deep restoration, those materials would have 2-mm depths of cures. So you would have to place an increment and light-cure it, and place another increment and light cure it, and then possibly another one.”
But with its 5-mm depth of cure, the Filtek One Bulk Fill Restorative can be applied in a single shot, which saves time. Despite that depth, the material remains opaque for a more natural look. Plus, its singular process and new chemistry eliminate the defects that may come with other materials as they shrink and stress the interface with incremental applications.
“Typically, materials have to be more translucent to let the curing light all the way down to the bottom. And when they’re that way, they tend to look a little grayish,” said Krueger. “With our new material, we’ve figured out how to manage the opacity and translucency better, still getting this depth of cure. And now the material is more opaque and aesthetic for the final restoration.”
The Filtek One Bulk Fill Restorative reduces shrinkage and relieves stress to allow bulk fill placement up to 5 mm, too. Its addition-fragmentation monomer relieves stress during polymerization. Also, its aromatic urethane dimethacrylate helps reduce the amount of shrinkage and stress that occurs during polymerization.
“It’s not sticky, which is really important because if it sticks and pulls back, it can create defects. Doctors like that it’s not sticky. And you can put in anatomy on the surface like that so it matches the other teeth,” said Krueger. “And then when we cure it, instead of doing the curing for each one of those increments, I do one cure from the occlusal surface. And it’s done, and the doctor goes to finishing the polishing.”
The material comes in A1, A2, A3, B1, and C2 shades, all matched to Classic VITA shade types, which is “probably 95% of what the dentist would ever want in the back of the mouth,” said Krueger. There is no need for layering or expensive dispensing devices, according to 3M. Also, 3M offers adhesive, curing light, finishing and polishing, and prevention products all designed to work together to help dental professionals practice more efficiently.
Dentists who want to check out new equipment in person before making a purchase don’t have many options. Trade shows highlight the latest and greatest tools and technology on expansive exhibit hall floors, though travelling to these conferences isn’t always convenient. Or, some dentists may be fortunate enough to visit fellow practitioners who already have some particular gear installed in their offices. Henry Schein offers a third alternative, with a recently opened, 13,000-square-foot facility in Moonachie, New Jersey.
“Typically, dentists think they’re coming here to look at a chair or an x-ray unit or something like that. But when they get here, they’re wowed by all the technology and all the equipment that’s here,” said Marty Schayowitz, a Henry Schein field sales consultant. “When they see this beautiful showroom with everything on display, they go, ‘Wow,’ and the mind starts thinking.”
When clinicians visit the new Henry Schein location, they can tour its selection of dental chairs, cabinetry, sterilization units, imaging systems, and more, including practice management software. Everything is on the showroom floor and operational, waiting to be tried. It’s not a retail location, though, where dentists drop in to browse the way they would their local hardware store. Henry Schein’s representatives simply build on their customer relationships.
“Most dentists that I work with don’t reach out to me. We’re creating the need for them to upgrade or replace their equipment. By being intimately involved in their practice, we know what their individual needs are and can appropriately advise them on how to help them grow their practice. By introducing that into the discussion, they then ask, ‘All right. What’s next?’ And that prompts the trip to this showroom, and the added assurance that they can rely on us as their trusted advisor,” said Schayowitz.
|Figure 2. A complete operatory based on A-dec’s Inspire line of furniture is on display at the showroom.||Figure 3. Clinicians interested in digital dentistry can get their hands on gear from 3Shape, Planmeca, and more.|
“The goal of this facility is to bring doctors through whatever scenario they imagine, from adding on to their practice, to starting anew, or a doctor just out of school who is picturing what their practice would look like,” said Zach Harrison, regional manager of Manhattan and Westchester. “This gives them an opportunity to see cabinetry, integrated technology, CAD/CAM platforms, and 3-D platforms. It gives them a great overview of what they’re trying to envision.”
Inside the Practice
The showroom features a complete operatory based on A-dec’s Inspire line of furniture. Dentists can put the 500 model dental chair through its paces as they wheel around on their choice of stools, adjust the LED lighting, sort through gear in cabinets designed for easy and organized access, monitor their work on digital monitors, and connect instantly to imaging and other software.
