Dental Abstracts Vol 70, Number 4

DENTAL ABSTRACTS

Editor-in-Chief

Douglas B. Berkey, DMD, MPH, MS

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Abstract Writer

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DENTALABSTRACTS

ASELECTIONOFWORLDDENTALLITERATURE

EditorialBoard

Editor-in-Chief

DouglasB.Berkey,DMD,MPH,MS ProfessorEmeritus, SchoolofDentalMedicine, UniversityofColorado, Aurora,Colorado

AssociateEditor

DanielM.Castagna,DDS AssociateProfessor,DepartmentofPreventiveandRestorativeDentistry, UniversityofthePacific,ArthurA.DugoniSchoolofDentistry, SanFrancisco,California

P.MarkBartold,DDSc,PhD,FRACDS(Perio) ProfessorEmeritus SchoolofDentistry, UniversityofAdelaide Adelaide,Australia

RobBerg,DDS,MPH,MS,MA ProfessorandChair, DepartmentofAppliedDentistry, UniversityofColoradoSchoolof DentalMedicine, Aurora,Colorado

TylerH.Berkey,DMD GeneralDentist Aurora,Colorado

FionaM.Collins,BDS,MBA,MA ConsultantandEditor, GeneralDentist Longmont,Colorado

AnthonyJ.DiAngelis,DMD,MPH ChiefofDentistry, HennepinCountyMedicalCenter, Professor,UniversityofMinnesota, SchoolofDentistry, Minneapolis,Minnesota

RaulI.Garcia,DMD,MMedSc ProfessorandChairman, DepartmentofHealthPolicyandHealthServicesResearch, BostonUniversitySchoolofDentalMedicine, Boston,Massachusetts

MichaelSchafhauser,DDS GeneralDentist, St.Paul,Minnesota

JoeVerco,DClinDent PaediatricDentist NorthAdelaide,Australia

DENTALABSTRACTS

JULY/AUGUST2025

VOL.70 No.4

Commentary

Oral/SystemicLinkages246 OralMicroorganismsCausingSystemicInfections MeaningfulConnections247

BeMindful,Grateful,andCurious

TheFrontOffice

DentalCareerSatisfaction/MentalHealth248 FactorsContributingtoJobSatisfaction

IdentifyingStressesandSupportsforDental Practitioners

MotivatedbyProfitorNonmale ficenceand Bene ficence?

MakeYourImageConveyPositiveandEthicalBehavior

PrenatalOralHealth271 DeliveringOralHealthtoPregnantWomenandTheir Children

VitalPulpTherapy272 TreatmentOptionsforIrreversiblePulpitisin PermanentTeeth

SilverDiamineFluorideforIndirectPulpCappingof theFirstPermanentMolar

IndirectPulpCappingforSevereEarlyChildhood CariesLesions

WaterFluoridation277

NewerResearchintoCommunityWater Fluoridation’sEffectsonChildhoodCaries EthicsandthePublicHealthIssueofWater Fluoridation

LiteratureAppraisalsofCommunityFluoridation EarlyExposuretoFluorideandIQ

Hands-On Cannabis285

HealthConsequencesofCannabisUse

EatingDisorders286 Avoidance/restrictiveFoodIntakeDisorder

GeriatricDentistry289 PragmaticTreatmentApproachesForOlderAdults ManagingTMD292 IdentifyingandFacilitatingCareofTMD

MSDPrevention295 AssumingtheBestPostureforDentalCare

PediatricFirstPermanentMolars296 AddressingCariesandHypomineralizationofFirst PermanentMolars

Sepsis299 RecognizingSignsandSymptomsofSepsis

SugaryMedicines/Children302 AddressingSugaredMedicationsforChildren

VapingandOralHealth305

CounteractingMisinformationAboutVaping

Inquiry

CompleteDentures/Taste307 EffectofDenturesonTastePerception

CostEffectiveness/RootCanalTreatment308 DeterminingTreatmentBasedonCost-Effectiveness

DengueFever309

OralManifestationsofDengueFever

DentalAnxiety311

DentalTreatmentUnderGeneralAnesthesia

Endodontics/RestorativeDentistry313

RestorationsforEndodonticallyTreatedTeeth

OralMicrobiome315

ChangesintheOralMicrobiomeOvertheLifespan

OrthognathicPsychology318

PatientSatisfactionandImprovedQualityofLife AfterOrthognathicSurgery

PeriodontalTreatment319 Bene fitsofPeriodontalTreatments

VerticalDimension320 ControversiesRegardingtheVerticalDimensionof Occlusion

Extracts

322 IsThatReallyTrue?

Notes

TofacilitatetheuseofDentalAbstractsas areferencetool,allillustrationsandtablesincluded inthispublicationarenowidentifiedastheyappear intheoriginalarticle.Thischangeismeanttohelp thereaderrecognizethatanyillustrationortable appearinginDentalAbstractsmaybeonlyoneof manyintheoriginalarticle.Forthisreason, figure andtablenumberswilloftenappeartobeoutof sequencewithinDentalAbstracts.

StandardAbbreviations

Thefollowingtermsareabbreviated:acquiredimmunodeficiencysyndrome(AIDS),humanimmunodeficiency virus(HIV),andtemporomandibularjoint(TMJ).

COMMENTARY ORAL/SYSTEMICLINKAGES

OralMicroorganismsCausingSystemicInfections

BACKGROUND

Mostpeopledon’tdevelopsystemicdiseasefromoral flora,but it’spossible.Themouthishometomanymicrobialspecies,witha myriadofthemlinkedtosystemicdiseases.Amongthesofttissue infectionsthatcanoccurarenecrotizingfasciitis(NF),strep throat,andimpetigo.Oftentheseinfectionsresultfrombacteria enteringthebodythroughabreakintheskincausedbyacut,an insectbite,orsurgery.Dentistsneedtobeawareoftheprimary oralorganismscausinginfectionsandwheretheseorganismslive sothattheycaninstitutepropermeasurestoavoidtheirdisseminationthatleadstosystemicdisorders.

THEMAINCULPRITS

Aquicklistingofpossiblemicrobialspeciesinthemouthincludes Actinomyces,Capnocytophaga,Corynebacterium,Fusobacterium, Leptotrichia,Prevotella,Rothia,Selenomonas,Streptococcus,Treponema, and Veillonella.Skininfectionsarecommonlycausedby Staphylococcusaureus.

SOURCESANDLINKSTODISEASE

Saureus iscarriedbyabout30%ofthepopulationinthenoseand about20%intheoralcavity.Highlycontagious, Saureus canbe spreadbycoughing,talking,orcontactwithacontaminatedsurface.Thisopportunisticpathogencancauseinfectioninanopen woundorinpatientswithsystemicmedicalconditions.

Spyogenes causesinfectionsrangingfromstrepthroattoNF.It’ s foundinthepharynx,anus,andgenitaliabutalsoinhabitsdental plaque,whichlikelyrepresentspharyngealcolonization.Upto 10%ofthepopulationcancarryit.AftertheCOVIDpandemic, strepinfectionshavedecreased,sothepopulationmayhavelost someofitsimmunity.

Researchhasidenti fiedthegut-brainaxiswhereinintestinal micro floramayaffectthebrainandcouldbelinkedtomental healthproblems.Theremayalsobeanoralcavity brainaxis. Somespecies,suchas Porphyromonasgingivalis,cancausesystemic

diseaseifitentersthebloodstream,withcardiovasculardiseasea possibleresult.IthasalsobeenlinkedtoAlzheimer’sdisease. Fusobacteriumnucleatum hasbeenlinkedtogastriccarcinoma.

DENTAL-RELATEDRISKS

Dentalproceduresareknowntocausebacteremia,ascandaily oralhygienepractices.Althoughthechanceofgettingasystemic diseasefromoral floraisverylow,theactualprocesslinkingoral bacteriatosystemicdiseasesremainslargelyunknown.

ClinicalSignificance

NFresultsfrombacteriaenteringthebodythrougha breakintheskin,althoughsomecasesarecaused byfungiorviruses.Thesemicroorganismsrelease extensiveamountsofendotoxinsandexotoxins thatcausenecrosisoftissuesthroughoutthebody, alongwithseveresystemicsymptoms.Patientsmust undergoaggressivetreatmentssuchassurgical debridement,intravenousantibioticsorimmunoglobulin,oramputation.Septicshock,kidneyfailure,and deathcanresult.Aspirationbiopsiesandsamples fromtissuesinthewoundareneededtoidentifythe causative floraandindicatewhichantibioticismost appropriate.Empiricalantimicrobialsworkwell,and someorganismsstillrespondtopenicillin.Dentists needtobealerttotheriskoforalmicrobiota related systemicdiseasesandtakepreventivemeasuresto ensurethatpatientsareoptimallyprotectedfrom infection.

DarbyI:Themouthasreservoirforsystemicinfection. Austral DentJ 69:249-250,2024

Reprintsnotavailable

MEANINGFULCONNECTIONS

BeMindful,Grateful,andCurious

BACKGROUND

In2023,theUSSurgeonGeneralannouncedtherewasanationwideepidemicoflonelinessandisolationthataffectedabouthalf ofalladults.Socialdisconnectioncanhaveanegativeimpacton mortalityandisassociatedwithanincreasedriskforcardiovasculardisease,dementia,stroke,depression,andanxiety.Thelonelinessandisolationepidemicresultedfromtherapidgrowthof socialmedia,arti ficialintelligence(AI),andremoteworkand wasexacerbatedbytheCOVID-19pandemic,whensomany wereisolatedfromlovedones,thecommunity,andsupportsystems.Ourphysicalhealthandwell-beingcanbepositivelyinfluencedbysocialsupportandhumanconnection.Speci ficeffects havebeenreportedonourwell-being,theabilitytomaintain bodymassindex,adecreaseindepressivesymptoms,therelief ofsymptomsofpost-traumaticstressdisorder,andpositivealterationsinoverallmentalhealth.Wenowfaceapoliticallypolarizedclimatewithdeeplydividedgapsincommunities,broken trust,andisolation.Waystocultivatemoremeaningfulconnectionsindentalsettingsweresuggested,includingmindfulness, gratitude,andcuriosity.

MINDFULNESS

Itcanbediffi culttoconcentrateandmaintainourfocusamidthe constantnotificationsanddigitalsignalswereceive.Wemay struggletoremainempathicinpatientcareandinourdailyinteractions.Mindfulnessinvolvesthemoment-to-momentnonjudgmentalawarenessofourthoughts,feelings,bodilysensations, andsurroundingenvironment.Itallowsustotakeabreathand seektounderstandothers’ perspectivesandemotionsrather thanconsideronlyourown.Thishelpsinbecomingmore responsivetotheneedsofotherpeople.

Withmindfulcommunication,welistencarefullytotheother personandobservetheircurrentstateandtheirbodylanguage. Thisallowsustoopenourheartsandmindsandseeourown emotionsandsensations.Asaresult,wecanrespondmore thoughtfullyandengagemorefullywiththeotherperson.

GRATITUDE

Expressingandreceivinggratitudehelpsusinitiate,maintain,and strengthenrelationships.Thisholdsinromanticrelationshipsas wellasfriendshipsandcanleadtocoworkersbeingevenmore helpful.Thankingsomeoneandreflectingonthosewefeelgratefultocanbuildpowerfulconnectionswithotherpeople.Through expressionsofgratitude,werealizeandshowotherstheirvalue inourlives.Buildingacultureofgratitudeinthedentalteamand practicecreatesahealthyenvironment,morepositiveemotions, andlesshostilityoraggression.

CURIOSITY

Reflectinggenuinecuriosityaboutapersonduringinterpersonal interactionscanhelptobridgeanygapbetweenthe2parties. Insteadofrushingtojudgment,whichpushespeopleaway,asking questionstobetterunderstandandreachtheheartofthemotivation,perspective,andbackgroundofothersshowsasincereinterestinlearningfromthemandtakesthefocusoffofourselves. Theabilitytoremaincuriousallowsustoopenourselvesto deepermeaningfulrelationshipsthatwemighthavemissed otherwise.Curiositycanfosterthegrowthofconnection.

ClinicalSignificance

Evenwiththeobstaclesthatwefaceinourcurrentenvironment,maintainingafocusonhumanconnectioncan remainthecoreofourdentalpracticeaswellasourpersonallives.Remainingmindful,grateful,andcuriouswill helpourpersonalhealthandwell-being,butwillalso strengthenconnectionswithothers.

YamamotoKK:Cultivatingmeaningfulconnectionsindentistry andbeyond. JCalifDentAssoc 53:2450327,2025

Reprintsnotavailable

THEFRONTOFFICE

DENTALCAREERSATISFACTION/MENTALHEALTH

FactorsContributingtoJobSatisfaction

BACKGROUND

About45,000dentistsareregisteredintheUnitedKingdom, withmostinprimarycaresettings.Inthepursuitofknowledge aboutworkforceretentionandthedevelopmentofeducation andtrainingopportunitiesfordentalprofessionals,asurvey wasconductedofdentists’ experiencesintheirprofessional careersandjobsatisfactionlevelsaspartoftheUKdental workforce.

METHODS

Thenationaldentalworkforcewasprovidedanonlinequestionnaire,and875ofthe1240respondentscompletednearlyallof thequestions,makingthemthesubjectoftheanalysis.Thequestionsaskedaboutthechallengestothehealthandwellbeingof thedentalworkforce,currentprofessionalcareertrajectories, andwhetherornotthedentists’ careeraspirationshavebeen orarebeingmet.

RESULTS

Nearly56%oftheparticipantswerefemale,about75%were white,most(about81%)weregeneralpractitioners,themajority (about92%)workedinEngland,mostgraduatedfromaUK school(about88%),andthegreatestnumbers(about63%) servedinprimarycaresettings.

DentalCareers

About41%reportedtheircareerplanswereasenvisioned, whereasabout58%notedchangesintheircareerplansover time.Inaddition,about42%wereplanningtochangetheircareersinthefuture.Mostofthemen(about47%)reportedtheir careerwasasenvisioned,whereasonlyabout38%ofwomensaw theircareersasontrackforwhattheyhadexpected.Allofthe ethnicgroupsexceptwhitepersonsreportedtheircareers werenotasenvisionedortheyhadhadtochangetheirplans. Theoverseasgraduatessigni ficantlylessoftenreportedtheir careerwasontrackcomparedtoUKgraduates.Peoplewho hadbeenintheirprimaryjobroleforlongerweresignificantly morelikelytoreporttheircareerplanwasasenvisionedand hadnoplansforchangingcareers.Dentistsinprimarycare weremorelikelytowanttochangetheircareerplansthanthose insecondarycare,universitypositions,communitydental

services,orarmedforces.Averagejobsatisfactionwasreported assignificantlygreateramongthosewhosecareerwasasenvisionedcomparedtothosewhohadachangeincareerplansor plannedtochangetheircareer.

Threemodelswereusedtoevaluaterelationships.Amongthe groupwhosecareerwasasenvisioned,jobsatisfactionandprimaryrolesettingweresigni ficantcontributorstotheirposition. Forthosewhohadadifferentcareerplanfromwhattheyenvisioned,jobsatisfaction,havingcountryqualification,andserving inaprimaryroleweresigni ficantpredictorsfortheirposition. Jobsatisfactionanddurationofprimaryjobrolecontributed significantlytothepositionofthoseplanningonchangingtheir career.

JobSatisfaction

Jobsatisfactiondifferedsigni ficantlydependingonethnicity, countryofinitialqualification,primaryrolesetting,workexperience,currentmainrole,andnumberofrolesheld.Whitepeople hadhigherjobsatisfaction,asdidUKgraduates,thoseworking outsideaprimarycaresetting,specialists,anddentistswith extendedskills.Personswhohad2jobroles,whichprovided diversityintheircareer,alsohadhigherjobsatisfactionlevels. Signi ficantassociationswerenotedbetweenjobsatisfaction andethnicity,durationofjobrole,primarysettings,current role,numberofroles,andcareerplans.

CONCLUSIONS

Thefactorscontributingtothecareertrajectoryofdentists includedsex,jobsatisfaction,primaryrole,countryofqualification,anddurationofworkingexperience.Dentistsfellintothe categoriesofhavingacareerastheyhadenvisioned,having changedtheirplan,orplanningonchanging.Women’ scareer planstendedtonotfollowthepatterntheyenvisioned,along withpeoplewhoqualifiedoutsideoftheUKandbeingalessexperienceddentist.Thosewhosecareerhadgoneasenvisioned tendedtohavegreaterjobsatisfactionlevels,asdidthosewho werewhiteorAsian,whoservedforalongertimeintheirposition,whoprogressedintheircareer,andwhoheldmultiplejob roles.Lowerjobsatisfactionlevelswerereportedbydentists workinginprimarycaresettings.

ClinicalSignificance

Researchisneededtobetterunderstandthelongtermfactorsthataccompanydentists’ careerpaths. Inaddition,dentaleducationandtrainingandinterventionstosupportdentistsinreachingtheircareergoals needtobeclarified.Thesemeasuresareimportantto ensurethattheneedsofthepopulationaremetbya suitabledentalworkforce.

ClarkM,McGregorA,KairuddinANM,etal:Dentalcareers: Findingsofanationaldentalworkforcesurvey. BrDentJ 238:249-256,2025

Reprintsavailablefrom MClark,OralSurgeryDept,Newcastle DentalHos,RichardsonRd,Newcastle,NE24A1,UK;e-mail: megan.clark12@nhs.net

IdentifyingStressesandSupportsforDental Practitioners

BACKGROUND

Allhealthcareprofessionalsareatriskformentalhealthchallengesrelatedtotheirwork,theirenvironment,andthebalance betweentimeandinvolvementinworkandlifepursuits.AsurveywasundertakenamongCanadiandentistsandstakeholders todeterminewhattheyseeasmentalhealthchallenges,what supporttheyfeeltheyneed,andwhatsupportcouldbeavailable tothem.

METHODS

Thedatawerecollectedfromsemi-structuredqualitativeinterviewsaswellasasurvey.Thedentalparticipantswereidenti fied throughsocialmediaplatformsande-mailinvitations.Inaddition, directe-mailsweresenttostakeholders.Asaresult,36interviewswereconductedwithpracticingdentistsand17withstakeholders.Thestakeholderscamefromdentalassociations, regulatorybodies,academicinstitutions,insuranceorganizations, andotherrelevantorganizationssuchasorganizeddentistry groups.

STRESSORS

The findingsweredividedinto2groups:(1)mentalhealthexperienceswithrespecttoworkpluspersonalandfamilialchallenges and(2)supportneedsandpotentialopportunities.

MentalHealthExperiences

Thedentistsreportedawiderangeofmentalhealthexperiences, includingstress,anxiety,depression,burnout,obsessivecompulsivedisorder(OCD),post-traumaticstressdisorder (PTSD),andsuicidalideation.Somehadbeenformallydiagnosed byamentalhealthcarespecialist;othersself-reportedtheseissues andexperiences;andstillotherswerereportedbystakeholders. Thestakeholdersmentionedthepotentialrepercussionsof

untreatedmentalhealthconditionsthatcouldpresentariskforpatientwell-beingandmayinvolveregulatorybodiesifdentists refusetoseekhelporusetheavailableresources.

Theseresultswerecorroboratedbythesurveyresults.Fortyfourpercentoftherespondingdentistsreportedsufferinga mentalhealthissue.Whenthedentists’ genderwasconsidered, 59%ofthefemaledentistsand39%ofthemaledentistshadexperiencedmentalhealthissues(Table2).

Work-relatedIssues

Theworkenvironment,professionaldemands,andpatientcare challengesin fl uenceddentists ’ rangeofmentalhealthsymptoms,whichincludedstress,anxiety,andburnout.Sex/gender alsoin fl uencedtheirexperiences .Amongtheexperiences relatedtopatientcareresponsibilitieswerestressasaresult ofdealingwithpatientswhohaveunreasonableexpectations anddealingwithchallengingpatients,suchastheelderly,patientsfrommarginalizedcommunities,andincarceratedpatients.Dentiststendedtointernalizetheirpatients ’ anxiety, distress,andfear,whichexacerbatedtheirownmentalhealth struggles.

Dentistsalsoreportedproblemsrelatedtoethicalpractices, especiallyinvolvingpatientsfrommarginalizedcommunities. Thefeeschedulefordentistscaringforthesepatientsisvery limited,sotheymustchoosebetweennottreatingthepatients, providingsuboptimalcare,andrisking financialloss.Ethicalproblemsalsoaroseinrelationtopressuresfromof ficemanagers,the drivetorecommendprofitableprocedures,andbeinggivenunrealistictargets.Femaledentiststendedtobelievethesetargets conflictedwithclinicaljudgmentandthreatenedtheirmental healthandwell-being.Theyalsoexperiencedprejudicerelated totheirabilitytoperformsomeprocedures,suchasoralsurgery.

Table2. MentalHealthIssuesandSourcesofStressExperienced byDentistsWhoRespondedtotheSurveyStrati fiedbyGender

Characteristic

Mentalhealthissues

Female,% (n) Male,% (n)

Mentalorpsychologicalstressordistress31.9(62)22.2(41)

Burnout24.2(47)15.1(28)

Anxiety36(70)16.2(30)

Depression12.4(24)3.7(7)

Substanceuse/dependence4.1(8)0

Posttraumaticstressdisorder3.6(7)0

Sourcesofstress:workrelated

Workoverload41.7(82)32.4(60)

Stressofrunningapractice,managing people,meetingbudgets

45.6(89)51.3(95)

Uncertainty15.4(30)11.9(22)

Poorrelationswithcoworkers/colleagues13.9(27)8.6(16)

Poorrelationswithpatients/clients9.3(18)6.4(12)

Ethicaldilemmas6.2(12)9.2(17)

Lackofpsychologicalsafetyatwork, includingbullying,harassment, discrimination,orworkplaceviolence

Sourcesofstress:nonworkrelated

5.7(11)0

Physicalhealthproblemorcondition16.5(32)14.6(27)

Debt/financialsituation23.7(46)16.7(31)

Caringforchildren29.9(58)11.9(22)

Caringforothers(outsideofwork)16(31)9.2(17)

Timepressure/notenoughtime39.2(76)24.9(46)

Emotionalormentalhealthproblems19(36)8(15)

Note: Thepercentagewascalculatedbydividingthenumberof respondingdentistsineachcategorybythenumberofdentistswhohave completedthesurveyinfull.Incompleteparticipationwasnotincludedin thepercentagecalculation.

(CourtesyofMaraghaT,AtanackovicJ,AdamsT,etal:Dentists’ mental health:Challenges,supports,andpromisingpractices. JDRClinical TranslationalRes 10:100-111,2025.)

Theyfelttheywereunderaddedpressureandwerefrustrated withbeingseenaslesscompetentthanmaledentists.

RoleinDentalPractice

Associatedentists experiencedalackofautonomyandcontrol overtheirschedules,withconflictsbetweenthemandtheirofficemanagersorpracticeowners.Thesedentistsfeltthey werebeingmicromanagedandexperiencedadverseeffects fromtheofficebureaucracyoractualbullyingexperiences. Someof ficepersonnelsetunreasonableandprofit-drivengoals forassociates,whosometimesleftthepracticeaftersigni ficant stress.About13%ofthedentistsexperiencedstressrelatedto poorrelationshipswithcoworkersandotherdentalpractice workers.Femaledentists,whetherinassociateorotherroles, felttheirpsychologicalsafetywasatrisk,butthiswasn’treported bymaledentists.

