Oral Health and Preventive Dentistry, 04/2013

Dear Readers, You may be astonished to find an editorial in OHPD, since it is our policy not to publish editorials in order to save the allocated space for publishing scientific manuscripts. But science may generate controversy, which must be discussed within the scientific community. Sometimes such discussions are triggered by letters to the editor. Earlier this year, OHPD received a letter to the editor arguing about a fluoride measurement method (see below). As good publishing practice, we sent this letter to the authors of the criticised paper and asked them to reply. Now we have received their answer, which we are printing as well (see next pages). The editorial team is convinced that this policy helps to improve the quality of research reports, and this is why we decided to use the space to make this discussion available to our readers.

Purpose: To identify the barriers to restorative care as perceived by dentists working in urban and semi-urban dental hospitals in Nigeria. Materials and Methods: The study was cross sectional and the sample consisted of 189 of 280 dentists who consented to, filled out and returned the questionnaire mailed to them. The questionnaire consisted of fifteen itemed statements and the respondents were asked to what extent they agreed or disagreed with each item on a four-point Likert scale; 'not at all', 'slight extent', 'some extent' and 'great extent'. Five barrier factors were extracted from the questionnaire. These were 'beliefs of patients', 'knowledge of patients', 'equipment/materials', 'attitude' and 'motivation of practitioner'. Two questions were not grouped with the barrier factors: 'dentistry is being looked down on by administration' and 'patients prefer extraction to filling'. Results: The barrier factor 'attitude of patients' had the highest score (mean = 3.73), followed by the 'knowledge of patients' (mean = 3.27). The barrier factor 'belief of patients' had the lowest score (mean = 2.43). Conclusion: Within the limitations of the study, the barrier factor 'attitude of patients' was the most important barrier to restorative care as perceived by dentists working in urban and semi-urban regions of Nigeria. Keywords: barrier, restorative care

Purpose: To follow up the variations of early morning concentrations of oral volatile sulfur compounds (VSCs) in periodontally healthy subjects who refrained from toothbrushing during a period of 5 days while continuing with other hygiene procedures. Materials and Methods: Thirteen subjects volunteered for this study. At baseline, all subjects stopped brushing their teeth for 5 days, but continued using dental floss and a tongue scraper twice daily. Organoleptic measurements, VSC quantification and plaque index were recorded in all subjects at baseline and on days 3 and 5 of the study period. Results: At baseline, the visible plaque index was significantly lower than that observed on days 3 and 5 (P = 0.0001). However, no significant differences in the amount of plaque were observed between days 3 and 5 (P > 0.05). The results of the organoleptic measurements and VSC quantifications did not show any statistically significant differences between baseline and day 3, or between days 3 and 5 (P > 0.05). However, a significant increase was observed in both VSCs (P = 0.008) and organoleptic scores (P = 0.032) when baseline values were compared to day 5. A positive correlation between VSCs and organoleptic scores was observed in all measurements (r = 0.67, P 0.0001). Conclusion: The results of this study suggest that the lack of toothbrushing may affect VSC levels and the organoleptic perception of oral malodour due to the development of biofilm on buccal and lingual surfaces of teeth in healthy subjects. Keywords: morning bad breath, periodontally healthy subjects, toothbrushing, volatile sulfur compounds

Purpose: The age of the patients, the presence of one or more chronic disorders and the patients' drug regimens can influence dental treatment and oral health. This is a prospective, descriptive study to identify subjects with compromised health who received dental treatment between November 2010 and June 2011 at private dental practices run by graduates of the Portuguese Catholic University. Materials and Methods: Application software in Microsoft Excel was developed containing the questionnaire, based on the EMRRH (European medical risk related history), which allowed the collection of data from 1603 adult patients. Microsoft Excel, G*Power and SPSS V.18 were used for statistical treatment. Results: The five most frequent medical conditions found were: 1) hypertension, 21.0%; 2) arrhythmias, 11.2%; 3) Angina pectoris, 8.3%; 4) allergies, 77%; 5) thyroid disease, 6.2%. The medications taken related to these were: a) antihypertensives, 11.0%; b) antidepressants, anxiolytics and hypnotics, 10.6%; c) acetylsalicylic acid, 4.2%; d) antiarrhythmic and sympathomimetic drugs, 4.1%; e) haemostatic treatment, 3.6%. 42.7% of the patients had no medical risks, 32.9% were classified as ASA II, 11.7% as ASA III and 12.7% as ASA IV. Conclusion: This study emphasises the importance of often-neglected anamnesis in oral care. The high prevalence of patients with medical conditions should be continuously studied to verify the changes over time and should be expanded to other regions and countries. Keywords: dental health status, health risk, medically compromised patient