The showroom also focuses on antimicrobial protection, with a full sterilization center on display. The station includes an area coded in red where assistants can put used trays, tubs, and other contaminated items, all foot-activated so they don’t have to worry about further dirtying their hands. Areas also are on hand for cleaning, with space for the ultrasonic and for rinsing instruments. A built-in dryer additionally is part of the package.
Intraoral scanners are playing a larger role as dentists and patients both begin to prefer digital impressions over the putties and trays of older analog systems. Practitioners who are interested in the technology can give the 3Shape TRIOS Intraoral Scanner, 3M True Definition Scanner or Planmeca PlanScan Scanner a try at the new facility. These handheld devices can craft virtual impressions and store those images with the practice’s software management system.
Plus, the scanners are compatible with Henry Schein’s Dentrix Ascend practice management software. Images are immediately stored with each patient’s file for comprehensive and easy to access treatment planning and record keeping. It also manages patient scheduling and finances. As a cloud-based system, it securely stores data on Henry Schein’s servers. Users access it via a browser-based portal that’s designed to be intuitive and easy to use.
Dentists who visit the facility and ultimately purchase any of the equipment are eligible for in-service training provided by Henry Schein, on site in their own practices and according to their own schedules. Depending on the gear they get, dentists also might travel to other facilities for more intense and hands-on workshops. The location in Moonachie includes a multifunctional conference room that could host continuing education classes on the products as well.
“Technology is always changing,” said Schayowitz. “The big conferences aren’t as intimate as this, where you can ask questions and not have any distractions. The team also is accessible here. The equipment and tech reps and field sales consultants all come here.”
“This gives dentists an opportunity to see cabinetry, integrated technology, CAD/CAM platforms, 3-D platforms,” said Harrison. “It gives them a great overview of what they’re trying to envision. And then whatever questions they have, our specialists are here to address them.”
California Dental Labs’ set of Diamond Impregnated Separators comprises oversized discs specially designed for the precise separation of zirconia, lithium disilicate, and porcelain restorations. Offered in sizes ranging from 26 mm to 29 mm with thicknesses ranging from 0.18 mm to 0.46 mm, the discs are particularly designed for perfect separation, countering, and finishing of the hardest and most difficult dental implants and bridge restorations.
The set features 3 disc styles: Ultra Thin (0.18 to 0.22 mm), Combo (0.22 to 0.26 mm), and Universal (0.46 mm). Specifically formulated to create minimal dust and smell with maximal cutting power, the discs can be ordered separately in one thickness or in a set of 3 different separators.
For more information, call Continental Dental Laboratories of California at (800) 443-8048 or visit continentaldental.com.
As healthcare models continue to evolve in the United States, George Washington University’s Health Workforce Institute (GWHWI) has issued a report that profiles how health workforce needs are changing—and what needs to be done to adapt to emerging needs in the 21st century. Among other areas, the report notes key adaptations that its authors say will help the dental profession better serve its patients, particularly underserved populations.
“The report will help health policy leaders identify new strategies for increasing access to healthcare, especially in remote or isolated regions of the United States,” said Patricia Pittman, PhD, co-director of the GWHWI. “Telehealth, nurse-led clinics, and Medicaid-financing of graduate medical education are just a few of the ways healthcare leaders can ensure that the US workforce is prepared for the future.”
For example, the report spotlights the need to integrate oral health into primary care teams, citing 8 case studies from the State University of New York (SUNY) Albany that documented the efforts of Federally Qualified Health Centers (FQHCs) to do so. Keys to this integration include integrated electronic health records and inclusion of new patient health information forms that ask patients about their history of dental disease and access to a dental home. Some FQHCs even embed a dental hygienist in offsite primary care practices to provide preventive and educational oral health services.
Next, the report associates less restrictive dental hygienist scopes of practice with better oral health. It says that dental hygienists are in a prime position to contribute to the transformation of oral healthcare due to their training and experience. Noting the significant changes in dental hygienist roles during the past decade, SUNY Albany has updated its matrix for assessing scope of practice laws for dental hygienists, enabling the university to demonstrate that states with less restrictive laws for dental hygienists had better oral health outcomes.