Theaddedresponsibilityofbeinga practiceowner ledtoconcerns aboutcompetitionaswellashowtomanagehumanresources, finances,andproductivity.Ownersarealsotaskedwithdoing troubleshootingandmanagingtechnologyissues,orderingsupplies,andkeepingtrackofinventory.Maintainingtrained,competentdentalstaff,includingreceptionists,assistants,andhygienists, wasreportedlyaspecialconcerninruralandremoteareas.

Practiceownersfelttheseresponsibilitiesalteredtheirperspectiveoftheprofession,especiallyalackofprofessionalsatisfaction. About49%ofthedentistsinvariousrolesreportedpractice managementresponsibilitiesasawork-relatedstressor.

Genderin fluencedtheparticipationofdentistsindifferentprofessionalroles. Femalepracticeowners citedaproblemofperceptionwiththeirstaffs,whooftensawthewomanaslessassertive, moredramatic,andlessproductivethanmeninthatrole.The respectandresponsestofeedbackthatfemaledentistsreceived withrespecttopracticemanagementandpatientcareduties werelacking.Femaledentistsoftenfelttheyshouldsuppress theiremotionssotheyseemstrongerandmoreincontrol likeaman.

Thesenegativeinfluencescausedwomentobelesswillingtoown apractice.Thosewhowereownerswereoftenmoreproneto sellingthepracticeandtakingonanassociaterolesotheycould balancepersonalandprofessionalresponsibilities.Morefemale dentistsreportedtheirworkloadasawork-relatedstressor comparedtomen.

LonelinessandIsolation

Bothpracticeownersandassociatesexperiencedlonelinessand isolation.Thisisaparticularprobleminruralorremotesolo practices.Associatesmentionedfeelingalackofsupportfortheir workandhadnoonetocallon.

PersonalandFamilyExperiences

Youngerdentistsandthosewhohaverecentlygraduatedexperiencestressrelatedtotheeducationaldebttheyhaveincurred. Thisisexacerbatedbyuncertaintyaboutjobandmentorship prospects.Youngerfemaledentistsalsoexperiencephysiological changesrelatedtopregnancy,peri-menopause,andmenopause andcitedthesechangesasinfluencesontheirmentalhealth andwell-being.

Dentistsfromvaryingethnicitiescanexperienceracism,especiallyinruralandremotesettingswherefewermembersoftheir minoritygrouplive.Dentiststrainedinternationallycanexperiencedifficultyintegratingintoacommunity,strugglewithlanguagebarriers,andhavetroublebalancingthesupportoftheir immediateandextendedfamilies.

Caregivingresponsibilitiescanalsoin fluencedentists’ mental health.Femaledentistscitedchallengesbalancingtheirtraditional responsibilitiesrelatedtothehomewiththedemandsofowning

Table3. PromisingPracticesThatVariousCanadianOrganizationsHaveDevelopedandImplementedtoSupportDentists’ Mental HealthandWell-being

OrganizationProgram/InitiativeDescription

CDSPIMember’sAssistanceProgramTheprogramisavailabletodentistswhoaremembersofsome ProvincialandTerritorialAuthorities,includingBritishColumbia, Ontario,NewFoundlandandLabrador,andNovaScotia.

BritishColumbiaDentalAssociation (BCDA)

DentistWellnessProgram(DWP)AnearlyinterventionprogramfundedbyBCDA.Theprogramwas launchedinMay2019toassistpracticingdentistsindealingwith mentalhealthissues(includingaddiction)inresponsetodentists’ needforadentistwhocanrelatetotheirstrugglesandunderstand whathappenswithchallengingpatientsandpracticemanagement. Asapartoftheprogram,counselingservicesareavailableto dentists,dentalstaff,andtheirfamilies.

AlbertaDentalAssociationandCollegeWellnessProgramAconfidentialprogramthatinvolves11dentistswhoactas firstline respondersandreferdentistsandtheirfamilymembersto registeredpsychologists(foraquote,seeinterview16).

OntarioDentalAssociation(ODA)WellnessProgramandNewsletterTheprogramprovidesODAmemberswithaccesstoaphoneline staffedbydifferentdentistsattheotherend,inadditiontoproviding dentistswithaccesstoonlinecounseling.TheODAalsoaddresses issuesofmentalhealthintheirnewsletterandhasorganizedan onlineworkshoptodiscussmentalhealth,stressors,andcoping strategiesfordentists.

NewfoundlandandLabradorDental Association(NLDA)

RoyalCollegeofDentalSurgeonsof Ontario(RCDSO)

UniversityofSaskatchewanFacultyof Dentistry

WellnessCommitteeandNewsletterThecommitteehassetupawellnessboothintheAssociation’s annualconference.Theassociationhasalsodesignatedapagein theirnewsletterstodestigmatizehelp-seekingformentalhealth issues(seeinterview6foraquote).

WellnessInitiativeTheinitiativeaimstohelpdentistsaccessnecessarytreatment throughdesignatedfacilities,particularlythosewithaddiction issues(Stakeholder-3ON).

Students’ WellnessCommitteeand Faculty-SpecificInterventions

StudentshaveaMentalHealthandWellnessCommittee(see interview11).

TheFacultyofDentistryisliaisingwiththeUniversity’sWellness Centretoprovideasessionduringorientationweektodiscuss mentalhealth,self-care,andwell-beingofstudents

UniversityofTorontoFacultyofDentistryMentalHealthLunchandLearnsTheLunchandLearnSessionsaimtodiscussthementalhealthand well-beingofdentalstudentsthroughouttheircareersindental school,inadditiontoprovidingsupporttostudentsthroughthe Students’ ServicesOffices.

(CourtesyofMaraghaT,AtanackovicJ,AdamsT,etal:Dentists’ mentalhealth:Challenges,supports,andpromisingpractices. JDRClinicalTranslationalRes 10:100-111,2025.)

adentalpractice.Oftenthereiscon flictandablurringofthe boundariesbetweenhomeandwork,leadingtoguilttowardchildrenandfamilymembersaswellasoverwhelmandstresstoward theirworksituation.

Familymemberscanalsopresentchallenges.About30%offemaledentistsandabout12%ofmaledentistswerestressed regardingchildcare.Femaledentistscitedalackofsupport frompartnersandtheneedtosecuregoodchildcareduringtheir workdays.Non-work-relatedstressorsthatwereidenti fiedin additiontochildcareweretakingcareofothersintheirenvironment,timepressures,andemotionalhealthissues.

MENTALHEALTHSUPPORT

Variousorganizationalandsy stemicmentalhealthandwellbeingsupportresourcesandinterventionsareavailableto

providesupporttodentistsdealingwithmentalhealthchallenges(Table3).Someprogramsoffertraininginprevention andawarenessofmentalhealth.Therearealsothosethatsupporttheearlyintegrationofmentalhealthintothedentalcurriculum.Dentistswhohavedevelopedmentalhealthissues tendnottohaveformalevaluationprocessesandinterventions availabletohelpthemthroughtheseexperiences.

Dentistssuggestedintroducingtheconceptsofmentalhealth, coping,andstressmanagementskillsintothedentalschoolcurriculum.Dentalschoolsshouldbecomemoreinvolvedinpreparingstudentsfortherealityofpracticemanagementandpossible stressors.Businessmanagementcoursesshouldalsobepartof dentalschooltrainingtomakedentistsmoreabletobalance therigorofclinicaldentalpracticewiththebusinesssideofthe profession.

EXPANDINGINTERVENTIONS

Mentalhealthinterventionsandresourcesneedtobedesignedto addresstheuniquecircumstancesofdentists.Thismayinvolve participationinonlinegroupswherediscussionsoftopicscan leadtotheidenti ficationofresources,issues,andstressors. Thesegroupscanhelpdentistsdealwithlonelinessandisolation andoffertherapeuticresponsestomanysituations.

Involvementinorganizeddentistrycanalsohaveapositive impactonmentalhealth.Dentistsreceiveasenseofcommunity andpurposewiththeseefforts.Thismayalsocreateasenseof communityamongwomenintheprofession,enhancingthesupportiveandempoweringroleoftheseorganizationswithrespect topracticemanagementandownership.

Amentoringinitiativehelpsyoungdentistsbridgethegapbetweenschoolandthejobmarket.Participatingdentistssuggested dentalassociationscouldcreateformalmentorshipprograms. Thesecansupportoverallmentalhealthandwell-being,increase theyoungdentists’ levelofassurance,andgivethemasenseof community.

ETHICS

ClinicalSignificance

Severalfactorscontributetothementalhealthstrugglesthatdentistsface.Amongthesefactorsaresex/ gender,practiceownership,ethicalpractices,isolationandloneliness,andempowermentforfemale practitioners.Mentoringinitiativesonthepartofdental associationscanincreasethesenseofcommunityand helptotransitionnewlygraduateddentistsintoworkingsituations.

MaraghaT,AtanackovicJ,AdamsT,etal:Dentists’ mentalhealth: Challenges,supports,andpromisingpractices. JDRClinicalTranslationalRes 10:100-111,2025

Reprintsavailablefrom TMaragha,DeptofOralHealthSciences, FacultyofDentistry,TheUnivofBritishColumbia,2199WesbrookMall,Vancouver,BCV6T1Z3,Canada;e-mail: tala.maragha@alumni.ubc.ca

MotivatedbyProfitorNonmaleficenceand Beneficence?

BACKGROUND

In2024,aCBSNewsreportdocumentedatrendwheremarginallydiseasedandtreatableteethwerebeingextractedsothat dentalimplantscouldbeplaced.Thereportfocusedonthemotivationbeingprofitratherthanethicalpatientcareandquestioned thedentalprofession’sethicsinthesecases.TheAmericanAssociationofEndodontistsandAmericanAcademyofPeriodontologyexpressedconcernsabouttheproblemsexposedinthereport andwarnedthatextractionofteethisirreversibleandmayseriouslyimpactpatienthealthandqualityoflife.Chasingprofitwas discouragedwhenpatienthealthwasatrisk.Ethicalpractice dictatedthatpatientsbefullyinformedofalltreatmentoptions, especiallythosethatpreservenaturalteeth.Notcompletelyinformingpatientsoftheoptionsisabreachofacoretenetof theAmericanDentalAssociation’ s PrinciplesofEthicsandCode ofProfessionalConduct (ADACode),speci fically,patientautonomyorself-governance.Theethicsofextractionandtooth replacementwithimplantsversusperformingperiodontaltreatmentwerechallenged.

EXTRACTIONANDREPLACEMENTOR RETENTION?

RemainingEthical

Patientswhoarediagnosedwithteethrequiringextraction andreplacementwithimplantsmustbeinformedofallthe reasonableoptionsavailablealongwiththeclinician ’ srecommendedapproach.CompliancewiththeADACoderequires thatthepatientcanrespondaf fi rmativelytothefollowing questions:

Didthecliniciandiscusstreatmentoptionsthatwouldretain andmaintainthenaturaldentitionsothatthepatientcan makeacompletelyinformeddecision?

Didtherecommendedtreatmentsatisfytheethicalrequirementofnonmaleficence(donoharm)andbeneficence(do good)?

Wasthetreatmentrecommendationtruthful(veracityor truthfulness)andnotmotivatedbyprofit?

ComplicationsofImplants

Theevidence-basedliteratureshowsthatstrategicextraction shouldbedeferredwheneverpossibletoavoidcomplications foundwithperi-implantitis.Dentalimplantsthatareproperly placedhave5-yearsurvivalratesof85%to90%,butthesurvival ratedoesn’talwaysmatchthesuccessrate.Betweenabout15% and20%ofpatientswithimplantsdevelopimplantitis.Implantlevel datarevealperi-implantitisinabout9%to13%ofimplants.Bone lossanddepthofpenetrationoftheinflammatoryresponseis greaterinperi-implantitisthaninperiodontitis.Thetreatmentof peri-implantitisismorecostlythanthatofperiodontitisandthe long-termprognosisisworse.Noneofthesefactorsarebeneficial forthepatient.

SupportforNaturalToothRetention

SeveralresearchersreportmolarswithgradeIIfurcationinvolvementcanbetreatedandhaveameansurvivalofabout15years. Thetreatmentofperiodontitisandmaintenancetherapyas appropriatecanpreservethedentitionforasubstantialnumber ofyears.Withthisinformationinhand,extractionandreplacementwithdentalimplantswouldappeartonotbethe firsttreatmentrecommendation.

WHENTOUSEIMPLANTS

Implantsarebene fi cialwhenthepatients ’ teethhavebeen lostorarebeyondsaving.Oftenpatientswhohavecomplete

traditionaldenturesbene fi tsigni fi cantlyfromatransitionto implant-supportedfunctionandachievelife-changingesthetics.Dentistsaretrainedtoknowwhenteetharetruly beyondhelpandwhentheycanbesavedwithreasonable treatment.Patientbene fi tandnotpro fi tshouldguide recommendations.

ClinicalSignificance

Implantscanbewonderfulbutshouldn’tbeusedin everycase.Thenaturaldentitionhastheinnateability tohealwithpropertreatmentandmaintenance.Implantscan’tactuallyreplacethenaturaldentition. Thepatient’slong-termhealthandqualityoflife shouldguidethedevelopmentandrecommendation ofanydentaltreatmentplan.

HarrelSK:Dentistryhasbeenputonnotice. JAmDentAssoc 156:261-262,2025

Reprintsavailablefrom SKHarrel,DeptofPeriodontics,Collegeof Dentistry,TexasA&MUniv,3302GastonAve,Dallas,TX75246; e-mail: skharrel@gmail.com

MakeYourImageConveyPositiveandEthicalBehavior

BACKGROUND

Unethicalactivityisoftenconsideredsomeoneelse’ sproblem,withonlytheperpetratorbeingaccountable.Somewill trytojustifythewrongdoer ’sactionsbecauseofhisorher situationasasingleparentorseetheindividualunder fi nancialstress,leadingtothemisbehavior.Areweactuallyinnocentofanyintegritybreachorlapseinthehonestyof others.?Themanagementstylewechooseandthevalues weprojectasleadersin fl uencethebehaviorsofourdental team.Maintaininganethicalleadershipisessential.

THEIMAGEWEPROJECT

Wechooseourmanagementstyleandvaluesandtrytomaintain animagethatwillconveythosechoicestoothers.Acommitment tointegritycaninfluenceourteamtoadheretothevalueswe have,whereasonethatisn’tsovirtuousmayencouragea flareupofapreexistingtendencytogoastray.Copingwiththedaily challengesintermsofpatients,colleagues,andeachothercan

becompromisedifwedon’thaveafocusonintegrityrather thanengaginginshadybehaviors.

SEARS,ROEBUCK,ANDCOMPANY’SEXAMPLE

Intimespast,Searsmanagersencouragedemployeestogrowproductioninautorepairorsalesquotas.Thegoalwastoincrease productivityandboostprofits.However,multiplecustomers complainedthatemployeesweremakinginappropriaterecommendationsandperformingunnecessarywork,leadingtolawsuits. Eventuallythecasesweresettledforabout$60million,butthe episodedestroyedthenationaltrustinSears’ autorepairdivision.

CONCLUSIONS

Leadersshouldactvirtuouslytomodelthetypeofbehaviorthatis desiredintheircompanyordentalpractice.Theemployeeshould thenbeabletotrustthattheleaderwillactintheemployee’sbest interest.Thiscreatesauthenticcommitmenttotheorganization anditsmission.Everyonecanbenefitfromthisworkethic.

ClinicalSignificance

Peoplearewatchingthosetheyinteractwithdaily, whichincludesthoseofuswhoaredentistsorother healthcareprofessionals.Ifwhattheyseeinour behaviordoesn’tappearaboveboardandethical, theywillquestionourgoodnessandmotivation.Any unethicalbehaviorwilleventuallybecomewhatpeople rememberwhentheythinkofourdentalpractice.It’s besttoprojectanimageofhonestyandactualcare forthoseweserve.

GrecoPMPAlleyesareonus. AmJOrthodDentofacOrthop 167:142-143,2025

Reprintsnotavailable

HIRINGANASSOCIATE

DecidingWhentoAddAnotherDentist

BACKGROUND

Theresponsibilitiesassociatedwithownershipofadentalpracticecanweighheavilyontheowner’sshoulders,butcanbe offsetbytherewardsofownership.Theseincludethesigni fi cant differencebetweenthewealthapracticeowneraccumulates andthatearnedbyanassociate.Iftheowneristhinkingof bringingonanassociatetosharetheburden,heorsheshould carefullyanalyzewhythiswouldbeagoodtime.Generally, thedecisionisalifestylechoice oraneconomicdecision.Lifestylechoicesaredesignedtosharetheburdenofpatientcare sothattheownercanhavemorefreedomand fl exibilityinhis orherlife.Economicdecisionsarebasedonthegrowthandrevenuecreationofthedentalpractice.Thesegoalsaren’tnecessarilymutuallyexclusive,butbeforetakingthestepofadding anassociate,thedentistshoulddeterminewhetherthemotivationisdrivenbyeconomicorlifes tyleconsiderations,thenlook atannualrevenue,numberofoperatories,newpatientsseen eachmonth,andplans(bothshort -andlong-term)forthepracticeandagoodassociate.

ECONOMICDECISIONS

AnnualRevenue

It’sdifficulttohireandretainagoodassociateiftheannualrevenueofthedentalpracticeisn’tatorapproaching$1million. Annualrevenuelessthanthislevelisinsufficientfortheassociate toearnenoughtopayhisorherlivingexpenses,loanpayments, andotherbills.Generaldentalpracticestypicallyseeabout25% oftotalproductioncomeinthroughhygiene,soina$1million practice,about$750,000shouldcomefromthedentists,which isabout$62,500permonth.At30%ofcollections,whichisa

reasonablecompensation,theassociateearnsabout$9000per month,whichisn’tgreat.

Iftheannualrevenueislessthanabout$1million,gooddoctors willbehardto findandretain.Practicesthathireassociates beforereachingthisannualrevenuetendtohavethelowestsatisfactionlevelsandthemostissues.

NumberofOperatories

Sixoperatoriesareneededtomaximizetheef ficienciesof bringingonanassociate.Withthisnumber,bothprovidersand thehygienistcanworksimultaneously.Thisallowsoverhead coststobereducedandof ficeproductivityincreased.Byhaving anextraprovider,revenuecangrowsignificantlywithoutadding daysthepracticeisopenandincreasingoverhead.

Practiceswithfewerthan6operatoriescanexpandthenumber ofdaysthepracticeisopen,whichofferssomeadvantages, includingexpandedavailability,whichcanbeadrawforpatients. Theownercanalsomentortheassociateadayor2eachweek whilefocusingprimarilyonnonclinicaltasks.Staffoverheadwill increase,buttheaddedrevenuegeneratedfromextradays shouldsignificantlyexceedtheaddedcost.

NewPatientsSeenEachMonth

Beforeaddinganassociate,thedentistshouldevaluateifhisor herrevenuesareincreasingandwhy.Ifthepatientbase’sageis increasing,placingmorecrowns,bridges,implants,andveneers canaccountforahealthierpicture.Per-patientvaluemayhave increasedwithoutaddingnewpatients.Ananalysisofhowfar outthehygienedepartmentisbookedandthenumberofnew

patientsconsistentlyscheduledeachmonthshouldindicateifthe practiceisgrowingorifthepracticeislosingpatientsorfailingto convertnewpatientstolong-termpatients.Thisisespecially importantifthenewpatientnumbersareincreasingbutrevenue isn’t.Apracticeshouldsee20to25newpatientseachmonth whentheadditionofanassociateiscontemplated.

Short-andLong-TermPlans

Beforehiringanassociate,thedentistshoulddecidehisorher plansforthepracticeandhowanassociatewould fitinto them.Short-termandlong-termplansneedtobeformulated. Thedentistmaydesireapartnership,ormaybeheorsheislookingtoretireandsellthepracticetotheassociate.Thegoalmaybe tosellthepracticetoathirdpartysomewheredownthelinewith orwithoutanassociatebecomingapartner.Theseissuesneedto bedecidedbeforehiringanyone.Atthetimeofhiring,theseplans shouldbediscussedtoavoidpoorcommunicationbetween ownerandassociate.Iftheassociateasks,theownershouldbe honestandestablishafoundationforagoodworkingrelationship.Planningaheadcanavoidlosingmoneythroughfalsestarts orbrokenplansandcanprovidecontinuityandstability.

LIFESTYLECHOICE

Ifthedecisionwillbealifestylechoice,theannualrevenueshould beatorabove$900,000tomanagecash flowandkeeptheassociatebusy.Associatesaremorelikelytostaylongtermandwork hardtobuildgoodwillandgrowwiththepracticeiftheyare givengoodlevelsofproduction.Theownercandecidehow manydaystotakeoffwhilemaintainingasteadyincomestream. Thegoalistogivethepracticesufficientgrowthtoestablisha stronginfrastructurethatwillsupportthedentiststeppingback

LEADERSHIP

ServantLeadership

BACKGROUND

Atsomepointinhistory,leaderswereputonpedestalsandworshipedasthosewhocoulddonowrong.Infact,noonewouldpresumetopointoutanymistakesormisstepsaleadermighthave takeniftheirservantswantedtokeeptheirheads.Asaresult, leadersoftendevelopedanarrogantdistancefrommeremortals. Manyhavelearnedtobethistypeofleader,demandingrespect withoutdoinganythingtoearnit.Ifanythingwaswrong,itwas theplebeianswhowereatfault.Formanyyears,inbusinessand evenindentaloffices,thistypeofleadershipwascommon.Changingtoanewleadershipmodelcanbejustwhatthedentalpractice needs.

withoutjeopardizingpracticegrowth.Inalifestyledecision,the owner ’sincomewillbesubstantiallylowerevenifannualrevenue ismaintainedorgrowingbecauseoftheaddedoverheadofthe additionalprovider.

Iftheannualrevenueisinsuf ficient,it’swisetoworkhardfor anotheryearandthensellthepracticeratherthanbringonan associate.Lower-incomepracticestendtocarryahighriskfor bothownersandassociatesleavingtherelationshipinfrustration. Theassociatedoesn’tmakeenoughincomeandtheownerfeels thepracticeisworseoffthanbefore.Thiscanundermineany chanceforthelifestylebalancethatwasinitiallysought.

ClinicalSignificance

Apracticeownermayfeellikethebusinessneeds addedhandstomakelifeeasierandtoachievethe growthneeded.Planstoaddanassociateshouldbe designedtocontinuallystrengthenthepractice,supporttheeconomicstatusofthepractice,andallow forthelifestyletheownerdesires.It’simportantthat thedentistknowhimselforherselfandunderstand whatisdesiredandthebestwaytogetit.

WoodJ:Howtoknowwhen(andwhy)tohireanassociate. Dentaltown 26:61-63,2025

Reprintsnotavailable

MOVINGFROMCAESARTOSERVANT

Thedentalpracticewasn’tthrivingandover100employees stayedforaveryshorttimebeforetheyranouttherevolving door.Theleadershipofthepracticeneededtobechanged. ThentheCOVIDpandemichit.Inthosedarkdays,aconsulting companyofferedabusinessfoundationscoursedesignedto openthemindsofpracticeownersandshowthemwhatthe futurecouldbecome.Thecourseleadersandotherpractice ownersbecameexamplestotheattendeesandmodeleda newleadershipstylewheretheownertookcareoftheteam byputtingtheneedsofothers fi rst,rewardinghardwork,and liftingothersup.Thedaywassaved.