Purpose: Sociodental indicators assess to what extent oral conditions interfere with normal social functions and alter behaviour such as attending work or school, parenting or home chores. The child OIDP (oral impact on daily performance), a sociodental indicator developed by Adulyan and Sheiham, is easy to apply and has a scoring system that quantifies the effect both by extent and frequency. The purpose of this study was to adapt the child OIDP into Hebrew and evaluate its validity and reliability. Materials and Methods: The questionnaire was translated from English into Hebrew and back again. After receiving permission from parents and from the children attending the consultation clinic of the Department of Children's Dentistry at the Hebrew University-Hadassah Dental School, we examined their dental condition and asked them to answer the questions. According to the results, we analysed the reliability and the validity of the questionnaire. Results: 179 children aged 6-11 years answered the questions. 88.8% of the children that attended the dental clinic experienced an oral or dental problem and 52.5% of them experienced interference in at least one of 8 everyday activities because of oral or dental problems in the 3 months prior to the interview. The OIDP was found valid in the aspects of Face, Content and Construct validity and with good internal reliability. Conclusions: The validity and the reliability of the Hebrew child OIDP found in the present study enables its use in future studies to assess the impact of oral health on children's quality of life. Keywords: child oral health, oral-health related quality of life

Purpose: To record the available current national and regional data on the oral health of community-dwelling (living in their own homes, not institutionalised) older people globally and discuss the future trends considering existing dangers and opportunities. Materials and Methods: A literature search on tooth loss, dental decay and periodontal disease in the elderly was performed using available databases and electronic sources. Results: The findings revealed that the updated national data are scarce in many parts of the world, particularly in Africa, Asia and South America, and direct comparisons are not always possible due to methodological variations. The available information may indicate that dental disease in older adults worldwide is more prevalent compared to younger age groups, with significant variation between countries and regions. Tooth loss is currently more common in the developed countries, while dental decay and periodontal disease are more widespread globally. There are important threats for further deterioration of the oral status among older adults in many developed and less developed areas due to existing sociodemographic and economic risk factors. Conclusion: National studies should be undertaken to record the specific oral problems of the elderly in each area. It is also necessary to develop gerodontology study programmes globally at the undergraduate, postgraduate and continuing education levels which will enhance dentists' knowledge, skills and attitudes towards oral care in the older population, and will promote opportunities for further research and development of relevant policies. Keywords: dental caries, elderly, oral health, periodontal disease, tooth loss

Purpose: To identify the most effective methods of toothbrushing in children, assessed according to their ability to remove dental plaque. Materials and Methods: After electronic research, randomised clinical studies in children which compared different toothbrushing techniques or different frequencies with the same technique were included. The evaluation criterion was plaque index. Results: Six of 534 identified articles were included. Because the protocols differed, regrouping of data was not possible. The level of evidence was moderate due to imprecise methods. The horizontal technique was found to be the most effective up to 6 to 7 years of age. For older children, there was no statistical difference between the techniques. No randomised clinical trial assessed different frequencies of toothbrushing. Conclusion: Based on current knowledge, it would appear prudent to propose that, at the stage of the late mixed dentition, the technique adopted by the child be modified to improve brushing quality without favouring a particular technique. In younger children, the horizontal technique should be advised. The recommendations published via the Internet by national and international associations should be reconsidered. Keywords: recommendation, systematic review, toothbrushing technique

Purpose: To determine the incidence of dental caries and evaluate the influence of socioeconomic, clinical and demographic variables on the time for disease to appear in the permanent teeth after 3 years of follow-up. Materials and Methods: The random sample of this cohort study consisted of 427 5-year-old preschool children attending 22 public preschools in Piracicaba, SP, Brazil. Dental caries was measured using the dmf/DMF indices. The Kaplan- Meier survival analysis method was used to study the isolated effect of socioeconomic, clinical and demographic variables on caries incidence after 3 years. A Cox proportional hazards regression model was built to test the influence of the variables collected at baseline on time to develop DMFT increment. Results: Survival analysis showed that children without past caries experience in primary teeth at baseline remained caries free in permanent teeth for a longer period than children with past caries experience at baseline. The variables monthly family income, parents' educational level, number of people living in the household, home ownership and car ownership were not significant. Conclusion: Children who presented past caries experience in primary teeth at baseline are at greater risk of developing DMFT increment than children who have no past caries experience at baseline. Keywords: dental caries, risk assessment, risk predictor, survival analysis