With this expansion in mind, the report cites 3 states—Minnesota, Alaska, and Maine—that license dental therapists to increase access to dental services in underserved communities. These professionals are known as “midlevel” providers because they can substitute for and supplement practice by a dentist in restorative therapy. SUNY Albany profiled an FQHC in Minnesota where the use of a dental therapist allowed greater flexibility for task shifting, such as performing simple restorations when a demanding emergency case was diverted to the dentist.
Dental assistants, meanwhile, face challenges. Typically involving clinical and administrative duties, dental assistant positions require middle to low levels of skill. However, training varies, ranging from on the job preparation to formal accredited education programs culminating in an associate’s degree. Allowable tasks also differ by state and sometimes are decided by the dentists who employ these personnel. Some but not all states recognize expanded function dental assistants, requiring extra training and competency testing for tasks such as applying sealants or performing dental radiography.
Outside of dentistry, SUNY Albany found that appropriate physician assistant training also can improve oral health. Currently, 3 out of 4 physician assistants received didactic and/or clinical instruction in oral health during their training. Also, physician assistants who received education in oral health and disease were nearly 3 times more likely to provide oral health services than those who did not receive any education in oral health competencies.
Meanwhile, technology can play a greater role in reaching underserved communities. Sites approved by the National Health Service Corps in states with more favorable telehealth coverage and reimbursement policies were more likely to use telehealth, including teledentistry, as were providers located in states with telehealth grant funds. SUNY Albany prepared 6 case studies of teledentistry programs that outlined strategies for increasing access to general and specialty dental services using remote technology.
Finally, FQHCs require personnel to operate if they’re going to reach underserved populations. SUNY Albany found that dental student externships and dental residencies can serve as a pipeline for FQHCs to hire new dentists. According to the report’s authors, it appears that participation in these clinical rotations is alleviating some of the difficulties that FQHCs face in recruiting dentists to work in the safety net.
This May, dental professionals from around the world will take part in the 47th Journées Dentaires Internationales du Québec. Presented by the Ordre des Dentistes du Quebec, the 3-day convention will provide a host of seminars and hands-on courses led by top dental experts at the Palais des Congrés de Montréal.
For example, TRAC Research’s Rella Christensen, RDH, PhD, will present “New Data—On Critical Dental Questions 2017” on Friday, May 26. Available for 6 continuing education credits, the day-long lecture will review the latest information from clinical testing about today’s cutting-edge technologies and techniques. Dr. Christensen recently gave us a preview of her presentation.
Q: What are the advantages of translucent zirconia?
A: The main advantage of translucent zirconia is its translucence. This allows a more lifelike appearance of zirconia in the aesthetic zone. A primary question today is if translucent zirconia can and should replace Ivoclar Vivadent’s e.max lithium disilicate. No one has the answer yet. Lithium disilicate has the advantage of historical perspective. Our clinical studies show that e.max can be durable when tooth preparations allow adequate thickness. Right now, our work has one year of clinical data on translucent zirconia.
Q: What are the disadvantages of translucent zirconia?
A: Two big disadvantages are its unknown clinical performance throughout time since it is so new, and its ability to match opposing and adjacent dentition reliably. It turns out that zirconia is difficult to color and it tends to have a bright white opacity that makes it stand out in the oral cavity, regardless of the improvement in translucence. In addition, zirconia finishing is an art rather than a science right now. When polished, the material can quite quickly take on an iridescent and gray cast, and it is difficult to impossible to go backwards and undo this problem once it has occurred during finishing. If the technician decides to glaze, we found that glazes begin to wear off within a few months and can leave a rough surface that patients can feel with their tongue and can wear opposing dentition. Right now there is a scramble to find ways to overcome these problems.
Q: Are there other options to translucent zirconia that dentists should consider, and when would they be indicated?
A: Dentists can also consider lithium disilicate and PFM for durability and aesthetics. Our studies show that the original full-strength full-contour zirconia (BruxZir) and PFM are still indicated in the following clinical situations:
- Molar restorations;
- Posterior multi-unit restorations;
- Patients with abusive occlusion;
- Patients with a high-risk lifestyle, such as athletes;
- Where future endodontic needs are anticipated.
Q: What are current alternatives to “drill and fill”?