SERVANTLEADERSHIP

Themantrathatledthechargeintoservantleadershipwas the missionofthepracticeistheboss. Withtimeandintention,the teamforgavetheonewhohadformerlyenslavedthem.With thenewapproach,everyonedevelopedanopenmind,relationshipswithothers,generouslistening,agenuinedesiretocare foreachother,andarecognitionthatweshould fi rstofallbe human.Noonepersonwasmoreimportantthananyother, andnopatientcomesbeforethedentalteam.

THEDAYWESOLVEDANIMPOSSIBLEPROBLEM

Thingsatthedentalpracticehadchanged.Ratherthanclockwatchingemployees,incredibleindividualscametoworkwith theteamalreadyinplace,provingtobebothinnovativeand inspirational.Thedentalpracticehadateamthathadworked togetherformorethanadecadeandsomecloseto2decades. Then2newemployeeswereadded,sotherewasatotalof15 workers.Butsomehowthenewassistantandassociate,who hadbeenwiththepracticeforlessthan4months,weren’t meshingwiththeothersandthecoursewasn’tsmoothlikeit usedtobe.

Noonewascomplainingaboutthesituation,buttheleader knewithadtobeaddressed.Thenewhireswereallowedto leaveearly,buttheremainder oftheteamgatheredinasmall roomtodiscussthesituation.Theleaderchosetositonthe fl oorinthemidstoftheteammemberswhowereinchairs oronacouch.Themessagethateveryonewasabovetheleader wasclear.

Theleadersharedthattheirpatientsseemedconfusedabout treatmentplanpresentationandtherewaslowacceptancein theassociate’sschedule.Inaddition,thenewassistantwas strugglingtolearntheof fi ceprotocols.Thenthequestion: Howdowesolvethis?

Eachteammembermadesuggestionsandofferedinnovativesolutionsthatwouldhaveneveroccurredtotheleader.Theteam collaboratedandconnected,showinghowmuchtheylikedeach otherandwereengagedinatrustingandsupportiverelationship thatwasbothunitedinpurposeandempoweredbytheirtask. Theimpossibleproblemwassolved.

CONCLUSIONS

Practiceownersshouldn ’tbetheonlyoneswhocansolvea problem.Infact,problemsareoftenbetteraddressedbythe teamastheysharetheirexperienceandexpertise.Connecting onahumanlevelcanresultinabetteroutcomethanwaitingfor the “importantleader” todictatethesolution.Becausethe leaderhadestablishedatrustingandsupportiverelationship amongtheteammembers,thewholeprovedtobegreater thanthesumofitsparts.

ClinicalSignificance

Teammembersaretalentedandhaveuniquestrengths anddegreesofknowledgethatneedtobenurtured. Combiningthetalentsoftheteaminvolvesletting themusetheirintelligence,independence,andinitiative inwhatevertaskisbeforethem.Thegreatestmagic happenswhentheentireteamactstogether.

AugustynM:Frompedestaltopartnership:Rede finingleadership. DentEcon 115:27-28,46,2025

Reprintsnotavailable

MOTIVATIONALINTERVIEWING

Patient-CenteredBehaviorChange

BACKGROUND

Motivationalinterviewing(MI)is anevidence-basedandpatientcenteredapproachtobehaviorchange.Itinvolvescommunicationdesignedtosupportapatient’smotivationtochangeby havingthepractitionerleadthepersontoconsiderabehavioral alterationwhilethemaintaininganeutralpositionregardingthe individual’sdecision.Theindividualisthenabletoovercomeany ambivalence,andhisorherchoiceishonoredastheresultof thepatienttakingcontrolofthesituation.Thisapproachallows

theessentialpatient-practitionerrelationshiptobemaintained. Thepractitionercanaskscalingquestionstoevaluatetheindividual ’sreadinessforchangeandtorevealanybarriersorfacilitatorstotheneededchange.Originallydevelopedforuseto promotebehaviorchangeinalcohol-dependentpatients,MI hasbeenusedsuccessfullyinma nyhealthcaresituations.The applicationofMIindentalsettingswasexplored,notingitscurrentusesaswellasinvestigationsintopotentialusesanddetailingthetrainingrequiredforadentalteam.

MIApproachtoResistancetoChange

Frustrationwithchangeeffortsisoftenexperiencedwhencliniciansgiveadvicewiththegoalofpersuadingpatientstodothe rightthing,anapproachcalledthe fixingreflex.InMI,resistance tochangeisaddressedthoughtheinteractionbetweenpatient andclinician.Itavoidsthe fixingreflexandinsteadencourages “rollingwithresistance,” whichadoptsare flectiveandcurious attituderatherthanconfrontationorarguments.Clinicians acceptthecontextoforalhealthwithinthelivesoftheirpatients andmaintainanonjudgmentalapproachtoachievesuccessful outcomes.Patientsareseenasexpertsontheirownhealth, withthecliniciansupportingpatients’ journeytoidentifyinggoals that fitthemselvesratherthanspendingtimeandenergyjust impartingknowledge.

InfluencesonChange

Healthbehaviorsarein fl uencedbymanyfactors,includingthe patient ’sbeliefs,income,andeducational,social,physical, mental,andsocialconsiderations.VarioushealthcarespecialtieshaveusedMItopromotepositivehealthybehaviors (Figure1 ).TheseincludeuseswithHIVpatientadherencetoantiretroviraltherapy,decreasingdepressionsymptomsinpatients,overweightissues,alcoholconsumption,andincreasing physicalactivity.SmokingcessationeffortshavebeenmoresuccessfulwithMIthanwitheffortstoconveybriefantismoking advice.

MIasaBriefIntervention

EvenbriefMIeffortscanleadtobeneficialchanges.Indentalsettings,timecanbealimitingfactor,sobriefinterventionsmaybe

allthatareavailable.Allmembersofthedentalteam,including students,canuseMItointeractwiththepatienteveninintervals ofjust5to10minutes.

SpecificAreasBenefitingfromMI

Behaviorchangeisoftenanessentialcomponentinimproving patients’ oralandgeneralhealthandenhancingtheeffectiveness oforalhealtheducation.MIpositivelyinfluencesself-ef ficacy, whichisthebeliefthatonecanmaketherequiredbehavior change.Thisbeliefiscentraltobeginningandmaintaininghealthy behaviors.Higherpatientself-ef ficacyinoralhealthbehaviorshas beenrevealedinstudiesofdental-relatedsituationssuchas reducingtherisksofcaries,periodontaldisease,toothwear, andoralcancer(Figure2).Inaddition,MIhasprovedeffective inreducingtheneedfordentalgeneralanestheticsandin reducingpatients’ dentalanxiety.

TRAININGTHEDENTALTEAM

DentalteammemberswillbenefitfromtraininginMIandwillbe morelikelytoseebetterpatientoutcomesinrelationtoreadiness forchangeoractuallymakingachange.Thistrainingcanbeoffered duringundergraduatelifeaswellasatpostgraduatelevels.

UndergraduateTraining

Dentalundergraduatesmustdevelopandshowevidenceofprofi ciencyincommunicationskillsbytheendoftheirundergraduateyears.Studiesofhygienistswhoattended14hoursof traininginMIandcompletedpre- andpost-trainingevaluations coulddemonstratesigni fi cantlyimprovedpatient-centered communicationskills.Evenwith3hoursoftraining,third-year dentalstudentswereabletousetheirMIskillsonapatient

Figure1. ExamplesoftherangeofhealthcaresettingsinwhichMIhasbeenreportedasused(thislistisnotexhaustive)(CourtesyofAimanH,KilgariffJK, MarksD,etal:Doesmotivationalinterviewinghavearoleindentistry? BrDentJ 238:166-171,2025.)

Figure2. ApplicationsforMIindentistry.(CourtesyofAimanH,KilgariffJK,MarksD,etal:Doesmotivationalinterviewinghavearoleindentistry? BrDentJ 238:166-171,2025.)

andcompleteanassignment.Thosewhoaccuratelyidenti fi ed thepatient’sreadinesstochangehadthemosteffectiveMIskills. ComparisonsofstudentstrainedinMIornottrainedinitundertooksmokingcessationinterventions.ThosewithMI traininghadasigni fi cantlygreaternumberofpatientsquitsmokingcomparedtothosewithouttheseskills.

TheuseofMIisalsoapplicable tonon-technicalskills,which arecognitiveandinterpersonalabilitiesessentialinclinicalsettings.Theseskillsincludecommu nication.Non-technicalskill developmentandassessmentstudieshaveindicatedtheneed forMItrainingtobeincludedinmedicalcurricula.

AbarriertointegratingMItechniquesintoundergraduate trainingistheabsenceofproperlytrainedclinicalmentors. EmbeddingMItrainingandproficiencyinitsclinicaluseintopostgraduatetrainingforexistingdentalteamsisneeded.

PostgraduateTraining

LittleevidenceexistsconcerningpostgraduateMItraining. Recognizingtheneedfornon -technicalskills,effective communication,andcare-coor dinationamongpostgraduate dentistswillhelptoin fl uencetheincorporationofMIinto thecurriculum.Dentalhygienistsalreadyhavebeenstudied fortheirtraininginanduseofMI.Dentalhygieniststrained inMIusebeforegraduationcontinuetoapplyitaftergraduation.It’ssuggestedthatperiodicrefreshertrainingmayhelp topromoteandsustainthevalueandlong-termuseofMI techniques.

CONCLUSIONS

TheuseofMIindentalsituationsappearstobevaluableandcan berecommended.Patientsareguidedtoexploretheirmotivationsforchange,recognizethebene fitsandbarriersforchange, andidentifytheirgoals.ThroughtrainingintheMIprocess,practitionersareabletoleadpatientstobetteroralhygienepractices, lesscariesdevelopmentorperiodontaldisease,andreduced dentalanxietyalongwithbettercopingstrategiesforpatients withdentalanxiety.

ClinicalSignificance

MIhasprovedtobeapowerfultoolforsupporting patientstoundertakepositivechangesthatleadto betterhealthoutcomes.Consistentevidenceshows it’sefficaciousandrelevanttousesindentalsettings. TraininginMIneedstobeincorporatedintoundergraduateand/orpostgraduateeducationtohelp dentalstudentsanddentistsdevelopstrongdentalpatienttherapeuticrelationships.

AimanH,KilgariffJK,MarksD,etal:Doesmotivationalinterviewinghavearoleindentistry? BrDentJ 238:166-171,2025

Reprintsavailablefrom HAiman:DundeeDentalHospand ResearchSchool,UK;e-mail: huma.aiman1@nhs.net

PATIENTRELATIONS ManagingAdultPatientBehaviors

BACKGROUND

Dentalprofessionalscanencounterchallenginginteractions whiledeliveringcareandtheirtrainingdoesn’talwayscover howtohandletheseevents.Dentalschoolteachesstudents howtodiagnoseandtreatdentaldiseaseandmaycoverhow tohandlepediatricpatients,butadultpatientmanagementgenerallyisn’tcovered.Amongthescenariosthedentistmayfaceare angrypatients,patientswithdentalanxiety,thoserefusetreatment,andsomewhowillengageininappropriatebehavior.Guidanceisofferedforeachoftheseexamplesbasedonthe experiencesofactualdentists,wisdomgainedwhileteachingat dentalschools,advicefromcolleagues,andpersonalresearch.

ANGRYPATIENTS

DentalfeariscommonamongadultsintheUnitedStates,and patientsoftenmasktheirfearbyashowofanger.Clear

communicationmaypreventtheangerbyensuringthepatientis well-informed.Forexample,it’swisetowarnpatientsaheadof timeaboutpainfulaspectsoftreatmentandpossiblecomplications.Activelylistening,remainingcalm,andacknowledgingthepatient’sfeelingscandeescalatethesituation.Non-confrontational languageisessential,alongwithexpressionsofempathyandthe avoidanceofdefensiveness.Intermsofpersonalcare,it’swise tokeepingasafepositionduringinteractions.Inapatientinteraction,it’sOKtoagreeoragreetodisagree justtryto findcommonground.

Thedentistshouldalsoclearlysetthelimitsoftheinteractionand makesurethepatientknowswhat’sunacceptableandthe possibleconsequencesofexceedingthelimits,includingcalling lawenforcement.Whentheinteractionendangersthedentist orothers,thedentist’sgoalistoisolatetheaggressor,evacuate everyoneelse,andcallforlawenforcementhelp.

Figure1. (CourtesyofJacobsonW:Betterbehavior. Dentaltown 26:45-49,2025.)

Empathyisvital,andthedentistshouldrecognizethatsometimesthepatientsimplyneedstovent.Duringthistime,the dentistshouldfacethepatientateyelevel(notlookingdown atthepatient),remaincalm,listenwithoutinterruption,and offernonverbalandverbalcommunicationthatvalidatesthe patient ’sfeelings(Figure1 ).Agreeingthatthepatient ’ semotionsarevalidandtakingthetimetosummarizewhatthe

problemseemstobereassuresthepatientthatheorshe hasbeenheard.

Inthecaseofanangryorrudepatient,thedentistshouldalso quittakingitpersonally(QTIP).Patientsmaybereactingtoa myriadofsituations,includingpain,fear,jealousy,prejudice, insecurity,undiagnosedoruntreatedmentalillness,stress,or

Figure2. (CourtesyofJacobsonW:Betterbehavior. Dentaltown 26:45-49,2025.)

Figure3. (CourtesyofJacobsonW:Betterbehavior. Dentaltown 26:45-49,2025.)

antiauthoritarianfeelings.Thede ntistcandeescalatethesituationbymakingeyecontact,remainingcalm,breathing,staying professional,andQTIP.

ANXIOUSPATIENTS

Patientswhohavedentalphobiacanexperienceextreme distressyetknowthattheirfearsareirrational.Tellingthepatienttorelaxgenerallyisn’tsufficient.Dependingonthe severityoftheanxiety,patientsmayrequirepharmacological and/ornonpharmacologicalmanagement.Thepharmacological optionsincludenitroussedation,oralsedation,oralconscious sedation,intravenoussedation,orgeneralanesthesia.Thenonpharmacologicalapproachescanvarysigni ficantlyandinclude thefollowing:

Assess:Identifytriggersandavoidthem.

Shareinformation:Whilethisreducesthepatient’sfear,the amountofinformationthatmustbesharedwillvary.

Signaling:Tellthepatienttoraisethelefthandoruseafrog clickerifheorsheisuncomfortableorneedsthedentistto stop(Figure2).Ensurethatthepatientisclearaboutwhich handistoberaisedbecauseotherwiseheorshemay encountersharpinstrumentsifthewrongoneisused,or youmayfailtoseetheraisedhand.

Tell-show-do:Demonstrateeachstepoftheprocedurefor thepatient.

Distraction:Offeraudiobooksormusic.

Cognitivemodification:Focusonpositiveoutcomesasyou explainwhatwillhappenandwhy.

Emotionalsupport:Maintainawarm,friendlydemeanor. Physicaltools:Givethepatientastressballtosqueezeduring injections(Figure3).

Retrospectivecontrol:Conductadebrie fi ngafterthe appointment,askingthepatientabouthowtheexperience wentandifheorshedesiresthatyoudosomethingdifferent atthenextvisit.

REFUSALOFTREATMENT

Somepatientstrytocontrolthevisitandtellthedentistwhathe orsheshouldorshouldnotdo.Ifthepatientisn’tallowingthe dentisttodiagnoseortreatactivedisease,thepatientandthe dentist’slicenseareatrisk.Thedentistshouldaskthepatient toexplaintherationaleheorsheisusingtomakethesedemands. Somethingsmaybeoptional,butdiagnosticproceduresand treatmentsforactivediseasearen’t.Ifthepatientcontinuesto refuseessentialcare,the finaloptionistodismissthepatient.

INAPPROPRIATEBEHAVIOR

Somepatientsaskinappropriatequestions,suchasthoserelated tothedentistbeingmarriedornot,whereheorsheisfrom, whenheorshegetsoffwork,orsuggestingasocialmeeting. Ratherthanignoring flirtatiouscomments,thedentistshould bedirectandmature,explainingheorshewon’tbesharingpersonalinformation.Refocusingthepatientonthedentalexaminationorprocedureandaskingthepatientaboutanyconcernshe orshehasareappropriateresponses.

ClinicalSignificance

Dentistsarehighlytrainedtodiagnoseandtreatdental problemsbutpatientscanpresentbehaviorsthat thedentisthasn’tbeenpreparedtohandle.Taking thetimetocalmpatientswhoarefearful,anxious,or angry;addressingissueswiththosewhorefusetreatment;anddirectlymanaginginappropriatecomments canhelptonavigatethesepotentiallychallenging situations.

JacobsonW:Betterbehavior. Dentaltown 26:45-49,2025

Reprintsnotavailable

PRACTICEMANAGEMENT

SettingRealisticandRelevantGoals

BACKGROUND

Dentalpracticeemployeesdon’talwaysunderstandthespreadsheetsownersusetoshowproductivityandotherstatistics. Ownershopethesedocumentswillencouragetheirteamto jumpintoactionandhelptomeetgoalsthatwillhelpgrowthe practice.Theymaysetthegoalsthattheywanttheteamto

buyinto,yettheteammaynotseehowthosegoalscanbetranslatedintowhattheydo.Teamsneedtohaveapersonalrelationshipwiththedatabeforetheywillinfluenceperformance. Involvingtheteamindevelopingrealisticgoalsandhelping themseehowwhattheydo fitsintothosegoalsarevitalparts ofanowner’sjob.

DEVELOPINGREALISTICGOALS

ProblemswithGoalSetting

Aquickwaytosetproductiongoalsistotaketheannualnumbers andincreasethembythesamepercentageusedtoincreasefees. Itmayseemlogical,butthisapproachhasproblems.

Theincreasedproductiongoalsaren’tsupportedbyaplanfor whattheteamwilldotoachievethenewgoals.Theresultcan beunachievablegoalsandfrustration.Inaddition,this approachisblindtotheimpactofsignifi cantpracticechanges. Amongtheseareincreasingthenumberofvacationdays, reducingorhiringhygienists,addingnewservices,orimplementingnewtechnologies.Anyproductiongoalshouldbe carefullycraftedtoreflectthesechangesandthechallenges thatcomewiththem.

Thedentistmustalsolinkanygoalstothepracticeexpenses. Withoutthislink,it’spossibletoachievegoalsandstillbeunable topayyourbills.Youneedtohavethecompletepicture which includesexpensesaswellasproduction.

Increasingfeesdoesn’talwaystranslateintoproducingorcollectingmore,especiallyifmanypatientshavePPOplans.Whatthe practiceproduces,charges,andcollectscanbesignificantly differentfromoneanother.

BetterGoalSetting

Tomakebettergoalsrequiresastep-wiseapproach.Theowner andteamshoulddevelopawishlistbudgetandanannualplanthat includesallproviderworkdaysandthepractice’shistorical collectionpercentage.Theproductiongoalssetwillthencover employeeraises,facilityimprovements,newtechnology,and compensation.Theteamshouldbemadeawarethatpracticeimprovementsandraisesaredependentonachievingthegoalsset, makingthegoalsrelevantandmorerealistic.

MAKINGSTATISTICSRELEVANT

Thedentistmustinspireemployeestobecomemoreengagedin thepracticestatisticsbeforetheywillunderstandtheirrelevance. Approachestomakethesestatisticsmorerelevantandmeaningfulincludethefollowing:

Involvetheteaminsettinggoals.Beginbyhavingthem brainstormthingsthatwouldimprovethepractice,which couldincludenewtechnology,supplies,ergonomic

furniture,andthingsthatwillimprovetheirlives.Raises, teamoutings,continuingeducationopportunities,andpaid lunchesarealsoonthetable.Oncethesehavebeenidentified,theteamshouldresearchthepricesonthewishlist inordertodevelopabudget.Budgetinhand,theentire teamcandetermineifresultingproductionandcollection goalsareachievable.

Charttheteam’sprogresstowardfulfillingthewishlist.This willstrengthentheconnectionbetweenaccomplishingthe goalsandobtainingthewishlistitems.

Createtemplatesthatdepictdailyprocedurescorrelatingto productiongoals.Usingthisguide,theteamshouldevaluate ifthedayisscheduledtomeetthegoal.Ifitisn’t,theteam shouldbrainstormhowtomakeupfortheshortfall. Invitetheteamtobecomestatisticaldentaldetectives.Each personontheteamshouldbeassignednumbersthatrelate totheirjobascluestothepracticesystems.Theyshouldspeculatewhythepractice’sactualnumbersareatoddswiththe goal.Theteamshouldanalyzethemonth’sprogressorlack thereofandwhetheritwasananomalyoratrendcovering severalmonths.Allpossiblecausesshouldbediscussedbefore theproblemsolvingbegins.Theteamshouldn’tbeallowedto skiptosolutionswithoutaclearunderstandingofwhat happened.

Endeachmeetingbylistingtheactionsthatshouldbetaken. Thesewillfallintothecategoriesofwhattocontinuedoing becauseit’sworking,whattostopdoingbecauseit’snot working,andwhatshouldbestartedtoobtainabetterresult.

ClinicalSignificance

Includingthedentalteamincreatinggoalsforthe dentalpracticeisthebestwaytohelpthemunderstandthatwhattheydomattersinaverysolidway. Creatinggoalsthatarebasedonimprovementsthe teamdesiresshowshowmuchtheyarevalued.Seeing thattheachievementofthegoalsismetbytheirdaily workcanincreasetheirsenseofempowerment.

WeissS:Isyourdentalteamnumbtonumbers? DentEcon 115:26, 41,2025

Reprintsnotavailable

AdvocatingforPatients

BACKGROUND

Costisanimportantreasonformanypeopletoavoidreceiving medical,dental,ormentalhealthcareorprescriptiondrugs. Oftencareisdelayedorskipped,potentiallyleadingtomore seriousconditionsandmoreexpensivecareneeds.Dentalcare hassomeoftheworstcosthurdles.Thirteenpercentofthepopulationfacedcostbarrierstodentalcarein2024,comparedto 4%to5%formedicalandmentalhealthservices,prescription drugs,andeyeglasses.Generally,thelackofinsurancecoverage andlowMedicaidreimbursementratesaretoblame,buteven insuredpatientsfacehighout-of-pocketcostsanddeductibles. Claimsareoftendenied,whichalsotendstodiscouragepatients fromhavingorcontinuingtreatment.Dentalpracticescantake onaproactiveroleinhelpingpatientsnavigatethechallenges andofferingexplanations,assistancewithpreauthorization, costestimatesandpaymentoptions,andsupportforappeals whenclaimsaredenied.

UNDERSTANDINGTHEPLAN

Itcanbeconfusingtodeterminewhattreatmentsarecovered, whatisthepatient’sresponsibility,andhowtochooseadentist. Whenthepatientselectsadentalpractice,providerscanhelpin explainingtheinsuranceplananditsbene fits.Inaddition,theycan cutthroughredtapeand “insurance-speak ” sothepatientcan receiveaclearexplanationofthecoveredservices,annualmaximums,deductibles,andcopayments.