Purpose: Dentin caries constitute a complex ecosystem with a diverse microbiota adapted to fluctuations in nutrient concentration and acidity. However, knowledge about the acid tolerant microbiota at different levels in the lesion is rather poor. Hence, the purpose of this study was to investigate the acid tolerant microflora at different levels in established dentin caries lesions using solid pH-selective media. Materials and Methods: Primary dentin caries lesions were sampled with a bur at three levels (superficial, centre and the clinically caries-free floor of the lesion) in 10 patients. Samples were incubated on pH-neutral and pH-selective (pH 4.0, 4.5, 5.0, 5.5) agars. Numbers of colony-forming units (cfu) were determined and colonies were subsequently characterised morphologically and isolated. Results: The total number of bacteria in the carious lesions, recovered using blood agar (BA), ranged from 5.88 x 103 to 5.85 x 105 (median 2.64 x 105; range 5.80 x 105) and numbers of recovered bacteria decreased with decreasing agar pH. Fewer bacteria were found in the clinically caries-free dentin (P = 0.042), but the mean number of cfu (BA) was still 5.88 x 103 in those samples. Conclusion: Each of the 10 investigated dentin caries lesions harboured a unique microbial flora, indicating that various combinations of aciduric bacteria can colonise, survive in and probably propagate dentin caries. Solid pH-selective agars can be used successfully to select acid-tolerant microorganisms in dentin caries lesions. This could be used to describe this subset of the total microbiome from a phenotypic point of view, an objective that cannot be accomplished using molecular methods. Keywords: aciduric bacteria, dentin caries, pH-selective agar

Purpose: To test the effectiveness of yogurt extract as an agent to protect tooth enamel from demineralisation in vitro. Materials and Methods: The crowns of 80 intact caries-free human premolars were selected, and standardised 5 x 3 mm2 enamel windows were isolated on the buccal and lingual surface of each tooth. The baseline weight of each specimen was recorded. Four demineralising solutions were prepared: S1: lactic acid (LA) at pH 4.8; S2: LA at pH 3.97; S3: LA + yogurt supernatant (YS) at pH 4.8; S4: LA + YS at pH 3.97. The calcium content of each solution was determined using compleximetric titration with Eriochrome black-T. The 80 teeth were randomly divided into 4 groups. Each group was incubated in its corresponding solution at 37°C for 96 h. The specimens were weighed again and the calcium content of the four solutions determined. Five samples from each group were randomly chosen, sectioned through the treatment windows, stained with rhodamine-B and viewed under a confocal laser scanning microscope (CLSM). Lesion area (LeA) and average fluorescence (AF) were calculated using Image J software. Total fluorescence (TF) values were obtained by LeA x AF. Results: There was a statistically significant difference between groups in terms of LeA and TF. No statistically significant difference was found between groups in terms of difference in weight. Conclusion: Probiotic yogurt extract is effective in reducing demineralisation of enamel under experimental conditions. Keywords: confocal laser scanning microscopy, demineralisation, probiotic yogurt, remineralisation

Purpose: The principal objective was to investigate the association between periodontal diseases and sickle cell anaemia (SCA). Materials and Methods: A group of 59 children with SCA (ages 12 to 16 years) were examined and compared to 54 healthy controls, matched by age and gender. Oral clinical examination included: plaque index (PI), gingival index (GI), probing depth (PD), clinical attachment loss (CAL), presence of calculus and tooth mobility. Clinical severity of SCA and oral hygiene habits were also assessed. Results: There was no statistically significant difference between cases and controls in terms of PI, PD, CAL and tooth mobility at the 5% significance level. However, there was a statistically significant association between GI and SCA (P = 0.002). The mean gingival index of SCA patients was 1.35 ± 0.19 compared to 1.18 ± 0.16 for the controls (P = 0.00001). There was a probability of 76.1% that the GI of SCA patients was greater than the GI of controls. The percentage of teeth with PD = 4 mm was greater in SCA patients compared to controls (2.5% vs 0.6%). Moreover, SCA patients had a higher percentage of teeth with CAL = 3 mm (0.7% vs 0.3%). There was a statistically significant association between having mild, moderate or severe gingival inflammation and the severity of sickle cell anemia (P = 0.028). Conclusions: The results showed a statistically significantly higher prevalence of inflammed periodontium in children with SCA compared to a similar healthy population. Keywords: children, periodontal diseases, sickle cell anaemia, Sudanese

Purpose: To evaluate the perceptions held by dentistry undergraduates about the relationship between general health and periodontal disease. In addition, student knowledge about treatment of patients with systemic disorders was also examined. Materials and Methods: Participants were all undergraduates in the last year of dental school from three different universities (N = 253). Inclusion criteria were students enrolled in their last year of the dental curriculum and who agreed to participate in the research. After the participants filled out a structured questionnaire, the results were analysed using Epi Info 3.5.1 software and the chi-square, Friedman and Wilcoxon tests. Results: The majority of participants recognised the relationship between periodontal and cardiac disease and diabetes mellitus. However, only half of the participants were aware of the relationship between periodontal disease and stroke (50.5%). In relation to caring for patients with systemic diseases, 61.4% of students surveyed did not know the blood glucose level that characterises a hypoglycemic status. The majority of participants (61.8%) stated the importance of evaluating vital signs prior to dental treatment. However, only 13.3% of the participants included temperature and respiratory rate as vital signs. Conclusion: The perception and attitude of undergraduates about the items on the questionnaire were deficient. Thus, a more holistic view of the patient is warranted within dental education, promoting health and quality of life. Keywords: dental education, dental students, higher education, periodontal diseases