A: Today, the most discussed and controversial option to “drill and fill” is silver diamine fluoride (SDF) disinfection. The major objection to the procedure is it causes demineralized tooth structure to darken to a brown or black color. Although it does not discolor healthy tooth structure, the discoloration of demineralized tooth structure is permanent. However, SDF use throughout many years in Japan has been shown to delay, and possibly arrest, dental caries. At this point in time, dentistry does not have any methods or chemicals that stop dental caries and maintain health over the lifetime of the patient without the patient’s control of diet, oral hygiene, and saliva flow. SDF is under intensive study and gaining use by pediatric, geriatric, and humanitarian dentists.
Q: Can teeth be remineralized today using various techniques or products?
A: Although mineralization can be demonstrated in vitro in the laboratory, we have not been able to show a significant and sustained affect in vivo. “Remineralization” is an interesting word because it implies different things to different people. We find that patients think it means that their teeth will be returned to their former perfect condition if they use products dispensed by clinicians such as 5,000 ppm dentifrice, amorphous calcium phosphate, xylitol products, etc. But as clinicians know, this is not possible. At our lab, we use the term mineralization rather than remineralization to indicate that ions can be exchanged, but the tooth does not return to its original chemical and physical state.
Q: How do you expect mineralization to evolve in the years ahead?
A: Based on history, progress will probably be slow and sustained. Everyone would like to be able to truly restore the tooth and/or prevent destruction in the first place. Some of the brightest minds in dentistry have tried to address this question for years, but we still appear to have a lot to learn.
Q: What are the advantages of laser use in general dentistry today?
A: Simple soft-tissue surgeries by general dentists have created a niche for lasers. These include troughing before impressions to control bleeding and gain access to margins, crown lengthening, implant access, operculum tissue removal, biopsies, etc. The ability of lasers to control bleeding during cutting has been a useful characteristic in all of these situations.
Q: What are some of the latest treatments that lasers are being used to provide?
A: Probably the most exciting area for lasers is hard-tissue cutting. Lasers are being developed that are now more precise and more rapid in their ability to cut enamel and dentin. I am thinking of Convergent Dental’s Solea CO2 laser. Another area where progress has been made is the elimination of the CO2 laser articulated arm and very precise cutting tips and smaller handpiece. I am thinking here of the Light Scalpel CO2 laser.
Q: Where do you see laser technology going next?
A: Many dentists would like to use a laser in periodontal treatment to kill microbes. We have not yet found a laser of any wavelength that does a credible job clinically in this area. The killing of certain microbes can be demonstrated in the laboratory, but our work shows clearly that the transition to clinical treatment does not give the same results microbiologically. However, this does not mean that methods will not be found in the future to accomplish this goal.
Q: Are there other exciting treatments or technologies emerging?
A: Certainly the area of digital impressions is a technology on the cusp of bursting into general use. We are seeking imaging technology that will allow the clinician to see through the soft tissue and blood to image margins. New ultrasonic equipment for endodontic canal cleaning has also become available that could greatly improve this procedure. The area of dental implants is also moving forward rapidly with new products and more general dentists performing the surgical procedures as well as the restorative procedures. Control of the oral environment in an attempt to control dental caries is of high interest worldwide and has some interesting ideas under development.
Quacquarelli Symonds (QS) has released its 2017 list of the top 51 dental schools in the world, with the University of Hong Kong Faculty of Dentistry taking the top slot for the second year in a row. The University of Michigan School of Dentistry was the top American school and number 2 overall, also for the second year in a row, followed by Tokyo Medical and Dental University, King’s College London Dental Institute, and Harvard School of Dental Medicine in the top 5.
QS scored each school’s academic reputation, employer reputation, and research citations per paper on a scale of zero to 100 and averaged these totals for each final score. Surveyed academics and employers identified up to 10 domestic and 30 international institutions they considered excellent, while QS used Scopus to determine the citation tallies. QS has been ranking the world’s top dental schools since 2011.
University of Hong Kong
“Last year, I told staff and students that being ranked number one in the world was a once in a lifetime achievement. I was wrong!” said Thomas Flemmig, DMD, MBA, dean of the Faculty of Dentistry at the University of Hong Kong. “The ranking is a wonderful recognition of the outstanding achievements of our staff and students and a testament to the excellence of our research, teaching, and service. It demonstrates what we can achieve together.”