Havinganindividualorateaminthedentalpracticewhocan guidepatientsthroughinsuranceandotherresourcesnotonly eliminatessurprisesbutcanbuildtrustbetweenpatientsandproviders.Patientsbecomemorecon fidentintheiractionsandmore willingtoseekdentalcare.

PREAUTHORIZATIONASSISTANCE

Changesaremadetoinsurancepoliciesyearly,andmanyare complexandtime-consumingfordentalproviders.Thepreauthorizationprocessclearlydeterminesapatient’ scoverage. Generally,planscover100%ofthechargesforroutineandpreventiveservices.Proceduressuchascrowns,rootcanals,gum surgery,dentures,bridges,extractions,andimplantsusually requirepreauthorization.Dentalproviderscanassistandpreventdelaysintreatment,surprisesinpaymentobligations,and coveragedenials.Althoughdelaysanddenialsstilloccur,patients willhaveanadvocatewhocanhelpnavigatethesituation.

COSTESTIMATESANDPAYMENTOPTIONS

Dentalservicecostsarerisingyearly,makingsome financialservicescompaniesholdoffoncoveringdentaltreatments.Asurvey

foundthat17%ofpatientsignoredarecommendedprocedure becauseitwasn’tcovered,andabout44%oftheseindividualsnoted thatthislackofcarecausedmoredentalproblems.Whencarewas delayed,22%foundthatotheroralhealthproblemsarose.

Providerscanguidepatientsthroughcoverageoptionsandoffer costestimatesand flexiblepaymentplans.Theseaccommodations canavoiddelaysintreatmentandfurtherdeteriorationoftheoral healthofpatients.Patientsshouldbeprovidedtransparencyintheir coverageandcostssotheycanmanagetheir financialresponsibilities.Financingandinstallmentpaymentsallowpatientstoreceive theimmediatetreatmentneededandpayforitovertime.

APPEALINGDENIEDCLAIMS

Patientsandpracticesbothbecomefrustratedwhendentalclaims aredenied.Thisprocessdelaystreatmentandcanleadtohigher costs.Denialsareoftenchallengedbypractices,which fileappeals andprovidesupportingdocumentationtojustifythecoverage.Recommendedtreatmentsaren’talwaysapprovedbyinsurancecompanies.Forexample,denialsarecommonforperiodontalscaling androotplaningproceduresdespitethefactthattheyareaccepted treatmentsforgumdisease.Theinsurancecompanylabelsthemas notmedicallynecessaryorexceedingcoveragelimits.

Reasonsfordenialofaclaimmayinvolvetheneedforpreauthorization,codingerrors,missinginformation,policylimitations, andnoncoveredservices.Providersshouldensurethatpatients knowtheircoveragelimitationsandadvocateonthepatient’ s behalfshouldaclaimdisputeensue.

ClinicalSignificance

Thecostofdentalservicesisrising,butreimbursementandcoverageforproceduresremaininsuf ficient tomeettheneed.Dentalcareproviderscanhelp patientsbyprovidingguidancethroughtheforestof coverageinformation,out-of-pocketcosts,andclaim denials.Patientsaremorelikelytokeeproutine checkups,followtreatmentplans,andachievebetter oralandgeneralhealthwhentheyhavethedental practiceastheiradvocate.

MitraniF:Helpingpatientsovercomecostbarriers,insurance disputestoaccessdentalcare. DentEcon 115:8-9,2025 Reprintsnotavailable

PRIVATEPATIENTMESSAGING

SocialMediaMessages

BACKGROUND

Socialmediaplatformsarepopularwithbothyoungandolderpersons,offeringeaseofuseaswellasspeedofcommunication.Asa result,it’snotsurprisingthatpatientsexpectandoftenwanttouse socialmediaplatformsandprivatemessagingtocommunicatewith dentalprofessionals.IntheUnitedKingdom,theGeneralDental Council(GDC)acceptsthatsocialnetworkingsitesandothersocialmediaoffereffectivecommunicationsinbothpersonaland professionalareas.Socialmediahasblurredtheboundariesbetweenpublicandprivatelife,however,sotheGDCoffersinsight intothestandardsexpectedofdentalprofessionals,whicharethe samewhetherthecommunicationisface-to-faceorviasocialmediaplatforms.Considerationsfordentalprofessionalswhousesocialmediatodirectlymessagepatientsincludetheneedtoprotect dataandtorespectprofessionalboundaries.

DATAPROTECTION

Organizationstendtobelegallyaccountableforhowtheycollect, store,use,anddestroypatients’ personalinformation.Dentalpracticesandsimilarorganizationshaveadutytoinformpatientsabout howtheyprocessdataintheircontrol.Usuallythisinformationis passedthroughaprivacynotice,butthedentalpracticemustensure thatthecommunicationclearlyconveystopatientshowtheirdata willbeused.Theprivacynoticemightincludeusingmobilephone numbersforsendingtextsthatremindpatientsofappointments. Ifthepatientconsents,thesetextmessagescanbesent,butthepatient’spersonalmobilephonenumbercannotbeusedforanything otherthanwhat’slistedintheprivacynotice.Ifthepracticeusesit otherwise,itmaybeabreachofthepractice’sdataprotectionpolicy andcouldleadtoapatientcomplaintorlegalaction.

Waystoensurethatcomplaintsandlegalactionareunlikely includethefollowing:

1.Beforeusingthepatient’scontactinformation,ensurethatthe patienthasconsentedtotheuseonthepractice’sprivacynotice.

2.Readthepractice’sdataprotectionpoliciesandproceduresto ensurethattheintendeduseisapproved.

3.Checkthepractice’semploymentagreementtoseeifthereare clausesregardingcompliancewiththepractice ’sinformation governance,confidentiality,anddataprotectionpolicies.Ensure thecommunicationiswithinthosepolicies.

Thedentalpracticeshouldneverstorepatientdataonapersonal mobiledevice.Thiswouldmakethepersonalinformationunsecuredshouldpublicnetworksbeused.Inaddition,personalmobiledevicescanbestolenorlost.

PROFESSIONALBOUNDARIES

Inadditiontoadheringtothestandardsofthedentalpractice, dentalpractitionersmustadheretoprofessionalstandards whendirectlymessagingpatients.Boundariesbetweenpatients andpractitionersmustbemaintained.Usingpersonalplatforms forpatientcommunicationsratherthantraditionalmeanscan blurtheboundaries,withtheriskthatthepractitioner’sintentionsmaybemisunderstood.Havingaconversationabout appointmentavailabilitycandevelopintoadetaileddiscussion aboutthepatient’sdentalhealthortreatment,whichisprotected privateinformation.Withthispossibilityinmind,thedentalpractitionershouldcarefullyconsidertheappropriatenessofdirect messagingwithpatients.

CONCLUSIONS

UsingdirectmessagingplatformssuchasWhatsApp,Twitter,Instagram,andTikTokhasthepotentialforleavingpatientdataunprotectedandleadingtomisunderstandingsinpatient-practitioner exchanges.Thedentalteamshouldbeawareofthepitfallsand ensurethattheymaintaintheprivacyofthepatient’sdataaswell asrespecttheprofessionalcommunicationsofthedental practitioner.

ClinicalSignificance

Workplacecommunicationplatformsmayofferasecure andcompliantalternativetos ocialmedia.Theseplatforms ensurethattherecordsofpatientscanbemoreseamlessly integratedintothesystemsofthedentalpractice.Inaddition,theriskofblurringpr ofessionalboundariesis reduced.

TaylorJ-A:Privatemessagingwithpatients. BDJTeam 12:42-43, 2025

Reprintsnotavailable

REFERRALLIABILITY

MitigatingReferralLiability

BACKGROUND

Healthcarepractitionersmaybelievethattheycouldfacepotentialliabilityexposureiftheyreferpatientstoanotherpractitioner andthereferreddoctorcommitsmalpractice.Usuallythisisn’t true,withthedoctor’snegligencenotimputedbacktothemunlessthepractitionersknewthereferreddoctorwasincompetent orimpaired.Acasewaspresentedfrommorethan20yearsago, andthevariouscourts’ findingswereshared.

CASEREPORT

Girl,age6years,wasbroughttohergeneraldentistforroutine cleaningandexamination.Thedentistobservedcrowdingofthe girl’spermanentteethandreferredthepatienttothein-house orthodontistatoneoftheGeneralDentalServiceCorporation (GDSC)of fices.Theorthodontistreferredthegirltoanotolaryngologist(ENT)toassesshertonsils,adenoids,andairway.The orthodontist’sreferralindicatedthatthepatienthadtongue thrustandanopenbiteandaskedifthepatient’stonsilsandadenoidswereout.Theorthodontistalsotoldthechild’smother thatprovidinganyorthodontictherapywouldbeuselessuntil thetonsilswereremoved.

Twodayslater,attheENT’soffi ce,thechild’smotherexplained thatshehadbeentoldbytheorthodontistthatthepatient couldn’thaveherteethstraighteneduntilhertonsilswere removed.TheENTindicatedthathewasn’tconcernedabout thetonsilsandwantedtoconsultwiththeorthodontisttosee whatconcernshehad.TheENTobservedinhisnotesthatthe patienthadearinfectionsaboutevery2monthsforthepast 2yearsandwasmouthbreathingmostofthetimeduringtheexamination.Heindicatedanadenoidectomywasneededandthat theorthodontistwouldbecontacted.Aftertheconsultationwith theorthodontist,theENTsaidhebelievedthepatientwasa candidatefortonsillectomyandadenoidectomy(T&A)to improvethechancesoforthodonticsuccess.Themother’ s impressionbasedontheENT’scommentswasthatthechild’ s surgerywouldbedonefororthodonticreasons,andthepatient’ s medicalinsuranceauthorizedtheprocedure.

Thesurgerywentwellbutafewnightslater,thechildwasvomitingblood,collapsed,andwentintohypovolemicshockand eventuallycardiac/respiratoryarrest,causingbraindamage.As aresult,thepatientwasunabletotalk,eat,orclotheherself, requiredafeedingtube,woreaclamshellfrompelvistoshoulderstocounteractscoliosiscausedbymusclespasms,and needed24-hourpersonalcare.

ThefamilysuedtheENT,orthodontist,andgeneraldentistfor negligencebecausetherewasnomedicalreasontojustifythe surgeryandinformedconsenthadn’tbeenobtained.Theclaim ofnegligenceagainsttheENTwasbasedontherebeingnovalid reasonforrecommendingaT&Aforpurelyorthodonticpurposesandthefamilywasn’tinformedthattherewastheoption tohavethepatientmonitoredandreevaluatedinafewmonths. Theclaimagainsttheorthodontistwasbasedonimproperlyrecommendingsurgeryandfailingtoexplaintherisksandbene fitsof theprocedure,alternativestosurgery,orthecontroversyinorthodonticsregardingtheorthodonticbene fitsoftonsillectomy.

ThejuryfoundinfavorofGDSC,theorthodontist,andtheENT regardingtheinformedconsentclaimbutwasunabletodecide regardingthenegligenceclaim.Thecasewasappealed,noting thattheinstructionstothejuryweretonotbasetheirdecision ontheoutcomeofthesurgery.Theplaintiffarguedthatthisinstructionmisstatedthelaw(whichsaysthatphysicianscannot guaranteeagoodmedicalresultandabadresultisn’tevidence ofwrongdoingbythephysician).Theyfurtherstatedthatgiving thisinstructionessentiallydirectedthejuryinthetrialcourtto returnaverdictforthedefendants.Thecourtsidedwiththe plaintiffandfoundthatthetrialcourtshouldn’thavegiventhat instruction.

Regardingtheclaimforlackofinformedconsent,thecourt notedthatpatientshavetherighttomakedecisionsabout theirmedicaltreatmentandshouldbeprovidedwithsuf ficientinformationtomakethisdecision.However,patients claiminglackofinformedconsentmustprovethatthehealth careproviderfailedtoinformthepatientofamaterialfact relatedtothetreatment,thepatientconsentedtothetreatmentwithoutbeingawareorfullyinformedofthematerial fact,areasonablyprudentpersoninasimilarsituationwould nothaveconsentedifheorshewasinformedofthematerial fact,andthetreatmentproximatelycausedinjurytothepatient.Theplaintiffblamedtheorthodontistforrecommending thetreatmentandprovidingtheclinicalreasonstotheENT fortheT&A.Theorthodontistsaidhedidn ’tperformthe surgerysohewasn’tobligatedtoinformthepatientofanything.TheENTwastheonewhoperformedtheprocedure andshouldhavebeentheonetoobtaininformedconsent. Thecourtnotedthatmostcourtsdon’tholdareferring physicianresponsibleforobtaininginformedconsentfora procedurethatanotherpractitionerwasgoingtoperform. Afteroutliningsupportingcasesforthisdecision,thecourt

notedthattheorthodontistwasliablebecauseheretaineda degreeofparticipationandcontrolinregardtothesurgeon’ s treatment.Theyheldthataphysicianwhorefersthepatient toanotherphysicianandretainsadegreeofparticipationhas aresponsibilitytoproperlyadvisethepatientaboutthetreatmenttobeperformedbythereferredpractitioner.The referredpractitioner(theENT)shouldalsobeheldliable fornotobtaininginformedconsentwhenorderingaprocedureorparticipatinginthetreatmentorprocedure.

Attheappellatecourtlevel,itwasdecidedthattheorthodontist hadn’tparticipatedinorcontrolledtheT&Aperformedandhad onlyreferredthepatienttotheENTforanevaluation.Even thoughtheorthodontistexpressedconcernoverthepotential forthepatienttodeveloporofacialanddentofacialdeformities asaresultofhermouthbreathing,hehadn’t finalizedatreatment planforthepatient,diagnosedtonsillitisinthepatient,orscheduledorrecommendedthesurgicalprocedure.Itwasalsohis practicetoreferpatientstoanENTforevaluation,andanytreatmentwouldbebasedontheENT’sindependentevaluation.The ENTaf firmedthathewouldnothaveperformedaT&Ajust becauseanorthodontistrequestedit.Thedecisionofthecourt favoredtheorthodontist.

ASSESSMENT

Thebestwaytoensureyouaren’tliableforthenegligentactionsofareferralyoumadeistoclearlystateinthereferral slip,form,orletterthatyouarerequestinganevaluationof theindividual’sspeci ficstructure(s)basedonhavingseenapotentialproblemduringyourexamination.Requestingthatthe referredpractitionercommunicatehisorher findingsandrecommendationstoyouisappropriate.Inthisway,thepatientis freetochoosethespecialistandyoudon’trefertoaspeci fic doctor.

Inthecasewhereyouareinanagencyrelationshipwiththe referredpractitionerorifyouexercisesomedegreeofparticipationorcontrolwithrespecttothetreatmentgivenbythedoctor,youcanpotentiallyopenyourselftolegaljeopardy. Actionsthatareincludedin “somedegreeofparticipation” includediagnosingthepatient,specifyingaproceduretobe done,helpingthepatientobtaininsurancecoverage,being involvedinschedulingtheprocedure,andprovidingpreoperative radiographsorothertestresultstothereferreddoctor.These canplaceyouatriskforlegaltrouble.

Referringapatientcanhavetheselegalpitfalls,butyoualsomust notsimplyignoretheneedtorefer.Somecourtsnotedthat “Whentreatmentisineffective,the[referring]doctormust knowit firstandrecommendotheraction. ” Indeterminingthe actiontotake,thereferringphysicianshouldconsiderthepatient’smental,emotional, financial,andanyotherstatusthat canhaveaneffectontreatment.

WHENTOREFER

Thedutytorefertoanotherpractitionershouldbegovernedby theawarenessthatthepatient’sconditionisbeyondtheoriginal physician’sskills,knowledge,orcapacitytotreatwithalikelihood thattheresultwouldbesuccessful.Thepractitionerwho finds himselforherselfinthispositionshoulddisclosethesituation tothepatientoradvisethepatientthatheorsherequires anothertreatment.

Thereferringdoctoralsohastheobligationtomonitortreatmentgivenbyareferreddoctor.Generalpractitionersstill owethepatientthedutytoobserveandexerciseskillsand knowledgethatwouldbeusedinsimilarsettingsbyothercompetentgeneralpractitioners.

ClinicalSignificance

Thepotentialforreferralliabilityexistsbutwisepractitioners canmitigatetheliabilitybyadoptingprudentrequestsfor evaluationbyareferredphysician.Orthodontistsinparticular needtorecognizethatnoteverymalocclusioncanbesuccessfullytreatedorthodonticallyorwithadjunctiveinterdisciplinaryefforts.It’sarelieftoknowthatpractitionersinother dentalspecialtiesorinmedical fieldscanbehelpfulwhenthe needforareferralarises.Takingcaretorequesthelpappropriatelycanminimizeanychanceforlitigationshouldabad outcomeoccur.

JerroldL:Referralliability?Perhaps,perhapsnot. AmJOrthod DentofacOrthop 167:371-374,2025

Reprintsnotavailable

THEBIGPICTURE DENTALTOURISM

InfluenceofMediaonDentalCareAbroad

BACKGROUND

Internationaltravelforlow-costdentalcare,ordentaltourism,is becomingmorecommoninhigh-incomecountriesandfallsinto regionalratherthanglobalcategories.IntheUnitedKingdom, dentaltourismisincreasing,withabout48,000seekingdentistry outsideoftheUKin2014,butabout144,000in2016.Themotivationsfordentaltourismfallintocategoriesbasedonfactors suchasareducedtreatmenttimescale,increasedvarietyintreatmentoptions,thehighcostoftreatment,longwaitinglists,lackof dentalcareavailability,andlackoftrustinNationalHealthService (NHS)dentists.Dentalprofessionalshaveexpressedconcern overpossibleadversehealthconsequencesresultingfromdental tourism.Controversyhasescalatedbasedonnewspaperaccountsofthispublicandprivateissue,soaninvestigationlooked intothekeytopicsorissuesthatarerelatedtodentaltourismin theUKnewsmediaandhowthemediaframesdentaltourism.

METHODS

Thenewspaperarticleswereidenti fiedusingtheLexisNexis database,thenthe10mostpopularnewspapersintheUK wereusedforthesearchstrategy.Atotalof131articlespublishedfrom2018on(mostin2022and2023)wereevaluated, with92.4%ofthesepublishedintabloidnewspapers,and106 publishedineitherthe TheSun or TheMail.

RESULTS

The5keythemesidenti fiedfromthenewspaperarticleswere pushandpullfactorstoleadtoseekingdentistryabroad; patient-reportedoutcomesandexperiences;warningsfrom dentalprofessionals;amplifyingsocialmediahype;andmedia shamingandstigmatizing.

PushandPullFactors

Whereaspushfactorsleadpeopletoleavetheircountryofresidence,pullfactorsdrawpeopletoanothercountryfordentistry. Pushfactorsincludetheperceptionofhighcostsanddif ficultyaccessingdentalcareintheUK.Thepullfactorsincludecelebrity influence,affordabilityofthetreatment,andself-esteem.

Thesignificantlylowercostofdentalcosmeticproceduresabroad, especiallyinTurkey,comparedtothecostintheUKwasacommontopic.PatientsoftenchosedentistryoutsideoftheUKtosave

moneyanddidn’tconsiderthequalityofthework.Patientsalso citedtheirinabilitytoaccesscarefromNHSdentistsevenafter callingmultipleoffices.Thisleftthemwithfewoptions.

Celebritystatusandtelevisionwereoftenmentioned.Inaddition, personswhohadlowself-esteemorconfidencerelatedtotheir toothappearanceweremotivated,aswellasthoselookingfora quick fixtoimprovetheirappearanceandboosttheirselfconfidence.Itwasnotedthatsomepeoplewithmultiplevulnerabilitiesincludingself-esteemissuesweremoresusceptibleto predatorymarketing.

Patient-reportedOutcomesandExperiences

Manypeoplewhowentabroadtohavedentalworkdonefeltitwas worthittoobtainthecosmeticimprovementstheydesired.Some patientsacceptedthepainofthedentalproceduresasnecessaryto improvetheirconfidence,self-esteem,andself-evaluatedattractiveness.Othershadbadexperiencesanddescribedissuessuch as “deadstumps” andabscessesorpain.Sometimesirreversible harmandongoinganxietyoccurredthatinvolvedthepatient’ s physicalhealth,andexpensiveremedialcarewasrequired.

Patientsalsonotedtheyfeltmisinformedaboutallofthecomponentsofthecosmetictreatments.Bothmentalandphysicalharm wasexperienced,withsomeofthecasesreportedbypeopleon theirsocialmediaplatformstodeterothersfromtakingthesame courseoftreatment.Influencerssometimesdescribedthemselvesasvictimsofpoor-qualitydentalcareandconfusedabout whatprocedurestheyhadconsentedtoreceive.Somesawthemselvesashealthadvocates.Otherswereawareoftherisksand valuedtheimprovedaesthetics.

WarningsfromDentalProfessionals

Thecarereceivedfromsomedentaltourismwassometimesat oddswiththeminimallyinvasivedentistrypracticedintheUK. Thearticlesofferingdentalprofessionals’ perspectivestended tobepaternalisticandgavelittlerecognitiontothestronglymotivatingfactorsthatledpatientstoengageindentaltourism.Dental professionalsunanimouslyagreedthattheUK’sapproacheswere preferredtomaintainhealthandimproveaesthetics.

Patientswhotraveledtoobtaindentalcarewerefacedwithfew regulatoryprocessesandnoaccesstolegalredressorfollow-up

careforanypooroutcomes.RemedialcarewassometimesprovidedbytheNHS,butsomeprivateprovidersactivelyavoided providingcareforpatientswhohaddentistrydoneabroad becausetheyfearedliabilityissues.

AmplifyingSocialMediaHype

Mostnewspaperarticlesusedasinglepostfromsocialmediato frameperspectivesondentaltourism.Oftenthesepostsdocumentedthepatient’sjourney,complications,orenhancedaesthetics.The#TurkeyTeethhashtagwascommonlyusedto identifypeoplewhohaveallbeentosimilarplaces,hadsimilar procedures,underwentsimilarexperiences,andultimately achievedsimilaroutcomes.Theseindividualsusuallyhadstories ofchallenges,disappointments,andadditionalcostsforremedial care.

Socialmediaoftenreportedonsuccessstoriesandwererewardedwithlikesandfollowers,butpotentialcomplications werealsousedtogeneratebuzz.Usingemotionallychargedlanguage,journalistsdescribedthenumberofviewsfromvideos aboutdentaltourismasimmense.Bothpositiveandnegative commentswereusedtoengagereadersandproducestories thatgavemedicalenhancementproceduressignificantheadlines.

MediaShamingandStigmatizing

Thelanguageusedinmediapostsrangedfromsupportand encouragementtovictimblaming,stereotyping,stigmatizing, andshaming.Peoplewerediscreditedbydescriptionsofunrelatedcharacterlabelsandwerebrutallymockedbyonlinetrolls. Thelanguageusedtendedtoconveyscornoracomicaldismissal ofunpopularfacts.Manyheadlineslabeledpeoplewithanimal namesorridiculedtheappearanceoftheirteeth.