In September 2016, the Faculty of Dentistry increased its bachelor of dental surgery (BDS) program by 40% to address the shortage of dentists in Hong Kong. The school also offers postgraduate programs in community dentistry, endodontics, orthodontics, oral and maxillofacial surgery, pediatric dentistry, periodontology, and prosthodontics.
Plus, the school recently launched its Institute of Advanced Dentistry, designed to be a center of excellence for the management of complex oral conditions. It will provide multispecialty advanced dental care and serve as a referral for practicing dentists. The school also says that it will foster clinical innovation, support translational and clinical research, and provide postgraduate and professional dental education.
University of Michigan
With an emphasis on strong links between clinical teaching and research, the University of Michigan retained its hold on the number 2 slot in the QS survey. More than 2,100 students applied for the 109 seats in 2016’s incoming class. Additionally, its faculty published 223 articles last year in more than 100 scientific journals. National and international awards, grants, fellowships, and appointments all bring in millions of dollars for research, too.
“We’re proud that we’ve consistently been recognized among the leaders in dentistry over our 142-year history,” said Laurie McCauley, DDS, MS, PhD, dean of the school. “We’ve been able to achieve that because we have faculty, students, and staff who strive to continually improve dentistry, teaching, and research. That commitment produces an environment of excellence that we’re always working to improve.”
King’s College London
The Dental Institute at King’s College London is the top dental school in Europe, with a strategy designed to integrate education with research, clinical approaches, and patient care. It serves more than 700 undergraduates, 140 graduate taught students, 300 distance learning students, and 110 graduate research students with more than 85 academic staff members. Plus, it cares for more than 300,000 patients each year.
The school comprises 4 research divisions—craniofacial development and stem cell biology, mucosal and salivary research, tissue engineering and biophotonics, and population and patient health—all established to complement the school’s teaching and clinical service initiatives. Clinical training is provided at Guy’s and St. Thomas’ hospitals.
“Rising to first in Europe in the global rankings reaffirms our position as a world-class institution and reflects the dedication, commitment, and innovation of our academic and professional staff, our students, and our alumni,” said interim executive dean Mark Woolford, BDS, MA, PhD.
Other US Schools
“Harvard School of Dental Medicine is delighted to be ranked among the top 5 dental schools in the world in the recently released QS 2017 rankings. This honor is especially noteworthy as the school is celebrating its 150th anniversary this year,” said R. Bruce Donoff, MD, DMD, dean of the school, which serves more than 25,000 patients during more than 57,000 dental visits each year.
“As the first US dental school affiliated with a university and its medical school, and the first to confer the Dentariae Medicinae Doctor (DMD) degree, we celebrate a proud history along with this significant achievement,” Donoff added. “We would also like to recognize and thank our dental school peers around the world who are united in the mission to advance dental education, research, and clinical care.”
In total, 14 schools from the United States made the list. Other schools included:
- New York University College of Dentistry (11th)
- University of North Carolina, Chapel Hill, School of Dentistry (12th)
- University of Washington School of Dentistry (14th)
- University of California, Los Angeles, School of Dentistry (tie 15th)
- University of Pennsylvania, Penn Dental Medicine (tie 15th)
- University of California, San Francisco, School of Dentistry (21st)
- University of Minnesota School of Dentistry (33rd)
- Boston University Henry M. Goldman School of Dental Medicine (36th)
- University of Southern California Herman Ostrow School of Dentistry (41st)
- Columbia University College of Dental Medicine (44th)
- University of Florida College of Dentistry (47th)
- Tufts University School of Dental Medicine (51st)
The Environmental Protection Agency (EPA) has rejected a petition it received on November 23, 2016, from a coalition of grassroots groups and activists asking it to exercise its authority under section 21 of the Toxic Substances Control Act (TSCA) to “prohibit the purposeful addition of fluoridated chemicals to US water supplies.” The EPA published its denial of the petition in the February 27 edition of the Federal Register.
Specifically, the petition urged the EPA “to protect the public and susceptible subpopulations from the neurotoxic risks of fluoride by banning the addition of fluoridation chemicals to water” and cited various studies to support the coalition’s position. However, the EPA reviewed those studies and found problematic basic data quality issues, such as the presence of antecedent-consequent bias. The EPA also reinforced the benefits of public fluoridation.
“After careful consideration, EPA denied the TSCA section 21 petition, primarily because EPA concluded that the petition has not set forth a scientifically defensible basis to conclude that any persons have suffered neurotoxic harm as a result of exposure to fluoride in the US through the purposeful addition of fluoridation chemicals to drinking water or otherwise from fluoride exposure in the US,” the EPA wrote in the Federal Register.
“As teeth are developing (pre-eruptive), regular ingestion of fluoride protects the tooth surface by depositing fluorides throughout the entire tooth surface,” the EPA further wrote. “Systemic fluorides also provide topical protection as ingested fluoride is present in saliva, which continually bathes the tooth. Water fluoridation provides both systemic and topical exposure, which together provide for maximum reduction in dental decay.”
The ADA has commended the EPA for its decision, noting that public water fluoridation serves approximately 211 million people across the United States to protect them from dental disease. According to the ADA, optimal fluoride levels in water can prevent tooth decay by at least 25% in children and adults. Plus, fluoridation costs range from 50 cents per person in large communities to $3.00 per person in small communities per year.
“It’s always heartening when our government comes down on the side of sound science,” said ADA president Gary Roberts, DDS. “Public health policy recommending community water fluoridation results from years of scientifically rigorous analysis of the amount of fluoride people receive from all sources. Water fluoridation is effective and safe.”
The American Fluoridation Society (AFS) also supports the EPA’s decision, adding that this is the second time in 4 years that officials there have reviewed and rejected petitions by fluoridation opponents. The AFS also noted that fluoridation occurs in more than 20 different countries and that it has been practiced safely for more than 70 years, prompting the Centers for Disease Control to call it one of the 10 greatest public health achievements of the 20th century.
“Once again, fluoridation opponents have been caught misreading or misrepresenting the science,” said Johnny Johnson, DMD, MS, president of the AFS. “We applaud the EPA’s response to this flawed position.”
Governor Jay Inslee of Washington State has signed Senate Bill 5079, which lifts restrictions on tribes from using federal funding for Dental Health Aide Therapists, who work under the direction of a dentist to provide cleanings, place fillings, and educate patients about oral health and disease prevention. The bill is designed to expand access to dental care on state tribal lands to address the disparities in oral healthcare faced by many Native Americans in Washington.
“I remember going to the Yakama Nation to a clinic and seeing dozens of kids with horrific caries trying to get emergency dental care. We want to get ahead of caries. We want our kids to have good dental health. We understand that dental health is as important as physical health,” said Inslee. “Finally, we’re going to have a situation where we use good, high-quality dental care in the state of Washington for our tribal members.”
Washington is now the sixth state to authorize some version of dental therapy. Dental therapists now can practice in Minnesota, Maine, and Vermont. Alaska allows dental therapists to practice on tribal lands, and Oregon has authorized pilot projects with several tribes. Massachusetts is currently considering a bill to allow dental therapists statewide. However, North Dakota’s legislature recently defeated a bill to allow dental therapists there.
“We’re going to unlock the door to dollars for healthcare from the federal government. I love the fact that we’re going to bring federal dollars to our state to provide tribal healthcare. These programs have worked in other states. They’ve made high-quality dental care available. They have not reduced health benefits in other areas. It’s great that this state is now building on success in other states,” said Inslee.
“This is a tremendous day for Indian Country here in Washington state. It just adds to the adage down here that the impossible takes a little bit longer. This took 12 years, but perseverance paid off, and we got it done,” said Senator John McCoy, a sponsor of the bill representing the state’s 38th District. “This will help all tribes in rural Washington, so this does mean jobs for rural Washington.”
In 2016, the Swinomish Indian Tribal Community collaborated with the Northwest Portland Area Indian Health Board to become the first tribe in the lower 48 states to hire a dental therapist. Now, tribal representatives say their next step will be to work with schools in the state to train the dental therapists who will be providing this care.
“That’s our next step, to work with community colleges, universities, to bring that training from Anchorage, Alaska, down here to Washington so our kids will stay here in the state and find a place to send them to be trained in the near future,” said Brian Cladoosby, chairman of the Swinomish tribe and president of the National Congress of American Indians. “All that exciting news will be coming out shortly as our next goal after this is implemented.”