Somepatientswhohadfull-mouthtransformationsreceived praisefromrespondents,butotherssawthesameworkas distastefulorsomethingtobeavoided.Influencerswerewarned thattheywouldlivetoregrettheirchoices.Peoplewereoften referredtoasvain,fake-looking,orfoolishfornotchoosingto haveaminimallyinvasiveproceduredone.

DISCIPLINARYACTIONS

CONCLUSIONS

Youngerpeopleandsocialmediausersseedentaltourismasa waytoimprovetheirappearancewithoutexcessivecosts,access dentalcarethatwasn’totherwiseavailable,andachievetheir goalsregardingaesthetics.Oftensocialmediatrendsin fluence theirchoicesandcanleadtosomenegativeandsomepositive outcomes.Mostofthedentalcareprovidedabroaddoesn’t conformtotheminimallyinvasivemodelusedinmoretraditional dentalof fices.

ClinicalSignificance

Journalisticdescriptionsofpeoplewhohaveundertakendentaltourismtogetcosmeticchangestotheir dentitioncanserveasinfluencesonotherstofollowor notfollowthesamepath.Theresultsofdentaltourism canbesuccessfulorunsuccessful,enhancingtothe patient’sfaceorproblematic,andatriumphora cautionarytale.Oftentheshort-termandlong-term risksassociatedwithaggressivecosmeticprocedures areunderplayed,butsomepatientssharepoorresults inmediapoststodiscourageothersfromfollowingin theirfootsteps.TheUKdentalprofessionstronglyadvocatesforminimallyinvasivedentalapproachesand evendiscouragestreatmentto fixproblemscausedby dentistryabroad.Themediahasnotalwayspresented anunbiaseddescriptionoftheprocess,whichcan alsoinfluencetheuseoravoidanceofdentaltourism.

DoughtyJ,MooreD,EllisM,etal:Contemporarydentaltourism: AreviewofreportingintheUKnewsmedia. BrDentJ 238:230-237,2025

Reprintsavailablefrom JDoughty,SchoolofDentistry,Univof Liverpool,UK;e-mail: janineyd@liverpool.ac.uk

ViolationsofDentalRulesandGuidelines

BACKGROUND

Misconductindentistryisofconcern,withthequalityofpatient caredependingonadherencetothestandardsofpracticesetfor dentists.Cliniciansshouldbecomemorecarefulintheirprofessionalgrowthandconsiderwhatactionscanleadtodisciplinary actionsbythedentalboard.Thisincludesenhancingthedentist’ s ethicalawareness,professionalconduct,riskmanagement,

patient-centeredcare,professionaldevelopment,andpeer accountability.Beingawareoftheprofessionalstandardsand theconsequencesthatcanbeimposedshoulddeterdentalprofessionalsfromunethicalornegligentpractices,whichshould resultinincreasedpatienttrustandsafety.TheTexasStateBoard ofDentalExaminers(TSBDE)regulatesdentistsinTexas,prescribingdisciplinaryactiontothosewhoviolaterulesand

Figure1. DisciplinaryactiondistributionfromJanuary2000throughJuly 2016.Mostinfractionswereduetofailuretoobtainormaintainadequate dentalrecordsinaccordancewiththeTexasStateBoardofDentalExaminers.(CourtesyofHuangY-W,DowlatshahiS,AyilavarapuS,etal:An analysisofdentalboarddisciplinaryactionamonggeneraldentistsin Texas. JAmDentAssoc 156:225-233,2025.)

guidelines.Theseactionsincludeanagreedsettlementorderora hearingandsubsequentorderoftheboard.Thedisciplinaryactionsarepublicinformation.AreviewoftheTSBDEdisciplinary actiondatawasdonetoidentifyviolationsthatresultedindisciplinaryactions,withthegoalofhelpingpractitionersbeawareof theproblemareasandavoidfutureviolations.

METHODS

TheelectronicsearchoftheTSBDEwebsitecoveringtheperiod fromJanuary2000throughJuly2016identi fied1056dentists whofaceddisciplinaryaction.Becausesomehadmultipleviolations,thetotalwas1707infractions.Thereviewofthedatarevealedrecurrentpatternsandthemes,withthemajor categoriesofinfractionsbeingdiagnosis,treatment,renewals,recordkeeping,andethicsandprofessionalism.

RESULTS

Thirty-ninepercentoftheinfractionsinvolvedinadequaterecordkeeping,23%inadequatetreatment,23%lackofethicsand professionalism,9%improperdiagnosis,and6%issueswithrenewals(Figure1).

Diagnosis

Periodontics,operativedentistry,andprosthodonticswere theprimaryareaswheredisc iplinaryactionswereneeded andaccountedforabout30%each.Pediatricdentistry had12%,endodontics11%,oralsurgery7%,andorthodontics 5%.

Treatment

Nearlyhalfofthetreatmentinfractionswerenotedinoperative dentistryandprosthodontics.Twenty-twopercentoccurredin

Figure3. Disciplinaryactionsbasedontreatmentinthecategoriesshown. Thenotapplicablegroupincludescasesthatcouldnotbeclearlyplacedin othermentionedcategories.(CourtesyofHuangY-W,DowlatshahiS, AyilavarapuS,etal:Ananalysisofdentalboarddisciplinaryactionamong generaldentistsinTexas. JAmDentAssoc 156:225-233,2025.)

endodontics,9%inoralsurgery,7%inperiodontics,and7%inpediatricdentistry,withorthodonticsonlyinvolvedin4%(Figure3).

Renewals

Sixpercentoftherenewalsinvolveddentallicensesorpracticing withanexpiredlicense,failuretorenewaControlledSubstances Registration(CSR)certi ficatewiththeTexasDepartmentofPublicSafety(DPS)ortheDrugEnforcementAdministration(DEA), andprescribingcontrolledsubstanceswithanexpiredCSRcertificate.Seventy-onepercentoftherenewalsinvolveddentallicenses.Twenty-sixpercentwererelatedtoafailuretorenew orprescribingacontrolledsubstancewithanexpiredCSRcertificatefromtheTexasDPS.Just3%wererelatedtoafailureto reneworusinganexpiredCSRcerti ficatewithaDEAlicense toprescribeacontrolledsubstance.

Recordkeeping

Thirty-ninepercentofthecasesinvolvedissuesrelatedtoinadequateorimproperdocumentation.Failuretoobtainappropriate informedconsent(18%),omissionofapropertreatmentplan (16%),failuretoobtainanddocumentthepatient’svitalsigns (15%),lapsesinmaintainingrecordsofthetreatmentplanadministered(14%),lapsesinrecordingdiagnostic findings(9%),deficientcaptureoforupdatestomedicalhistory(8%),lackof periodontalcharting(6%),andnotobtainingappropriateradiographs(6%)allfellintothiscategory(Figure5).

EthicsandProfessionalism

Twenty-threepercentofallinfractionsinvolvedethicsandprofessionalism.Twenty-sixpercentwererelatedtoprescriptionerrors,whichrangedfromself-prescribingcontrolledsubstances fornon-dentalpurposestoattemptingtousethecredentialsof anotherprovidertoprescribecontrolledsubstancesfornon-

Figure5. Disciplinaryactionsbasedonrecordkeeping.Thenotapplicable groupincludescasesthatcouldnotbeplacedintheothermentioned categories.(CourtesyofHuangY-W,DowlatshahiS,AyilavarapuS,etal: Ananalysisofdentalboarddisciplinaryactionamonggeneraldentistsin Texas. JAmDentAssoc 156:225-233,2025.)

dentalpurposes.Twenty-threepercentoftheinfractionswere relatedtoimproperpersonalconduct.Theseinfractionsincluded improperlyobtained,used,ordistributedhabit-formingdrugs; drivingwhileintoxicated;assaultandcriminalconviction; consumingnitrousoxidefornon-dentalpurposes;possessing childpornography;falsifyingtestimonyunderoath;andattemptedsexualassault.

OtherinfractionsinvolvedfailuretoadheretotheTexasAdministrativeCodeguidelinesfordiscontinuingpatientcare(6%), improperbillingpractices(15%),andunauthorizeddelegation (10%).Improperbillingincludedbillingforservicesnotprovided, billingthepatientfortreatmentcodesnotcompletedordocumented,andbillingtheMedicaidprogramforservicesthat wereimproper,unreasonable,orclinicallyunnecessary.

CONCLUSIONS

Areasofconcernindentalpracticethatrequireattentionand interventionincludeddiagnosis,treatment,renewals,recordkeeping,andethicsandprofessionalism.Ineachcasetheinfractionscouldbeevaluatedtodetermineabetterwaytoproceed andavoidhavinginfractionsoftheguidelines.

ClinicalSignificance

Analysisofthereportedinfractionsallowedforan identificationofareaswhereinterventionsareneeded. Examplesincludethefollowing:

Fordiagnosticinfractions,dentistsmaybenefitfromaheightened senseofdiligenceandadherencetodiagnosticprotocols,with targetedinterventionssuchascontinuingeducationprograms focusedondiagnosticaccuracypossiblyofferingbenefitsto avoidinginfractions.

Treatment-relatedissueswereoftenseenwithyoungdentistswho arebusyandhaven’thadtheadvantagesofcontinuingeducation. Theymaylacktheclinicalskillsorfailtoappreciatetheimportance ofadheringtotreatmentstandards,whichmightbeaddressed throughenhancedtraining,peerreviews,andstricterenforcement ofclinicalguidelines.

Maintainingcurrentprofessionalcredentialsandensuringcompliancewithrenewalrequirementswouldhelpwithrenewalissues. Sendingouttimelyremindersmaybeamitigatingapproach. Theimportanceofmaintainingcomprehensiveandaccurate dentalrecordsmustberecognized.Specificdeficienciesthat werefoundinvolvedafailuretoobtaininformedconsent,alapse indocumentingtreatmentplansandvitalsigns,andomissions inupdatingmedicalhistoriesandperiodontalcharting.Dentalstaff maybenefitfromongoingeducationandtraininginproperdocumentationpracticessothattheregulatorystandardsaremetand patientcareremainssafe.

Prescriptionerrorsindicateaneedformorestringentcontrolsand oversightintheprescribingprocess.Improperbillingprocedures showthattheofficemustadopttransparencyandethicalconduct in financialtransactions.

Alloftheseareasneedtobeaddressedforthenumber andseriousnessofdentalpracticeinfractionstobe reduced.Thisstudyfocusedonasinglestate,so largerstudieswithmultiplestatesandspecialties shouldbeundertaken.

HuangY-W,DowlatshahiS,AyilavarapuS,etal:Ananalysisof dentalboarddisciplinaryactionamonggeneraldentistsinTexas. JAmDentAssoc 156:225-233,2025

Reprintsavailablefrom SEswaran,DeptofPeriodonticsand DentalHygiene,SchoolofDentistry,UnivofTexasHealthScienceCtratHouston,7500CambridgeSt,Suite6421,Houston, TX77054;e-mail: sridhar.veerkeralam.esw@uth.tmc.edu

PRENATALORALHEALTH

DeliveringOralHealthtoPregnantWomenandTheir Children

BACKGROUND

Professionalguidelinescallingformoreattentiontoprenataloral healthwerepublishedin2013andendorsedbytheAmerican DentalAssociation,yettheratesofprenataloralhealthcarein theUnitedStatesremainlowandhaven’tgrown,withfewer thanhalfofUSpregnantwomenreceivingdentalprophylaxis. Thefactorscontributingtothissituationwereevaluated.

DENTALCAREDURINGPREGNANCY

Pregnancyisknowntoincreasetheriskofdevelopingdentaldiseases,soprenataloralhealthcareshouldbeseenasessentialto theoralandgeneralhealthofpregnantwomenandtheirchildren. Deliveringperinataldentalcareduringpregnancyissafe,whereas notprovidingoralhealthcareprenatallyincreasestherisksofdiseaseforthepregnantwomanaswellasherchild.Pregnancyisa timeofincreasedneedfordentalcare,yetwomenfromracialand ethnicminoritiesandthoseinsuredbyMedicaidhavehigherrates ofcariesandperiodontaldisease,aremorelikelytoenterpregnancywithdentalproblems,andyetreceiveprenataloralcareat lowerratesthanotherwomen.Oftenlow-incomewomenare onlyabletouseMedicaiddentalbene fitswhentheyarepregnant orhavedeliveredachild.Thismakespregnancyanopportunity toaccessoralhealthcare.

BARRIERSTOPRENATALORALHEALTHCARE

Besidestheinfluencesoflowincome,minoritystatus,andinsuranceonlythroughMedicaid,pregnantwomenmayhave pregnancy-relatedcomorbidconditions.Thisincludesgestational diabetesandpre-eclampsia.Womenwiththeseconditionsshould nothavelowerratesofprenataloralhealthcarethanthosewithout theseconditions.Thecommoncomorbidconditionsraisetherisk ofhavingadifficultpregnancyandpoorbirthoutcomes,butthey alsoincreasetheriskofdevelopingoraldiseases.Thewomen whohavecomorbidconditionsarethepeoplewhoshouldreceive increased,notdecreased,attention.Oralhealthcaredeliveredto themwouldimprovetheoralandgeneralhealthofthesevulnerable individuals.

Otherbarrierstoprenataloralhealthcareincludelimitedaccesstodentalcarebuthighratesofcaries,gingivitis,andperiodontaldisease.Thisbarriermaybeovercomebyintegrating oralhealthscreeningsandrefer ralsintomedicalprenatalcare. Psychosocialandsociobehavioralfactorscaninteractwith oralhealthandoralhealthcare,possiblyidentifyingthosewho areatincreasedriskfordevelopingoraldiseasesiftheydon’t receiveprenatalcare.

Overcomingpatient-levelandprovider-levelbarrierstoprenatal oralhealthcarecanbechallenging.Womenwhosepregnancies arecomplicatedfaceincreasedcostsandmoretimeconstraints becauseofmorefrequentrequiredmedicalvisits,whichtheircohortswhohavenon-complicatedpregnanciesdon’tface.Ifthese womenprioritizetheirmedicalvisits,theymayminimizethe importanceoforalhealth.Thosepractitionerswhoprovideprenatalmedicalcaremaynothavethetimeorfreedomtoaddressthe woman ’soralhealthneeds.Inaddition,prenatalanddentalcare providersmaynotbeawareofthelinksbetweencomorbidconditionsandprenataloralhealthormaynotrecognizethatoral health relateddiseaseentitiesareapotentialareawherethey couldintervenetoimprovethewoman’sgeneralandoralhealth.

Somedentistsarereluctanttodeliveroralhealthcareprenatally. Someofthismaybetheresultofoutdatedconceptsbeingtaughtin dentalschool,suchasbelievingthatcertaintreatmentsmustbe restrictedtospecificpregnancyperiodsorthatdentalradiographs cannotbeobtainedinpregnantwomen.Somemayfeartherewill beariskforliabilityiftheytreatpregnantwomen.Today’sguidelinesspecificallystatethatprenataloralhealthcareisasafeand importantpartofprenatalcare.Withourgreaterawarenessof theacuterisksforthepregnantwomanandherchildrelatedto infection,dentistswhofailtoprovideneededandtimelyoral healthcaremaybetheoneswhowouldbeatriskforliability.

STEPSGOINGFORWARD

Oralhealthcareandprenatalcareprovidersmustpromoteoral healthduringpregnancyforallpregnantwomenwhoneedthese interventions.Forprenatalcareproviders,oralhealthscreening questionsshouldbeintegratedintotheoralhealthscreening questionnairetoidentifythewoman’soralhealthcareneeds. Performingoralhealthscreeningsandreferralsshouldbea partofprenatalhealthcare.It’sjustasimportantassmoking cessation,nutritionalcounseling,andHIVtesting.

Dentalcareprofessionalsshouldunderstandthatprenatalpatients needtohavepreventive,emergency,androutineoralhealthcare throughouttheirpregnancies.Theymaybenefitfromattending continuingeducationofferingsonpregnancyandoralhealthto ensuretheyhavethemostcurrentinformation.

Havinganoralhealthcarereferralsysteminahospitalormedical systemorbetweenamedicalanddentalofficecouldprovideevaluationsformorepregnantwomenandensurethattheyreceive oralhealthcare.Thecontinuedcareofthewomanandchild couldthenextendbeyondtheperinatalperiod,ensuringapool

ofpatientsfordentalcareproviders.Havingdentalandmedical electronicrecordintegrationandotherjointapproachesto carewouldacceleratethecaredelivered.

ClinicalSignificance

Dentistsneedtorecognizethatpregnancyoffersa windowofopportunitywhereoralhealthcarecanbe deliveredtothepregnantwomanandtoheroffspring. Oraldiseasesinapregnantwomencauseunnecessarypainand,ifleftuntreated,canintroducerisk factorsthatwillextendbeyondthepregnancy.When oralhealthcareisdeliveredduringthepregnancy andtheperinatalperiod,ithasthepotentialtobreak thecycleofpoororalhealththatcanpersist throughoutgenerationsinsomefamilies.

RussellSL,HuangSS,BirdC,etal:Addressingchallengesof prenataloralhealthcare. JAmDentAssoc 156:177-179,2025

Reprintsavailablefrom SLRussell,DeptofPediatricDentistryand CommunityHealth,RutgersSchoolofDentalMedicine,110BergenSt,Newark,NJ07103;e-mail: stefanie.russell@rutgers.edu

VITALPULPTHERAPY

TreatmentOptionsforIrreversiblePulpitisinPermanent Teeth

BACKGROUND

Makingdecisionsisadailytaskinthepracticeofdentistry,butthis isacomplexprocedurerequiringtheapplicationofclinicaland biomedicalknowledge,clinicalskills,problem-solving,and considerationofprobabilitiesofsuccessforthevariousoptions. Manyoptionsmustbeweighedtoeitheravoidorfallintocompliancewithvariousstandards.Theclinician’sexperienceandskills mustalsobebalancedwiththepatient’spreferencesandsocial status.Anonlinequestionnairewasdevelopedtodetermine thefactorsthatin fluencedentists’ approachestothetreatment ofirreversiblepulpitisinmaturepermanentteeth.

METHODS

The17-questioninstrumentwasdistributedtoagroupofdental practitioners,withabout37%fromtheUniversityofQueensland,about33%fromotherAustralianuniversities,andabout 30%fromoutsideAustralia.Abouttwothirdsoftheparticipants workedintheprivatesector,withtheremainderpracticinginurbanareas.Atotalof262participantscompletedthesurvey. Approximately83%hadmorethan5yearsofexperienceand abouttwothirdsweregeneraldentists.

RESULTS

Theresultswereevaluatedaspractitioners’ opinions,in fluencing factorsforclinicaldecisions,andresponsestoacasescenario.

Practitioners’Opinions

Mostpractitionerschoseextractionasthemostsuccessfulmanagementoption,followedbyrootcanaltreatment(RCT).Vital pulptherapy(VPT)wasrankedaslesssuccessful,withpulpotomy asthethirdmostsuccessfuloption,directpulpcappingasthe fourth,andindirectpulpcappingasthelast.Menandwomen differedintheirchoices,withmorewomenrankingdirectpulp cappingassuccessfulthanotherparticipants,andmensignificantlypreferringextraction.

Ageofthepractitioneralsoin fluencedthechoiceoftreatment. Thoseage25to35yearsconsistentlychoseextractionasthe mostsuccessfultreatmentcomparedtoolderparticipants.Asignificantdifferencewasnotedbetweenthe25and35agegroup andthoseoverage55years,withyoungerpractitionersfavoring extraction.Thoseage45to55yearsrankedpulpotomyasaless successfultreatmentmorethananyotheragegroup.

Experiencealsosigni ficantlyin fluencedtreatmentpreference. Thosewith1to5yearsofexperiencechoseextractionasthe mostsuccessfultreatment,withsignifi cantdifferencesbetween thisgroupandthosewithmorethan20yearsor11to15years.

PractitionersworkingintheprivatesectorsawRCTasmoresuccessfulthanthoseworkinginpublicorhospitalsectors.Graduates fromoutsideAustraliarankedpulpotomyasmoresuccessfulthan Australiangraduates.Inaddition,practitionersfromoutside AustraliafavoredextractionlessoftenthantheirAustralian counterparts.

PractitionerswerealsoaskedhowoftentheyperformedVPT, RCT,andtoothextractionforirreversiblepulpitis.Theprocedureperformedmostoftenwasextraction,withabout23%performingmorethan1extractionperweek.About13%of practitionersperformedRCTmorethanonceaweek.VPT wascarriedoutlessthanonceamonthbyabout71%ofthesurveyrespondents.

Participantswereallowedtogivemultipleanswerstoaquestion aboutbarriersthatpreventthemfromchoosingVPTforirreversiblepulpitisinapermanentmaturetooth.VPTwasconsideredinappropriateforachievinglong-termtreatmentresultsbymorethan 29%oftheparticipants.About22%to23%oftherespondents feltlackofknowledge,lackofaccesstomaterials,lackoftraining, andlackofconfidencewerebarrierstodoingVPT.Otherbarriers werepatientfactorssuchasage,preference,compliance,livingin ruralorremoteareas,medicalissues,socioeconomicstatus,and choiceofaspecifictreatment.Workplacerestrictionsonendodontictreatment,universitytraining,existingknowledge,uncontrolled pulpalbleeding,case-dependentfactors,cost-effectiveness,lackofa microscope,andconcernsoverlongevitywerealsoseenas barriers.

InfluencingFactors

Patientpreferencewasthemostcommonlycitedreason(about 29%)formakingatreatmentdecision.Otherpatientfactorswere age,socioeconomicstatus,patient’seducationallevel,oralhygieneanddentitionstatus,motivationorcomplianceexpectations,preference,medicalconsiderations,demographics,and accesstodentalcare.

Theparticipantscitedvariousotherinfluences,includingthe dentist-patientrelationship,publicrestrictionsonRCT,costof MTA,preferenceofthereferringdentist,skillsandtrainingof thedentist,accesstomagnification,andtimeavailability.Dentists alsoconsideredtherestorabilityofthetooth,thelocationofthe tooth,whetherthereisanopenapex,severityofthecondition, anddurationofsymptoms.

Severalclinicalfactorswereidenti fied,with91%oftheparticipantsconsideringtherestorabilityofthetoothasthemainfactor. Periodontalstatus,radiographicstatus,presenceofspontaneous pain,andavailabilityofmagnificationwerealsocited.Participants mentionedpatientmotivation,compliance,andpreference;oral

Figure4. Illustrationofpercentageoftreatmentoptionsselectedby practitionersforthecasescenario:A27-year-oldpatientpresentsa cold-sensitivetooth45slightlytendertopercussionwithspontaneous pain.(CourtesyofAlfaisalY,IdrisG,PetersOA,etal:Factorsin fl uencing treatmentdecisionsinpermanentmatureteethwithirreversiblepulpitis: Aquestionnaire-basedstudy. AustralDentJ 69:293-303,2024.)

hygienestatus;publicguidelines;timeanddentist’sskills;access tomaterials;rootanatomy,toothmobility,andabilitytoplace adentaldam;aestheticsandfunction;persistentpain;statusas anabutmenttooth;previousdeeprestoration;pulpbleeding; cracksorfractures;andorthodonticconcerns.

CaseScenarioResponses

Forty- fivepercentofthepractitionersselectedRCTasthebest treatmentfortheclinicalscenario(Figure4),followedbyindirect pulpcapping(about23%)andpulpotomy(about17%).Theleast selectedoptionwasextraction,withjust6%choosingthis approach.Approximately12%choseotheroptions,including restoreandreassessandchoicesbasedonthepatient’slocation, pulpexposure,orpatientpreferences.

Directpulpcappingwasselecteddependingonthepractitioner’ s placeofgraduation.ThosefromtheUniversityofQueensland tendedtochoosedirectpulpcappinglessoftenthanthosefrom otherAustralianuniversitiesandchoseitmuchlessoftenthan thosefromuniversitiesoutsideofAustralia.Generaldentists weremorelikelytochooseindirectpulpcappingthanpostgraduate studentsorspecialtydentists.Thespecialiststendedtochoosepulpotomy,whichgeneraldentistspreferredlessoften.Urbandentists weresignificantlylesslikelytochooseextractionthanthoseworkinginotherareas.

CONCLUSIONS

Theparticipantschoseextractionasthemostsuccessfultreatmentforirreversiblepulpitis.ThiswasfollowedbyRCT,then VPT.Manyfactorsin fluencedthedentists’ decisions,including thoserelatedtogender,age,yearsofexperienceasadentist,patient’spreferences,location,theuniversityfromwhichthe dentistgraduated,andguidelinesoftheplacewherethedentist practiced.

ClinicalSignificance

Manyfactorsinfluenceddentists’ decisions,butoverall, VPTwasnotacommonpracticeamongAustraliandentists.VPThasbeenshowntobeanefficient,minimally invasive,predictable,andcost-effectivealternativeto conventionalRCT,butthereseemstobeagapbetween theevidence-baseddataandclinicalpractice.VPTmay bechosenmoreofteniftheteachingofthisapproach wereincreasedinthedentalcurriculumandifhandsoncontinuingprofessionalcoursesweredeveloped.

AlfaisalY,IdrisG,PetersOA,etal:Factorsinfluencingtreatment decisionsinpermanentmatureteethwithirreversiblepulpitis:A questionnaire-basedstudy. AustralDentJ 69:293-303,2024

Reprintsavailablefrom CIPeters,SchoolofDentistry,TheUnivof Queensland,Rm7114,Level7,OralHealthCtr,288HerstonRd, Brisbane,Qld4006,Australia;e-mail: c.peters@uq.edu.au

SilverDiamineFluorideforIndirectPulpCappingofthe FirstPermanentMolar

BACKGROUND

The fi rstpermanentmolar(FPM)isespeciallysusceptibleto dentaldecaybecauseofitsfunctionalandmorphologicalcharacteristicsandhasthehighestincidenceofdentalcaries.Therefore, anycariouslesionsareaddressedintheirearlystages.Removalof adeepcariouslesionsfromtheFPMriskspulpexposureandmay

requirerootcanaltherapy.Indirectpulpcapping(IPC)isdoneto preservepulpvitalityandavoidirreversiblepulpalterations.IPC isminimallyinvasive,requireslesstime,andislessexpensive comparedtoconventionaltreatments.Thematerialsusedin IPCshouldideallyoffergoodadhesion,sealing,anddimensional stability,whilelackingsolubility,resorbability,andtoxicor

Figure3. RepresentativecaseofGROUP1(SDF)showingclinicalphotographsandradiographs. A-G, Clinicalphotographs(A, preoperative; B, preoperative withrubberdam; C, immediatepostoperative; D, 3months; E, 6months; F, 9months; G, 12months). H-K, Radiographs(H, preoperative; I, immediate postoperative; J, 6months; K, 12months).(CourtesyofZaghloulMAA,ElSayedMA,Al-GawadRYA,etal:Clinicalandradiographicevaluationofsilver diamine fluorideversusmineraltrioxideaggregateasindirectpulpcappingagentsindeeplycarious firstpermanentmolars:Arandomizedclinicaltrial. BDJ Open 11:4,2025.)

Figure4. RepresentativecaseofGROUP2(MTA)showingclinicalphotographsandradiographs. A-G, Clinicalphotographs(A, preoperative; B, preoperative withrubberdam; C, immediatepostoperative; D, 3months; E, 6months; F, 9months; G, 12months). H-K, Radiographs(H, preoperative; I, immediate postoperative; J, 6months; K, 12months).(CourtesyofZaghloulMAA,ElSayedMA,Al-GawadRYA,etal:Clinicalandradiographicevaluationofsilver diamine fluorideversusmineraltrioxideaggregateasindirectpulpcappingagentsindeeplycarious firstpermanentmolars:Arandomizedclinicaltrial. BDJ Open 11:4,2025.)

carcinogenicqualities.Theymustberadiopaque,biocompatible, andhavebioactivity.Noneoftheavailablechoiceshaveallthese qualities.Althoughcalciumhydroxide(CaOH)wasusedfor years,concernshavepromptedthedevelopmentofabettermaterial,mineraltrioxideaggregate(MTA),whichisnowthegold standardforIPC.Itsdrawbacksarehighcost,dif ficultymanipulatingit,andlongsettingtime.Silverdiamine fluoride(SDF), whichisusedtoarrestcariouslesionsinprimaryteeth,has beensuggestedasanoptionforIPC,offeringsilver’santibacterial propertiesand fluoride’sremineralizingpotential.Inaddition, SDFinhibitstheproteolyticenzymesresponsibleforprotein degradationandblocksdentinaltubules,makingitadesensitizing agent.WiththelackofavailableresearchonusingSDFinIPC,a randomizedclinicaltrialwasdonetomeasuretheclinicaland radiographicsuccessofIPCovera1-yearperiodforMTAand SDF.

METHODS

Thirty firstpermanentmolarswererandomlyassignedto receiveIPCwithSDForMTA.Thirteenboysand17girls (age9to14years,meanage10.75years)wererandomly dividedinto2groupsof15participantseach.Thesingle-step IPCtechniquewasperformed.Theclinicaloutcomeswere measuredatbaselineandafter3,6,9,and12months;radiographswereobtainedatbaselineandafter6and12months; andpostoperativepainwasrecordedonce.Successrate, radiographicsuccessrate,anddentinbridgethicknesswere comparedbetweenthe2groups.

RESULTS

BoththeSDF(Figure3)andtheMTA(Figure4)groupshad100% clinicalsuccessafter12months.Noriskforswelling,sinus,or fistulaorevidenceofthesewasdetected.

Bothgroupsalsodemonstrated100%radiographicsuccessafter 12months.Dentinbridgethicknesswassignificantlyincreasedafter12monthsinbothgroups,withnostatisticallysigni ficant differencebetweenthegroups.

CONCLUSIONS

SDFandMTAprovidedsimilarhighsuccessratesinpermanent teethrequiringIPC.Nodifferencesinclinicalorradiographic outcomeswerenoted.

ClinicalSignificance

SDFappearsabletoprovideanalternativetoMTAfor IPCinpermanentmolars.Thedentalpulptissues demonstratednoadverseeffectsforupto12months whenSDFwasused.

ZaghloulMAA,ElSayedMA,Al-GawadRYA,etal:Clinicaland radiographicevaluationofsilverdiamine fluorideversusmineral

trioxideaggregateasindirectpulpcappingagentsindeeply carious firstpermanentmolars:Arandomizedclinicaltrial. BDJ Open 11:4,2025

Reprintsavailablefrom MAAZaghloul,PediatricDentistryand DentalPublicHealth,FacultyofDentistry,CairoUniv,Giza, Egypt;e-mail: marwa_zaghloul@dentistry.cu.edu.eg

IndirectPulpCappingforSevereEarlyChildhood CariesLesions

BACKGROUND

Earlychildhoodcaries(ECC)isdiagnosedforchildrenyounger thanage6yearswhohave1ormoredecayed,missing,or filled surfacesinprimaryteeth.Asevereform(S-ECC)includesany signofsmoothsurfacetoothcariesinchildrenyoungerthan 3years;1ormorecavitated,missing,or filledsmoothsurfaces inprimarymaxillaryanteriorteethinchildrenage3to5years; andadecayed,missing,or filledscoreof4ormoresurfacesfor childrenage3years,5ormoresurfacesforchildrenage4years, or6ormoresurfacesforchildrenage5years.Vitalpulptherapy (VPT)isaminimallyinvasive,conservative,andmoreprognosticallysuccessfulstrategyforprotectingpulpvitality.Indirectpulp capping(IDPC)isoneVPTapproachthatisusedforteethwith deepcariouslesionsapproximatingthepulpbutnotexhibiting irreversiblepulpitisorperiapicaldisease.InIDPC,thelesionis partiallyremoved,butleftinplacenearthepulptoavoidexposing it.Alayerofbiocompatiblematerialsealsoffthecavitybase,with laterrestorationofthecavitytodecreasethelevelofbacterial exposureandarrestthecaries,remineralizethedentin,andsupportpulpvitality.IDPChasreducedtechniquesensitivity,ismore costeffective,islessdestructive,andisassociatedwithhigher levelsofpatientacceptancethanothertreatments.Itssuccess rateinprimaryteethisatleast90%anddoesn’tdecreasesignificantlywithtime.Itisthereforethepreferredapproachforpreservingtoothpulpindeepcariessituations.Anevaluationwasdone ofthesurvivalrateofIDPCinchildrenwithS-ECCoveralong periodoffollow-up,withtheaddedgoalofindicatingpotential riskfactorsthatcaninfl uencetreatmentoutcome.

METHODS

Themedicalrecordsof352children(186boysand166girls,mean age3.51years)withS-ECCin1197teethwereevaluated

Table1. TheResultofSurvivalRates

retrospectively.Sixhundredforty-nineteethwerelocatedanteriorlyand548wereinposteriorareas.AllreceivedIDPCwiththe childunderdentalgeneralanesthesia(DGA)betweenJanuary 2015andDecember2020.Evaluationsweredoneimmediately postoperativelyandafter6,12,18,24,30,36,42,and48months. Follow-uplastedamedianof19.75months,withthelongest periodbeing5.23years.

RESULTS

SurvivalData

Forty-sevenchildrenhad67teeththatfailedtosurvive,with31 locatedanteriorlyand25posteriorly.Timetofailureaveraged 15.80months.

Survivalrateat6monthswas99.4%(Table1 and Figure3).After 48monthsthesurvivalwas82.3%.

RiskFactors

Just2factorsweresignificantlydifferentbetweentheteeth thatsurvivedandthosethatdidnot.Tootharchposition andwhethercariesaffectedthemesialproximalsurfaceexertedsigni ficanteffectsonthesurvivalrateofIDPCinmultivariateanalysis.TheriskofIDPCprimarytoothtreatment failureinmandibularteethwas2.35timesgreaterthanthat ofmaxillaryteeth.Thefailureriskofalesionwithamesialsurfacewas2.76timeshigherthanthatofacavityinatoothlackinginvolvementofthemesialsurface.

CONCLUSIONS

IDPCwasshowntoachievehighsurvivaldataasatreatmentfor S-ECC.Havingthesurvivalratesremainhighforupto4years

Follow-uptimepoint(month) 612182430364248

Allincludedteeth99.497.695.493.691.288.186.482.3

Survivalrate(%)Toothlocation

Anteriorteeth99.397.294.794.092.389.985.895.8 Posteriorteeth99.497.796.393.290.286.386.379.6

(CourtesyofDaiS-S,HeS-Y,WangP-X,etal:Survivalanalysisandriskfactorsofindirectpulpcappinginchildrenwithsevereearlychildhood caries:Aretrospectivestudy. BrDentJ 238:51-56,2025.)

Figure3. Survivalcurveofallteeth(n=1197).Thesurvivalratesat6months,12months,18months,24months,30months,36months,42months,and 38monthswere99.4%,97.6%,95.4%,93.6%,91.2%,88.1%,86.4%,and82.3%,respectively.(CourtesyofDaiS-S,HeS-Y,WangP-X,etal:Survival analysisandriskfactorsofindirectpulpcappinginchildrenwithsevereearlychildhoodcaries:Aretrospectivestudy. BrDentJ 238:51-56,2025.)

indicatedthatIDPCcansuccessfullystopcariesprogression, avoidvitalpulpexposure,andrestoretoothfunction.

ClinicalSignificance

TheAmericanAcademyofPediatricDentistryhasrecommendedIDPCasthepreferredtreatmentformanagingdeepcariesinprimaryteeth.Morehigh-quality clinicalrandomizedtrialsofthismethodshouldbe donetobuilduptheevidence-basedfoundationfor IDPC.Furtherclari ficationoftheroleoftootharchpositionandmesialsurfaceinvolvementincariouslesions,whichwerefoundinthisstudytoinfluencethe IDPCoutcome,wouldbehelpful.

DaiS-S,HeS-Y,WangP-X,etal:Survivalanalysisandriskfactors ofindirectpulpcappinginchildrenwithsevereearlychildhood caries:Aretrospectivestudy. BrDentJ 238:51-56,2025

Reprintsavailablefrom FLiu,KeyLaboratoryofShaanxiProvince forCraniofacialPrecisionMedicalResearch,CollegeofStomatology,Xi’anJiaotongUniv,Xi’an,P.R.China;e-mail: liufei6630@gmail.xjtu.edu.cn

WATERFLUORIDATION

NewerResearchintoCommunityWaterFluoridation’s EffectsonChildhoodCaries

BACKGROUND

Communitywater fluoridation(CWF)effortstopreventdental cariesarenowbeingmetwithchallengestoprovethat fluoride addedtothewateractuallyofferssignificantbene fitsinterms ofcariesreduction.Amongtheelementsthatmustbeevaluated arepopulationburdenofdisease,oralhealthbehaviors,diet,and theavailabilityanduseofothercaries-preventionefforts.Thehistorical findingsoftheCochranereviewandthe findingsofmore

recentstudiesmustbeconsideredwhenCWFschemesare proposed.

THECOCHRANEREVIEW

Studiesdonein1975orbeforeconsistentlyshowthatCWFoffersaclearandsigni ficantpreventiveeffectontoothdecayinchildren.TheCochranereviewincludeddatafromprospective studiesandcontrolsthatcompared fluoridatedandnonfluoridatedcommunities.Theseolderstudiesfoundsigni ficant evidencethatwater fluoridationreducedtheincidenceofdental cariesandincreasedtheproportionofcaries-freechildren.

TheCochranereviewdoesn’tprovideevidencesufficientto informdecisionmakersontheimpactofremovinganexisting CWFintervention.Italsodoesn’tprovideevidencethatCWF changesthedisparitiesincariesrelatedtosocioeconomicstatus. Harmsweren’tsystematicallyassessedintheCochranereview, sonoconclusiveevidencewasgivenindicatingtheassociationbetweenoptimalCWFandotherhealthconditions.

RECENTFINDINGS

Morerecentstudiesmustconsidertheeffectofadopting fluoride intoothpaste,whichappearstoreducethemagnitudeoftheeffectofCWF.Morecontemporarystudiesindicatethatinitiating CWFmayresultinslightlyfewerdecayed,missing,and filled (dmft)primaryteethovertime.Thedifferenceindmftisabout aquarterofatoothinfavorofCWF.Thereisgreatuncertainty aboutwhetheradding fluoridetowaterreducestoothdecayin permanentteethinchildren.

CONCERNSFORNEWCWFINTERVENTIONS

Theobservedbene fitsofCWFhavebeenreducedovertime,so theinitiationof fluoridationcannotbeginwithoutacarefulevaluationofcostsandhowtheschemewouldbeimplemented.Potentialharmsandbene fitsmustbeevaluated,alongwiththe economicaspectsoftheundertaking.IfCWFisdeterminedto

beanappropriateinterventionandisimplemented,itmustbe carefullymonitoredtoensurethatthedeliveryof fluorideisat aconsistentleveltoensureoptimalhealthoutcomes.Water companydatatendtoshowthatinconsistentconcentrationsof fluorideareaddedtothewater,soitcan’tbeassumedthatthe populationslivinginCWFareasactuallyreceiveoptimally fluoridatedwater.Thesituationshouldbecloselymonitoredtoguide effortstopreventvariationsandensureoptimalpotential bene fits.

CONCLUSIONS

TheoriginalCWFstudiesindicatedasignificantbene fitfrom fluoridationintermsofpreventingtoothdecay.Today,most toothpastescontain fluoride,sotheeffectofCWFisreduced. Newerstudiesindicatethisreductionanddon’tshowthe fluoridehavinganyimpactonthehighercarieslevelsfoundinsocioeconomicallydepressedareas.

ClinicalSignificance

Objective,criticalevaluationandassimilationof emergingresearchevidencemayindicatethatcaries preventionisn’tasrobusttodayasitwasbefore 1975.Newinformation,newinterventions,andnew methodologieshavebeendeveloped,changingthe findingsofmorerecentinvestigations.Thedental communityshouldbeopentoacceptingchangesin theevidenceevenifthechangesaren ’tinlinewith stronglyheldbeliefs.

O’MalleyL,ClarsonJ,LewisS,etal:Water fluoridationforthe preventionofdentalcaries. BrDentJ 238:241-242,2025

Reprintsnotavailable

EthicsandthePublicHealthIssueofWaterFluoridation

BACKGROUND

Althoughcommunitywater fluoridationhasbeenwidelyused sincethe1940s,concernoverthepossibleadverseeffectsof fluorideonoralandgeneralhealth,including fluorosisandother negativehealthimpacts,ledtodebatesbeginningintheearly 1970s.Despiteevidenceoftheeffectivenessof fluorideinpreventingdentalcariesandthebeliefthatthispositiveeffectoutweighssafetyconcernsorhazardouseffects,thesedebateshave raisedabundantconcernandcitedtherightofindividualsto choosewhatisaddedtothepublicwatersupply.Ethicalissues

havealsobeenraisedregardingtherightsofindividualsversus thebene fitsforcommunitiesandsocietyingeneral.Ethicsreferstorules,actions,orbehaviorsthatareusuallyinformed bymoralphilosophy.Thosepertinenttopublichealthtendto bepracticalanddefineallowableactions,whereasthemoral theoriesrelevantinpublichealtharebasedonguidingprinciples andideasthatdefi newhatisrightandwhatiswrongandwhy. Oftenmoralsareself-determinedandincludeinfluencesranging fromfamilyandeducationtoreligion.Politicaltheoriescanalso shapepublichealthethicalperspectives.Themoral-based

philosophiesandpoliticalphilosophiesthatcontributetothe ethicalframeworksrelevanttocommunitywater fluoridation wereexplained.

MORAL-BASEDPHILOSOPHIES

Moral-basedtheoriescanbebroadlyclassifiedasconsequentialist andnon-consequentialisttypes.

ConsequentialistTheories

Inconsequentialisttheories,themoralvalueofanactionisbased onitsconsequence,sotheactionthatprovidesthebestconsequencesisthemoralchoice.Problemsarisebecause “best” can beinterpretedinvariousways.Inutilitarianism,whichisaconsequentialmoraltheory,themoralchoiceistheonethatoffersutilitytothegreatestnumberofindividuals.Publichealthisa utilitarianeffortinthatitsgoalistoprovidethegreatestpopulationutilityforhealthandwellbeing.It’simpartialbecauseeveryone ’sutilityshouldcountequally.Utilitarianargumentsinfavorof justifying fluoridationwouldfocusonitsabilitytomaximizeoral healthbyreducingcariesevenifasmallnumberofindividualsare adverselyaffected.

Non-consequentialistTheories

Innon-consequentialisttheories,moralactsareindependentof consequences.Severaltheoriesfallintothiscategory,including deontologicaltheories,virtuetheories,andprinciplism.

Deontologicaltheories emphasizeobligationsandrules,andduty andobligationstoallindividualsmustbeconsidered.People shouldn’tbetreatedasmeanstoanend,soanypublichealth interventionmustconsidertheminoritythatwouldbeharmed. Inaddition,thereisadutytowardvulnerablegroupsthathave limitedin fluencethatmustbeconsidered,sothattheyshould bene fitfrom fluoridationandhavetheirneedsmetaswellas thosewhoaren’tsusceptibletoharm.

Virtuetheories arerootedinEasternphilosophyandemphasize behaviorssuchaskindness,courage,andhonesty.Theethical decision-makingprocessissimilartothatwithdeontologicaltheories,withnon-virtuousdecisionswithrespectto fluoridation beingthosethatdon’tincludetherighttochoosewhatisadded tothewaterorthosethatdon’tconsidertheneedsofthoseat highriskofcaries.Virtuetheoriesrequireasensitivebalanceof theclaimsofindividualandcommunity,butthelackofaframeworktodeterminewhatisandisn’tvirtuoushasbeenadrawback inapplyingthesetheories.

Principlism usesaseriesofethicalprinciplesthatareinformedby moraltheories.Thisapproachtopublichealthissuescanbemore practicalthansomeoftheothertheories.

Withallofthesechoices,manypractitionersapply4bioethical principles,speci fi callyautonomy,non-maleficence,bene ficence,

Table1. EthicalPrinciplesProposedasImportantintheJustificationofPublicHealthInterventions

AuthorsPrincipleDescriptor

Upshur

‘Harmprinciple’ Powershouldonlybeexercisedoverindividualsagainsttheirwilltopreventharmtoothers.Derived fromJ.S.Mill’sharmprinciple

Leastrestrictiveor coercivemeans

Morerestrictiveandcoercivemeansshouldonlybeusedwhenlessrestrictiveandcoercivemeans havefailed

ReciprocityPublichealthinterventionsmayrequiresacrificesandleadtocostsforindividualsorcommunities. Societyshouldseektocompensatethoseimpactedandfacilitatetheircontinuedroles TransparencyAllstakeholdersshouldbeinvolvedindecision-making,whichshouldbeaclearandaccountable process,andasfreefrompoliticalanddominationofspecificinterestsaspossible

Childress etal. EffectivenessIfinfringingmoralconsiderations,theremustbeevidencethatpublichealthwillbeprotected ProportionalityProbablehealthbenefitsmustoutweighadverseeffectsfrominfringementofmoralconsiderations, suchasautonomy

NecessityNotallinterventionsthatareeffectiveandproportionatearenecessary.Iftherearealternatives,the leastmorallyproblematicshouldbechosen

LeastinfringementOnmeetingthe firstthreeprinciples,infringementofmoralconsiderationsshouldbeminimised.For example,ifautonomyisinfringed,theleastrestrictivealternativeshouldbesought PublicjustificationWhereinterventionsinfringemoralconsiderations,thisshouldbejustifiedpublicly.Thisshouldbe democraticandtransparenttoestablishaccountability22 andbuildpublictrust

KlugmanSolidarityAutilitarianprinciple,builtonequity(benefitsshouldbesharedfairly),communityautonomy (communityrepresentativesdecide),andpaternalism(infringementofliberty),inwhichcommunities cometogethertoimprovehealth

EfficacyEvidencethattheinterventionshouldbesuccessfulinreachinggoals,isscientificallysound,and socially,politically,andculturallyfeasible

IntegrityThenatureandcultureofacommunityshouldbepreservedandrespected.Thecommunityshould beinvolvedindevelopinginterventionssotheyareconsistentwiththeirvalues

DignityAllincommunitiesareofequalworth,deservethesamemoralrespect,andshouldbetreated accordingly.Whereverpossible,theleastrestrictiveinterventionshouldbechosen

(CourtesyofPatelV,PatrickA,DyerTA:Theethicsofcommunitywater fluoridation:Part1 anoverviewofpublichealthethics. BrDentJ 238:311315,2025.)