The ADA formally opposes the licensing of dental therapists, noting that there is no available data demonstrating that new practice models have increased access to care at a lower cost. Also, the ADA reports that the current number of dentists will continue to grow through 2035 and outpace population growth, while 27% of dentists can add more patients. Instead of new professionals, the ADA believes efforts should focus on better connecting patients with care.
The dental lobby is currently opposing a separate effort in the state’s House of Representatives, House Bill 1364, that would permit dental therapists to practice statewide. But while the Washington State Dental Association is part of those efforts and had joined the ADA in previously opposing work to introduce dental therapists to tribal lands, it chose not to work against Senate Bill 5079.
“To the Washington State Dental Association, a big thank you to them for standing down on our bill this year,” said Cladoosby. “That really meant a lot to us when they came to visit us in Swinomish before the session started to give us their great news that their board voted 10 to zero to do that. That was huge for the dental association to do that.”
“We know this bill means fewer emergency visits to the ER. We know this bill’s going to mean fewer extractions. We know this bill will mean fewer infections. We know this bill is going to mean people with compromised cardiac conditions are going to have fewer problems associated with oral health, which is a real risk,” said Inslee. “It means people are going to have earlier and more frequent cleaning of their teeth, better x-rays, and easing the demand for affordable care on tribal reservations.”
Fluoride is essential to healthy teeth. However, diet plays a widely varying role in supplying children with beneficial amounts of fluoride. A team of researchers at the Indiana University School of Dentistry, then, recently examined how much fluoride is present in the foods and beverages typically consumed by children in the Midwest who are aged 2 years.
The researchers used total diet study food lists cross-referenced with the National Health and Nutrition Examination Survey—What We Eat in America. They also determined concentrations of fluoride via a modification of the hexamethyldisiloxane microdiffusion technique. Daily dietary fluoride intake was estimated using a simulation analysis.
The study, “Fluoride in the Diet of 2-Years-Old Children,” was published by Community Dentistry and Oral Epidemiology. E. A. Martinez Mier, DDS, PhD, MSD, of the department of cariology at the Indiana University School of Dentistry shared her insights about the study’s results with Dentistry Today.
Q: What are the main sources of fluoride for children?
A: There are different fluoride sources depending on the age of the children. The relative contribution of these sources to the total amount of fluoride ingested in a day also varies according to the children’s age. Our study showed that the daily intake from the diet for 2-year-old children will depend on the foods typically consumed by each child based on his or her choice of foods and beverages.
Q: Specifically, what foods provide the most fluoride?
A: In our study, popsicles, mild cheddar cheese, raisins, saltine crackers, creamy peanut butter, beef cheese tacos, chicken/pork franks, and plain wavy potato chips were the items with the highest fluoride content. Previous reports have included fish, tea, and sardines as items with high fluoride content.
Q: What role does public water fluoridation play in children’s fluoride intake?
A: Water and swallowed toothpaste are the greatest sources of fluoride intake for children younger than 6 years. It is estimated that water and water-based beverages contribute to approximately 75% of the total fluoride consumed though the diet in communities that are optimally fluoridated. This should not place these children at risk for excessive consumption. At the currently recommended levels, community water fluoridation has been proven to be safe and effective.
Q: How can parents tell if their children are getting enough fluoride to prevent dental caries?
A: Children who live in communities where water is fluoridated are already receiving the benefits of fluoride. In addition, parents should ensure their children are brushing their teeth with a toothpaste that contains fluoride. They also should visit their dentist, who may recommend additional fluoride.
Q: What impact does too much fluoride have on developing teeth?
A: Too much fluoride consumed when teeth are developing may result in enamel fluorosis. No other negative health effects have been associated with the consumption of water fluoridated at the recommended levels.
Q: Is there anything parents can or should do to mitigate this impact?
A: Parents should supervise their children while brushing to prevent them from swallowing toothpaste. If they consume well water, they should have it tested to find out if it has too much fluoride.
Q: What role should dentists play in ensuring that children are getting the right amounts of fluoride to ensure oral health?
A: Dentists should continue to support community water fluoridation and assess their patients’ risk of developing caries in order to develop individualized fluoride recommendations.