Table2. AnOverviewofPublicHealthEthicalGuides/Frameworks

Authors/countryFormat

KassUSASixquestions

Childress etal. USAGeneralmoral considerationsmap

Factorsconsideredwhenassessinginterventionsand programmes

Thepublichealthgoalsoftheprogramme

Effectivenessoftheprogrammeinachievingitsgoals

Knownpotentialburdensofharmsoftheprogrammes

Minimisationofburdensandharmsandalternative interventions

Fairimplementationoftheprogramme

Burdensandbenefitsarebalanced

Productionofbenefits

Avoidance,prevention,andremovalofharms

Maximalbalanceofbenefitsoverharms

Distributionof/communicationofbenefitsandburdens

fairlyandensuringpublicparticipation

Respectofautonomouschoicesandlibertyofaction

Protectionofprivacyandconfidentiality

Maintenanceofpromisesandcommitments

Disclosureofinformation,honesty,andtruthfulness

Buildingandmaintainingtrust

Moralandethicalvaluesreflectedin framework

Wellbeing,benefits,minimisingharms, liberty,justice,autonomy,respect, distributivejustice

Wellbeing,utility,benefits,minimising harms,distributivejustice,procedural justice,autonomy,liberty,transparency

NuffieldUKTwoanalyticaltools:

Stewardshipmodel

Interventionladder

TannahillUKDecision-makingtool basedonevidence, ethicsandtheory

Stewardshipmodel

Protectingandpromotinghealth

Ensuringaccess

Reducingrisksofillhealth

Reducinginequalities

Interventionladder

Restricting/eliminatingofchoice

Guidanceofchoicesthroughincentivesanddisincentives

Guidanceofchoicesthroughchangingpolicy

Enablingchoice

Providinginformation

Doingnothingormeremonitoring

Evidence Theory

Ethicalprinciples

Wellbeing,benefit,minimisingharm, distributivejustice,fairness,liberty

Doinggood,minimisingharm,respect, empowerment,socialresponsibility, participation,openness,sustainability, accountability,equity

(CourtesyofPatelV,PatrickA,DyerTA:Theethicsofcommunitywater fluoridation:Part1 anoverviewofpublichealthethics. BrDentJ 238:311315,2025.)

andjustice.However,autonomyisusuallyrestrictedsomewhatbypopulation-basedpublichealthmeasures.Inaddition, non-male ficence,theprincipleofcausingnoharm,isfaced withadoubleeffectinthatthereareadverseeffectsthat canbetoleratedaslongastheywerenotintendedandthe primaryaimwastodogood.Bene ficenceisthecounterpoint tonon-maleficenceandcallsforactingforthebene fitof others.Justiceisaprincipleconsistentwithnotionsofsocial justiceandamelioratingdisadvantages,suchasinequitiesin resourcedistribution.

Theusefulnessofalltheseprinciplesisquestionablebecause oftheirlimitations.Mostdon ’tadequatelyaddressthebalance oftheindividualwithbene fi tstothepublichealthstatus. Publichealthprinciplism isbasedonthebeliefthatacommoncitizenshipexistsandacommunitycanhavesharedloyaltiesand dutiestoself.Byprotectingcommunityhealth,onecanprotecttheindividual’shealth.Therefore,publichealth

interventionssuchas fl uoridationthatarebasedon communalinterestextendtraditionalmedicalethicsandindicatetheneedforapublichealthperspectivetoethicalconsiderations( Table1 ).Variousprinciplesfocusedonpublic healthpolicymakinghavebeenproposed.

POLITICALPHILOSOPHIES

Liberalismandcommunitarianismarethe2mainpoliticalphilosophiespertinenttopublichealthethics. Liberalism isthe righttoself-determinationbasedontheconceptofautonomy, withanemphasisontheperson’srighttofollowhisorher ownconceptionofgoodandliveaccordingtopersonalbeliefs ofworthorvalue.Inaliteralperspective,publichealthinterventionsmaybechallenged,eveniftheintentionisforthe population’sgoodhealth.LiberalobjectionsrelatedtoautonomyincludetheharmprincipleofMillandtheinfringement ofpersonalfreedom.Arecentdevelopmentislibertarian

paternalism,whichpositsthatinfluencingwithoutcoercioncan allowindividualstomakerationalchoicesintheirbestinterest butstillbeinformedbypublichealthinterventionsand messaging.Thisnewapproachmaysupportthoseableto choosebutdoesn’taddressthesituationinwhichpersons areunabletodecideforthemselvesandisinconsistentwith populationapproachesthatbene fitsuchgroups.

Communitarianism focusesontheinterconnectionofindividuals andcommunities,withspecialconcernforhowaperson’sidentityisshapedbycommunity.Sharedresponsibilityisaparticular emphasis.Thefocusoncommunitymeansthatutilitarianperspectivesandeffortsaremoreconsistentwithcommunitarian politicaltheories,sopublichealthinterventionssuchas fluoridationaremorereadilyjusti fied.

Liberalandcommunitarianperspectivescancoexistbecausea population’sbestinterestswillalsobene fitindividuals.Because liberalperspectivesaccepttheneedtoavoidharmtoothers whenexercisingtherighttochoose,politiciansofallparties andbeliefscansupport fl uoridation.

ETHICALFRAMEWORKSFORPUBLICHEALTH

Ethicalframeworkshavebeenproposedtohelpdetermine whetherinterventionsarejusti fi ed.Theseframeworksprovidede fi nitionsofvaluesandpostquestionsto “frame” decisions.Theytendtobroadlyapplyaprinciplismapproach (Table2 ).Thesestructurescanproveusefulasanalytical toolstoguidediscussions,butshouldn’tbeappliedrigidly andsimplistically.

ClinicalSignificance

Thegoalofpublichealthmeasuresistobenefitpeople bypreventingdisease,promotinghealth,andreducing oreliminatinginequalitiesintheseefforts.Therightsof individualsandtheneedsofcommunitiescancome intoconflict,andethicalanalysisisrequiredtodetermineifindividualpatientcareisappropriateforpublic healthinterventions.Variousprinciplesandethical frameworkshavebeensuggestedthatidentifyfactors tobeconsideredinanydeliberations.Fluoridationisa publichealthmeasurethatisundergoingpressureto weightherightsofindividualstobeprotectedagainst possiblenegativeeffects,todecidewhatisorisn’tput intothewater,andtoconsidertherightsofthepublic toobtainthepositiveeffectsoffewerdentalcariesin children.Thisissueisbeingdiscussedwidelyinthe UnitedStatesaswellasothernations,seekingtoidentifythebestwaytoapproachtheadditionof fluorideto drinkingwater.

PatelV,PatrickA,DyerTA:Theethicsofcommunitywater fluoridation:Part1 anoverviewofpublichealthethics. BrDentJ 238:311-315,2025

Reprintsavailablefrom TADyer,SchoolofClinicalDentistry, UnivofSheffield,19ClaremontCrescent,Sheffield,S102TA, UK;e-mail: t.dyer@sheffield.ac.uk

LiteratureAppraisalsofCommunityFluoridation

BACKGROUND

Theevidencefoundinthe1930sregardingtheinversecorrelationbetweennaturallyoccurring fl uorideinwateranddental cariesledtotheadditionof fl uoridetopublicdrinkingwater. Althoughtherewasanincreasedriskfordental fl uorosis, fl uoridationwasaneffective,cost-effective,andsustainablemethod toreducedentalcaries.Morerecently,addedconcern(without supportingevidence)hasbeenraisedthatlinkscancersand otherhealthproblemsto fl uoridation.Publichealthmeasures suchas fl uoridationaredifferentfromclinicalinterventions becausetheyareaddressingpopulationhealthandnotindividual wellbeing.Therightsofindividualsareoftenseenaslessimportantthanthebene fi tstothecommunity.Publichealthethicsfocusesonthehealthofpopulationsratherthanindividuals,but includesindividualrights whenconsideringwhetheran

interventionisfairandjust.Relativelylittlehasbeenpublished regardingtheethicalimplicationsof fl uoridationfromthe perspectiveofvariousmoral,ethical,andpoliticalphilosophies. Howtheethicsof fl uoridationhasbeenappraisedintheliteraturewasinvestigated.

METHODS

AsearchwasdoneintheMedlineviaOVID,Scopus,WebofScience,CochraneLibrary,UniversityofSheffieldStarPlus,and GoogleScholardatabases.Othersourcesincludedreferencelists ofarticlesfoundinthedatabasesearch,handsearchesofkey journals,websitesofrelevantnetworks,andthepublicationsof organizationsandconferences,alongwithagreyliteraturesearch inOpenGrey.Atotalof51articlesfrom15countrieswereidentifiedandusedinascopingreview.

RESULTS

Thescopingreviewpresentedinformationinadescriptionofthe theoreticalandphilosophicalbasisofthestudiesandtheapparent stanceon fluoridation.

TheoreticalandPhilosophicalBasisofAnalyses

Moststudiesdiscussedtheethicsof fluoridationusingmoralbasedtheoriesandpoliticalphilosophies,whilecitingorimplying variousprinciples. Moral-basedtheories wereinformedbyor impliedconsequentialisttheoriessuchasutilitarianism.Forty studiesappearedtofollownon-consequentialisttheories,with 1offeringadeontologicaltheorythatsaw fluoridationasaviolationofinternationalagreementsonhumanrightsandbiomedicines.Principlismandpublichealthprinciplismofferedethical principlesconsidering fluoridationbeyonditsconsequences. Someauthorscitedprinciplesformedicalcare,includingautonomy,non-male ficence,bene ficence,andjustice.Thirty-six studiesaddressed fluoridationinrelationto1ormoreofthese principles.Inaddition,22studiesfocusedonautonomyornonmale ficence,bene ficence,andjustice,with6discussingall4principles.Publichealthprinciplismwasmentionedin6studiesas ethicalprinciplestobeusedinassessingtheethicsof fluoridation.

The politicalphilosophies werediscussedorimpliedin17studies withreferencetolibertyandfreedom.Communitarianismwasn’t directlycited,butitsprincipleswereimplied.

Variousothertheoriesandmodelswerealsousedinethicalarguments.Fluoridationwasconsideredintermsofaviolationof medicalethicsandtheNurembergcodein4studies,whereas 10usedtheNuf fieldBioethicsreportforpublichealthmeasures andthestewardshipmodel.Thelastproposesanintervention ladderencouragingapproachesthatarelessintrusive(loweron theladder)andallowforpublicconsultationtomakedecisions.

StanceonFluoridation

The3stancesadoptedintheliteratureweresupporting fluoridation,opposing fluoridation,andneutralwithrespectto fluoridation.

SupportingFluoridation

Fifteenstudiesthatsupported fluoridationreferredtotheethical positionsofprinciplismwithrespecttobene ficence,nonmale ficence,andutilitarianismasdeterminedbytheconsequencesorimpliedcommunitarianism.Thismeansthatthebenefits,minimalharm,andmoraldutyofthepolicywere determinedbythegoalofpreventingcaries,thusservingthe commongood.Someauthorsadvocatedforaddingthevoiceof society,especiallyfromthosememberswhosesituationcould beconsidereddisadvantaged.Professionalfreedomwasalso identi fiedasaright,sothat fluoridationwasn’tconsideredunduly restrictivetosocietyandservedatemporarycommongood.It wasrecommendedthatitbelawfullyregulated.

UsingtheprinciplesoftheNuf fieldframework,severalstudies presentedutilitarianarguments.Democraticdecision-making

wasimportantinimplementingpublichealthmeasures.The emphasisofindividualautonomyshouldn’tbeahindranceto communityhealthbene fitsandfewerinequalities.Fluoridation wasalsoseenasnon-coerciveinthatitrequirednolifestyle changecomparedtoalternativemeasures.Theimperativeofindividualconsentwaspresentedaspossiblyrequirednotonlyfor instituting fluoridationbutalsoif fluoridationistobe discontinued.

Communitarianandutilitarianprincipleswereusedinarguing thatwell-focusedpaternalismpromotesbroaderfreedomfor themany.Inaddition,theperspectiveofliberalismversusutilitarianismwaspresented,notingthatbioethicshasdevelopedin countriesthatareeconomicallydevelopedwithgoodaccessto information.Thusethicaldebatesmaydifferfromculturalinfluencesandmaynotberelevanttoothercountrieswheretheinformationneededforinformedchoiceisn’tavailable.

OpposingFluoridation

Sevenstudieswereassessedasopposing fluoridation.Mostcited individualethicalprinciplesasareheldinprinciplism.Somecited moral-basedconsequentialismandnon-consequentialisttheories.AstudyinAustraliaespousedalternativecariesprevention, notingthat fluoridationinfringesontheprincipleofautonomy andviolatestheprincipleofnon-male ficencebasedondental fluorosisandotherhealthrisksthathavebeenclaimed.The resultwasthattheethicaljustificationfor fluorideinthatcountry wasinsufficient.

Twoadditionalstudiesindicatedthat fluoridationismorallyand ethicallyunacceptableanddoesn’tcomplywiththeNuremberg codeofpracticeorothermedicalcodesandregulations.The conclusionwasthatconsumersshouldbefullyinformedabout therisksandbenefitsto fluoridation,whichtheycurrentlyarenot.

NeutraltoFluoridation

Twenty-ninestudiescitedmixedethicalviewpointsbutwere seenasneutralto fluoridation.Amongtheethicalstanceswere principlism,utilitarianism,liberty,andtheNuf fieldapproach. Mostofthesestudiesweredesignedtoappraiseethicsbut someconsidered fluoridationmoregenerally,althoughethics wasincluded.Often,thesestudiesacknowledgedthetensionbetweenautonomyandbene ficenceinpublichealthinterventions aswellastheneedforpublicdebateinmakingpublichealth decisions.

Onestudyfoundthatanti- fluoridationargumentshaveoverstatedcontroversiesthatidentifyharmsandview fluoridatedwaterasamedication.ThisstudyproposedthattheUnited KingdomDepartmentofHealth’sfundingoforganizationsthat support fluoridationandselectivereportingofresearchundermineitsscienti ficindependence.Thelimitationsofstudiesused tosupport fluoridesafetywerecited,includingthesmallsample sizes,anditwassuggestedthatselectiveuseofevidencecanunderminepublictrust.

Twopublichealthethicalframeworkswereusedinaneutral analysisoffoodforti ficationand fl uoridation.Aspectsofboth frameworkswerenotful filled.Theconclusionwasthattheethics ofpublicinterventionsshouldberevisitedregularly.

Principlismwasusedin1studytoassess fluoridation,butthis investigationalsoappliedtheidealsofefficacy,integrity,solidarity, anddignity.Itwasproposedthatefficacymaybeunclear,although thereisevidenceof fluoride’seffectiveness.Theauthorquestionedwhetherit’sfeasibletoseethiseffectivenessinthecurrent politicalandsocialclimate,butdidsee fluoridationasfavorablefor solidarity,althoughitwasunclearforintegrityanddignity.

Althoughethicalargumentswereusedinanotherstudy,they wereinthecontextofimpactsofvarioussocial,cultural,andreligiousphilosophies.Withrespecttoautonomy,theauthors consideredwhetherresponsibilityshouldbeshared,remainindividual,beprofessional,orinvolvethestate.Theyconcludedthat themostimportantaspectofanypolicyinvolvesengagement withthepublicandtransparencyofgovernmentintent.Bene ficenceandmaximizedcommongoodwereseenfromautilitarian perspective,butthein fluenceofprofessionalpowerintheprocesswasacknowledged.

CONCLUSIONS

Arelativelysmallbodyofliteratureexistsonthetopicofthe ethicsof fluoridation.Appraisalsoftheethicsof fluoridation tendtobecouchedintermsmoreoftenrelatedtomedical

EarlyExposuretoFluorideandIQ

BACKGROUND

Water fluoridationandtheuseof fluoridatedtoothpastearethe primarywaysusedtoprotectagainstdentalcaries.Theeffectivenessandsafetyof fluoridemustbeconstantlymonitoredtoensure publichealthisbeingenhancedandtoreassurethepublicthatwater fluoridationissafeandeffective.Theriskofdevelopingdental fluorosismustbebalancedagainstthebenefitintermsofpreventingdentalcaries.TheNationalToxicologyProgram(NTP)has raisedconcernabouttheeffectsof fluorideoncognitiveneurodevelopment,yetcredibleevidenceforanynegativeeffectislacking. Majorreviewshaveconcludedthat fluorideatthelevelsusedin water fluoridationprogramshasnonegativeeffectonchildneurodevelopment,yetotherreviewscontinuetoindicatethereare problems.Potentiallinksbetweenearlyexposureto fluoridein fluoridatedwaterandcognitiveneurodevelopmentweresought inapopulation-basedsampleofAustralianyoungadults.

carethatthantopublichealthinterventions.Oftentheethical approachwasn’tidenti fiedbutonlyimplied,butstudiestended tofavor,oppose,orexpressaneutralattitudetoward fluoridationasapublichealthmeasure.

ClinicalSignificance

Theappraisalsof fluoridationintheliteratureoften emphasizedprinciplesortheoriesthataren’tadequate toresolvethetensionbetweentheindividualconsent forandcollectivebenefitof fluoridationasapublic healthmeasure.Approachesdesignedtospecifically assesspublichealthinterventionsshouldbeusedin debatesovertheethicalstatusofcommunitywater fluoridation.

PatelB,DyerTA:Theethicsofcommunitywater fluoridation: Part2 howhastheethicsofcommunitywater fluoridation beenappraisedintheliterature?Ascopingreview. BrDentJ 238:336-343,2025

Reprintsavailablefrom TADyer,SchoolofClinicalDentistry,Univ ofSheffield,19ClaremontCrescent,Sheffield,S102TA,UK; e-mail: t.dyer@sheffield.ac.uk

METHODS

Australia’sNationalChildOralHealthStudy(NCOHS)20122014providedthesampleof357participantsinthisstudy. NCOHSchildrenwereevaluatedfordental fluorosis,whichisa reliableclinicalbiomarkerfortotal fluorideintakeduringearly childhood.TheNCOHSalsocollecteddataonsocioeconomicfactors,oralhealthbehaviors,andresidentialhistorytoestimate fluorideexposureduringthe first5yearsoflife(%LEFW).Follow-up ofthesamplein2022-2023(whentheparticipantswereage16to 26years)measureddataoncognitiveneurodevelopmentusingthe WechslerAdultIntelligenceScale4th edition(WAIS-IV).Three groupswereformed:having0%LEFW,>0%to<100%LEFW, and100%LEFW.The%LEFWfrombirthtoage5yearswas usedtomaintainconsistencybetweenparticipants.Associations between%LEFWanddental fluorosiswereinvestigatedusing full-scaleintelligencequotient(IQ)scores(FSIQ).

RESULTS

Theproportionsofparticipantswhodidn’thaveaneurodevelopmentaldiagnosiswerecomparableamongthe3groups,andthe distributionsbysexandsocioeconomicfactorswerecomparable betweenthosewithandwithout fluorosis.Ahigherproportion ofparticipantswithoutdental fluorosisreportedlyhadaneurodevelopmentaldiagnosis.

ThemeanFSIQwas109.2,withaslightlylowerunadjustedmean FSIQamongthosewith0%LEFWthaninparticipantsintheother 2groups.Thosewhohad0%LEFWalsohadlowerFSIQscores thanthosewholivedallorpartoftheir first5yearsoflife exposedto fluoridatedwater.TheunadjustedmeanFSIQscores werecomparablebetweenthosewithandwithoutdental fluorosisontheirmaxillarycentralincisors.

TheadjustedFSIQscoresofthosewhohad100%LEFWwere slightlyhigherthanthoseoft he0%LEFWgroup.Inaddition, theadjustedestimateoftheFSIQscoresofthosewithdental fl uorosiswasn’tinferiortothatofthosewithoutdental fl uorosis.

Inmultivariableanalysis,FSIQ scoreswerecomparableamong thegroupswithdifferentlevelsof fl uorideexposureinearly childhood.WAIS-IVindexscoresshowednoassociations withlevelof fl uorideexposure.Neitherthepercentageof

LEFWnordental fl uorosisshowedanassociationwithFSIQ scores.

CONCLUSIONS

Earlylifeexposureto fluorideinAustralianchildrenhadnomeasureableeffectontheircognitiveneurodevelopment.

ClinicalSignificance

Theevidenceshowsthatchildren ’sexposureto fluorideinthe first5yearsoflifehadnonegative relationshipwiththeircognitiveneurodevelopment. Thecurrentwater fluoridationprogramsremainboth effectiveandsafeforyoungchildren.

DoLG,SawyerA,SpencerAJ,etal:Earlychildhoodexposuresto fluoridesandcognitiveneurodevelopment:Apopulation-based longitudinalstudy. JDentRes 104:243-250,2025

Reprintsavailablefrom LGDo,SchoolofDentistry,Facultyof HealthandBehaviouralSciences,TheUnivofQueensland, HerstonOralHealthCtr,7th Flr,Herston,Queensland4006, Australia;e-mail: l.do@uq.edu.au

HANDSON CANNABIS

HealthConsequencesofCannabisUse

BACKGROUND

Theuseofcannabisisbecomingmorecommon,withseveral countrieslegalizingitsuseformedicinalpurposesandsome evenlegalizingitsrecreationaluse.Marijuanacanbeconsumed invariousways,includingthesmokingofhand-rolledcigarettes (joints),hollowed-outcigars(blunts),pipes,waterpipes (bongs),orcigars;theingestionoffoodordrinks(edibles); andtheuseofcompoundsofthecannabisplant,suchascannabidiol(CBD),whichistakensublingually.Withthewideruseof cannabis,dentalprofessionalsaremorelikelytoencounterpatientswhoadmittousingcannabisrecreationally.Guidancethat ispracticalandevidencebasedispresentedregardinghowto recognizetheimpactofrecreationalcannabisonoralandgeneralhealthandhowdentalpractitionerscanhelppatientsand referthemtoavailablesupportservicesanddealwithlegal issues.

ORALANDGENERALHEALTHEFFECTS

OralHealth

Cannabisusehasbeenassociatedwithseveraladverseoralconditions,suchasreducedsalivary flow,whichleadstoxerostomia, andreducedsalivarybufferingcapacity,whichincreasestherisk ofcariesandperiodontitis.Long-termcannabisuseincreases theprevalenceofgingivalin flammationandtheaccumulationof plaque.Inaddition,tetrahydrocannabinol(THC),whichisthe primarypsychotropicagentincannabis,stimulatesappetite, causingfrequentconsumptionofcariogenicfoodsanddrinks. Chronicin flammationoftheoralcavity,leukoplakia,andimmunosuppressionthatcanleadtooralcandidiasishavealsobeen linkedtocannabisuse.Someevidencehasconnectedcannabis usetomalignanciessuchasoralcancer.

ClinicalConsiderations

Thedentistshouldlookforsignssuchasdrymucosa,increased plaquelevels,andperiodontaldeteriorationinpatientswho reporttheregularuseofcannabis.Theclinicalexamination plusadetailedpatienthistoryshouldindicateifthesechanges arerelatedtocannabisuse.Dentistsshouldalsoconsider refusingtotreatacannabis-intoxicated(high)patientbecause heorshehasareducedabilitytoconsenttotreatment.

GeneralHealth

Cardiovasculareffects,includingtachycardiaandarrhythmias, havebeenlinkedtocannabisandcancomplicatedentalproceduresthatarestressfulorincludetheuseoflocalanestheticswith vasoconstrictors.Patientcooperationandanxietylevelscanalso becomeproblematicbecauseofcannabis’ psychoactiveproperties.Druginteractions,includingwithopioidsandsedatives, canbeaconcern.

Bothcognitivefunctionanddecision-makingpropertiescanbe compromisedwithregularcannabisuse,makingsomepatients skiporalhygieneorappointments.Whendevelopingpersonalizedpreventivecareplansforpatientswhousecannabisregularly,thedentistshouldkeeptheseissuesinmind.

ClinicalConsiderations

Oralhealthcareprovidersshouldmaintainanonjudgmentalattitudeandasupportiveapproachtopatientswhousecannabis.To betterunderstandthefrequency,duration,andmethodofuse, thedentistshouldaskopen-endedquestionsaspartofthe comprehensivemedicalandsocialhistory.Adietdiarymaybe usefulintrackingirregularsnackingbehaviors.Allofthisinformationwillhelpinformulatingarisk/susceptibilityassessmentand hopefullyleadtoopenandhonestdialoguebetweendentist andpatient.

Dentistsshouldalsoadvisepatientsregardingtheoralhealthrisks associatedwithcannabisuse,notingespeciallybehaviorssuchas theneedforenhancedoralhygiene,properhydration,regular dentalvisits,andmodificationsofthepatient’slifestyle,specifically,reducingoreliminatingcannabisuseifthat’sappropriate. Thedentistshouldmaintainapatient-centeredcarefocus, ensuringthisadviceisinformativeandsupportive.

SUPPORTSERVICES

Servicesareavailabletoassistpatientswithsubstanceabuse.In theUnitedKingdom(UK),theNationalHealthService(NHS) offersspecializeddrugandalcoholserviceswherethepatient canreceivecounseling,joinsupportgroups,andevenreceive pharmacologicalinterventions.ThelocalDrugandAlcohol RecoveryServices(DARS)canprovideadditionalassistance.

Thepatient’sgeneralmedicalpractitionermaybeabletorefer thepatientforspecialistservices.TalkToFrankcanprovide adviceandsignpostuserstosupportgroups.Throughlocal referralpathwaysandsupportnetworksthedentistcanprovidecomprehensivecareforpatients’ generalanddental healthneeds.

LEGALISSUES

IntheUK,recreationalcannabisisillegal,withpossessionleadingtocriminalcharges.Thedentist’sroleistoprovidesafe, effective,andnonjudgmentalcareandnottoenforcelegalrules. Providerscandocumentpatients’ disclosurestokeepaccurate andcon fi dentialrecordsaboutcannabisuse;advisepatientson legalimplications;reassurepatientsthathisorherprimaryfocus isonthepatient ’shealthandwellbeing;andworkalongside medicalcareprovidersandsupportservicestotreatpatients holistically.

EATINGDISORDERS

ClinicalSignificance

Dentalpractitionersarelikelytohavepatientsintheir practiceswhousecannabis.Dentistsshouldbeable torecognizethesignsofcannabis-relatedoralhealth problemsandundertakeempatheticandeffective communicationtohelpsuchpatients.Theseindividualsrequireacomprehensiveapproach,including clinicalvigilance,supportiveeducationandreferrals, andanonjudgmentalattitudethroughouttheprocess.

DaveM,PatelN:Theclinicalimplicationsofcannabisusein dentistry. BDJTeam 12:137-139,2025

Reprintsnotavailable

Avoidance/RestrictiveFoodIntakeDisorder

BACKGROUND

Avoidance/restrictivefoodintakedisorder(ARFID)hasonly recentlybeenidenti fiedasaneatingdisorder.It’scharacterized byapersistentdisturbanceineatingthatleavestheindividualunabletomeethisorhernutritionalorenergyneeds.Long-term medicalandpsychosocialproblemscanresult(Table1).TheARFIDdiagnosisreplaces ‘feedingdisorderofinfancyandearlychildhood’ intheWorldHealthOrganizationclassificationofdiseases. ARFIDpatientsaren’tconcernedabouttheirweightorshapeand theavoidanceorrestrictionoffoodsisnotrelatedtoculturalor religiousreasonsorpre-existingmedicalconditions.ARFIDcan developatanyage,andtheglobalprevalencehasbeenestimated tobebetween5%and11%,withchildrenandmenmorelikelyto beaffected.ThesignsanddiagnosticelementsofARFID,itspsychosociologicalimpactandcomorbidconditions,treatments,and dentalimpactweredetailed.

CHARACTERISTICSANDDIAGNOSISOFARFID

Characteristics

ARFIDoccursas3subtypeswithspeci ficsignsofeach.Theseare lowappetite,sensorylimitations,andaversive,asfollows:

Thosewithlow-appetiteARFIDhavelimitedintakeofspeci fic typesandquantitiesoffood,takealongtimetoeat,andhave dif ficultyeating.

Amongthesensoryproblemsthatlimitintakeoffoodare aversionstocertainfoods,inhibitingsensoryelements,and profoundrigidityineating.ARFIDindividualscanbehighlyselectiveinthetypesoffoodtheywilleatandcanbecome extremelyanxiousaboutnewfoods.Tastes,texture,smells, appearance,ortemperatureofthefoodcanbecome problematic.

Aversivetypecanleadtothepatientbeingviewedashavinga poorappetiteandbeingunabletoenjoyfood.Oftenaversion orrestrictionisrelatedtoaneventorfearofchokingor vomiting.

Thecharacteristicsandpresentationoffoodavoidancecanbea mixofthese3types(Box1).Comparedtopatientswithanorexia orbulimia,patientswithARFIDtendtobemorelikelytohavea medicaloranxietyconditionandlesslikelytohaveamood disorder.

Diagnosis

Althoughnouniversallyaccepteddiagnosticmethodhasbeen developed,helpfulinvestigationsincludeapsychologicalevaluation usingastructuredclinicalinterview,self-reportingquestionnaires, amedicalevaluation,growth-developmentalassessments,and testsfornutritionaldeficiencies.ThediagnosisfocusesonthenatureoftheARFIDpresentation,withmedicalconditionsconsideredsecondarytonutritionaldeficienciesorcoexistingdisorders.

Table1. SummaryoftheDSM-5DiagnosisfromARFID1

CriterionA

Eatingdisorderresultingina persistentfailuretomeet necessarynutritionaland/or energyneeds

Criterion8

CriterionC

CriterionD

DatafromAmericanPsychiatricAssociation. DiagnosticandStatistical ManualofMentalDisorders, 5th ed.AmericanPsychiatricPublishing: Arlington,VA,2013.(CourtesyofHamidS: ‘Fussyeating’ oravoidant/ restrictivefoodintakedisorder? BrDentJ 238:271-274,2025.) Box1.

1.Weightlossinchildren/inadequate growth/delayedgrowth

2.Significantnutritionaldeficiencies

3.Relianceonenteralfeedingororal nutritionalsupplements

4.Substantialimpairmentin psychosociologicalfunction

Theconditionisnotaffectedbyfood availabilityorculturalnorms

Thediagnosisshouldnotinclude anorexianervosa/bulimianervosa (althoughcomorbiditymayexist)or personalconcernsofweightorbody shape

Thecausecannotbeexplainedbyother medicalconditions(egallergies)or eatingconditions(eganorexianervosa)

PSYCHOSOCIOLOGICALIMPACTAND COMORBIDCONDITIONS

Theavoidanceoffoodoreatingcancausesocialanxietyandchallengetheindividual’sself-confidenceandabilitytomanagerelationships.Youngpeoplemayavoiddailysocialgatheringsand interactionswithpeers.Parentsmayclassifytheirchildasa ‘picky eater,’ rebellious,orattention-seeking.Seeingthattheindividual hasuncommoneatingpatternsorretreatsfromsituations involvingfoodsshouldprompttheconsiderationthatthereisa possiblemedicalcondition,withhelpneededfromageneralmedicalpractitioner.

Selectivefoodintakeoravoidanceiscommonlyseeninindividuals withautismspectrumconditions,anxiety,orattentionde ficit hyperactivitydisorder.TheseconditionscancoexistwithARFID. ThedistinguishingfeatureofARFIDisthattheoutcomeofthe conditionresultsinamedicalproblemorproblems.Theresearch onARFIDhasfocusedonyoungerindividuals,butinolderpatients,restrictive-likesignsthatleadtoreducedappetitecanbe relatedtomedicationsusedtotreattype2diabetes.

TREATMENTOPTIONS

Aninterdisciplinaryapproachisrecommended,involvingmedical practitioners,psychotherapists,dietitians,andeducationalsupportpersonnel.Thegoaloftreatmentistomanagethepatient’ s physicalhealthconditionsandpreventhisorhermedicaldeterioration.Dietaryhabitsshouldbeassessedtoidentifythefoods beingavoidedandwhy.Nutritionalde ficienciesandweightloss areoftenmanagedwithmultivitamins,mineralsupplements, andmedicationsthatincreaseappetite.Educatingthepatient andadvisingaboutalternative ‘safe’ foodscanhelpbringdeficienciesintobalance.

Physicalappearance

Weightloss

Growthappearanceofchildlessthanexpected.

Medicalhistory

Developingnutritionaldeficiencies,suchasanaemia,through nothavingenoughironinthediet

Needingtotakesupplementstomakesurenutritionaland energyneedsaremet

Episodesofhospitalisationandtheneedfornasogastric feeding.

Eatingbehaviours

Eatingareasonablerangeoffoodsbutnotenoughtostay healthy

Notalwayssurewhenhungry

Feelingfullafteronlyafewmouthfulsandstrugglingtoeatmore

Takingalongtimeovermealtimes/findingeatinga'chore'

Missingmealscompletely,especiallywhenbusywithsomething else

Sensitivitytoaspectsofsomefoods,suchasthetexture,smell, ortemperature

Appearingtobea'fussy'or'pickyeater'

Alwayshavingthesamemeals

Alwayseatingsomethingdifferenttoeveryoneelse

Onlyeatingfoodofasimilarcolour

Attemptingtoavoidsocialsituationswherefoodwouldbe present

Beingveryanxiousatmealtimes,chewingfoodverycarefully, takingsmallsipsandbitesetc.

(CourtesyofHamidS: ‘Fussyeating’ oravoidant/restrictivefoodintake disorder? BrDentJ 238:271-274,2025.)

ThegoalofpsychologicaltreatmentistohelpARFIDpatients thinkandreactdifferentlytonewfoodsorthosetheyhave avoided.Therapistscanlistandrankfoodbyacceptanceandanxietycaused,thenuseagradedexposureapproachtohelpthepatientacceptnewfoods.Patientswhoassociateeatingwith vomitingandchokingbene fitfromthisapproach.Foodchaining, wherenewfoodsthathavesimilarqualitiesareintroduced,can helpwithsensoryaversions.Thesequentialoralsensory approachcanhelpyoungerpatients.Playandsensoryexperiencescanalsohelpchildrenbetterunderstandhealthyeating.

Nopharmacologicalinterventionshavebeenapprovedtoease ARFID,butsomestudieshaveinvestigatedantipsychoticdrugs. Thesetendtoimprovegeneralappetiteandreducepsychological distress.

Familyandcaregiversupportarekeycomponentsoftreatment. Thegoalistocreateanenvironmentthathelpspatientsunderstandsafefoodsandthosethatproduceanxiety,createstructure androutineatmealtimes,makechangestothehomeenvironmentasneeded,andteachpatientshowtomanageanxiety.

DENTALIMPACT

NostudieshaveconfirmedtheimpactofARFIDongeneraloral healthandwhetherit’srelatedtoanincreasedprevalenceof

Figure1. PossibleoralmanifestationsofARFID.(CourtesyofHamidS: ‘Fussyeating’ oravoidant/restrictivefoodintakedisorder? BrDentJ 238:271-274, 2025.)

dentalcaries,periodontitis,orsystemicsofttissueoralmanifestations.Poororalhygieneisthemostcommonfeature,with thepatient findinghavingatoothbrushortoothpasteinthe mouthfear-inducingoruncomfortable.Thetaste,texture,and sensationofthetoothpastemaycauseanaversiontoapplying topical fluorideaswell.

Withthisunderstanding,it’slikelythatpoororalhygienewould leadtoahigherriskforperiodontitisandcariesaswellasoromucosalconditionssuchasangularcheilitis,ulcers,andinflammation ofthelips,tongue,andintraoralmucosa.Neuromuscular developmentandunderdevelopedoromotorskills,causing problemswitheating,mayoccurinyoungerchildrenwithARFID (Figure1).

Thedentalteamshouldbefamiliarwiththesignsandsymptoms ofARFIDandrecognizebehaviorssuchasareluctancetobrush theteethorunusualorselectiveeatinghabits.HavingaheightenedanxietyovertheoralexaminationmayindicateapsychomedicalconditionsuchasARFID.Supportforthemanagement ofARFIDinvolvesamultidisciplinaryapproachthatincludes careforthegeneralphysicalwellbeingofthepatient,psychologicalcounseling,dietaryassistance,andencouragingcommunicationwithschoolsorworkplacesettingstoaccommodatethe patient’seatinghabitsormedicalneeds.Dentalrecallsshould beshortenedsopreventivemeasuresandobservationsforcaries aswellasperiodontalandsofttissueproblemscanbecarriedout

regularly.Ifthepatienthasanxiety,aroutinedentalexamination maybechallenging,sothepatientmaybereferredtospecialized centersforaninitialexaminationundersedation.

ClinicalSignificance

ThediagnosisofARFIDshouldpromptdentalcare providerstoaddressanypoororalhygienehabits andseekindicationsaboutwhytheseeffortsaren’t made.Ifthechildhasahistoryof ‘fussyeating,’ a mentalhealthdisordermaybeinvolved.Furtherinvestigationiswarranted,alongwithareferraltoamedical practitioner.TreatingapatientwithARFIDislikelyto bechallenging,butpreventingpatientsfromdevelopingasenseofinadequacyorbeingjudgedfortheir dentalconditioncanhelptoovercomethedifficulties ofaconditionsuchasARFID.

HamidS: ‘Fussyeating’ oravoidant/restrictivefoodintakedisorder? BrDentJ 238:271-274,2025

Reprintsavailablefrom SHamid,14aLeytonRdDentalPractice, 14aLeytonRd,Harpenden,AL52TQ,UK;e-mail: shabazhamid@icloud.com

GERIATRICDENTISTRY

PragmaticTreatmentApproachesForOlderAdults

BACKGROUND

Withtheagingpopulation,dentalpractitionersmaybecalled upontoprovidemanypatientswithrestorativecare.Insomesettings,dentaltherapists(DTs)maybeabletomeettheneedsof theseolderpatients,includingdirectaccesscare,patientassessment,andpersonalizedcareplanning.However,bothgeneral dentalpractitionersandDTsmayrequireguidancewhenfaced witholderadultswhohavecomplexdentalneeds.Alinkbetween dependencyandtreatmentplanningchoicesmaybeachievedusingtheSeattlePathway(Table1).Thisguidetotreatmentchoices fordentaldiseasefocusesonmatchingthelevelofdependency withappropriatecarechoices.Thelimitationsofthepatient canbeconsidered,whetherphysicalormental,andapragmatic approachisencouraged.TheapplicationoftheSeattlePathway andtheuseofredorgreen flagstoindicateproblematicorpragmatictreatmentapproachestomultipledentalsituationswere discussedwithrespecttoriskorsusceptibilityassessments,examinationsanddiagnoses,andtreatment.

RISK/SUSCEPTIBILITYASSESSMENT

Whenolderpatientscomeforcare,severalaspectsofthestandardhistorypathwayneedtobeconsidered.Theseincludethe patientcomplaint,patientwantsandwishes,medicalhistory,specialconsiderations,andconsentissues.

Complaints

Oftentreatmentisguidedbythepatient’spriorities,butwith olderadults,it’sthecaregiverswhomayvoicecomplaintsrather thanthepatient.It’simportanttodeterminewhoiscomplaining andwhattheproblemis.Ared flagisraisedifthefamilydesires savinghopelessteethbutthepatientisn’tconcernedoverthis.A green flagcanbegivenifthepatient,evenonewithlimitedcapacitytoconsent,clearlyindicateswhatheorshewants,suchasthe removalofapainfultooth.Withincreaseddependencyandlower lifeexpectancy,howwellthepersonisfunctioningandwhether theriskofinterventionoutweighsthebene fitshouldbe considered.

PatientWantsandWishes

Ifexpectationsareunrealisticorresourcesarelimited,thedental practitionershouldbehonestaboutthefeasibilityofthevarious approaches.Ared flagisjusti fiedifthepatienthasunrealisticexpectationsorlimitedpossibilitieswiththeavailableresources. Ontheotherhand,agreen flagisappropriateifclinicianandpatientcanagreeandchooseapragmaticviewofwhatcanbe achieved.

MedicalHistory

Riskassessmentismoreaccurateifthedentalpractitionerhasa goodunderstandingofthepatient’smedicalhistory.Thisincludes anycomplexmedicalsituationsthatexistandwhetherthese wouldbenegativelyimpactedbyprovidingdentaltreatment,if theyactuallyprecludedentaltreatment,andwhetherthe complexitywouldaffectthesuccessofdentalinterventions. Amongthediseasecomplexitiesthatarecommoninolderpatientsarerespiratorydisease,cardiovasculardisease,type2diabetes,liverdisease,andkidneyissues.Patientsmaybeundergoing oncologytreatments.Inaddition,frailtyanditsaccompanying pain,infection,fatigue,andpoorphysicalstrengthaswellaspolypharmacyleadingtoadversedruginteractionsthatcandiminish cognitionandfunctionandcausedrymoutharecommonly seeninolderpatients.Drymouthcancontributetoproblems eating,speaking,andsleeping;greaterprevalenceoforaldiseases andinfections;anddiscomfortinwearingdentures.Asaresult, patientscanhaveapoorqualityoflifeandimpaireddailyfunction.

Olderadultscanalsohavediffi cultywithmobility,instability,falls, incontinence,cognitivedecline,sensoryimpairment(suchas hearingandvisionloss),andimpairedcommunication.Personalizedcareplanningmusttakealloftheseintoaccount(Box2).A red flagisindicatedforadependentpatientwhohasmultiplecomorbidities,polypharmacy,andcognitivedecline.Green flagsare appropriateforpatientswholiveindependentlyandareingood healthwithgooddentalpreventivehabits.Dentalpractitioners mustalsobeawarethatchronologicalage,biologicalage,and overallhealthcandiffersigni ficantly,soassumptionsbasedjust onagearelikelytobeinaccurate.

Consent

Manypatientspresentwithacombinationofredandgreen flag indicatorswhentheabilitytogiveconsenttotreatmentisconcerned.Mentalcapacityrequiresunderstandingandusinginformationtomakedecisionsandbeingabletocommunicatethose decisions.Olderadultsoftenhavedesignatedindividualstoserve astheirmedicaldecisionmakersbeforetheylosecapacity,and thedentalcareprovidershouldensurethattheseindividuals areinvolvedinchoicesforcare.

Thementalcapacityofolderadultscanchange,withmentalcapacityoftenspeci fictothedecisiontobemade.Ifthepatient cannotdecideforhimselforherself,theclinicianmustactin thepatient’sbestinterestandchoosetheleastrestrictiveoption. Forconsent,red flagsareappropriatefordecidingtoundertakea complexcaseforapatientwhocannotconsentforhimselfor

Table1. SeattlePathway2

Assessment Adoptappropriate recallintervals

Identifyconditions threateningoralhealth

Developstrategicoral healthcareplantoinclude professionalandself-care

Treatment RoutineConsiderlongtermviability ofrestorationsand prostheses,Plan treatmentoutcomesfor easymaintenance.

Levelofdependency

Identitycausesofincreased dependency(forexamplestroke, polyphamacydementia)

Partcipatewithothermedical servicestoassesshealthlisks generally.

IncreasedfrequencyofrecallReassesslong-termviabilityof oralhealthrelatedprevention

Examinepatients'physical, cognitiveandsocialcontextfor barrierstoemergencypalliative andelectiveoralcare

Monitortheburdenoforalcareon thepatientsandothers

Increasevigilanceforsignsof elderabuse

Identity,repairorreplace strategicallyimportantteeth guidedbytheprincipleof 'shorteneddentalarch'withor withoutimplants.tomaintainoral function

Repairandmaintainstrategically importantteethwith conservativetreatments (forexample,Atraumatic RestorativeTechniqueARTwith fluoridatedglassionomer)and designoralprosthesesto simplifyoralhygieneandprevent infection

Offerpalliativetreatmenton demandfromthepatientto controlpainandinfectionand maintainsocialcontactsand activities.

Planforongoingmaintenance includingrestorativeandsurgical treatments,tomaintainfunction andpreventorcontrolinfection orpain

Useprosthodonticattachments betweenoverdenturesand abutmentteethorimplantsto simplifyhygieneand maintenance

(ReproducedwithpermissionfromPrettyIA,EllwoodRP,LoECM,etal:TheSeattleCarePathwayforsecuringoralhealthinolderpatients. Gerodontology 31(Suppl1):77-87,2014.Courtesyof TarnowskiA,EmanuelR:Wavingthe red or green flagforpragmatictreatmentoptionsinolderadults. BDJTeam 12:24-28,2025.)

Box2. SpecificConsiderationsAffectingPersonalizedCare Planning

- Medications(interactions,bleeding,andMRONJ)plus polypharmacy

- Frailty

- Allergies

- Mobilityandphysicalaccess

- Hearingandvisualimpairments

- Dysphagia

- Oralcareissuesandassistancefromdependents

- Cognitiveissues,dementia

- Socialhistory

(CourtesyofTarnowskiA,EmanuelR:Wavingthe red or green flagfor pragmatictreatmentoptionsinolderadults. BDJTeam 12:24-28,2025.)

herself.Complexpathologyortreatmentrequiringaddedmeasuresmaybeabetteroption.Inthesecases,documentationof thesupportforthedecisionandapersonalizedcareplancan helptoensureallpartiesareonboard.Ifthereisaclearagreementontheplan,thefamiliesarepragmaticandsupportive, andtheindividualswithpowerofattorneyandthoseproviding careareonboard,agreen flagcanberaised.

Table2. RedandGreenFlagsTable

EXAMINATIONSANDDIAGNOSES

Thepatient’slevelofcooperationandavailableresourcescan interferewiththethoroughnessofanexaminationanddiagnostic process.Thedentalpractitionermayberestrictedinhisorher abilitytoprovidecarebeyondanyimmediateandapparentissue. Olderadultswhoarereluctanttoallowassessmentsorradiographsaregivenared fl ag.Thosewhoareindependentand don’tlimitassessmentsordiagnosticprocesseswouldhavea green flagtoproceed.

TREATMENTS

Treatmentisaccomplishedinseveralphases,includingimmediate measures,controlofdisease,rehabilitationoffunctionandaesthetics,andongoingcare.Thesephasesoftreatmentareintrinsicallylinkedtothepatient’sprioritiesandreflectgoalsinachieving theultimatetreatmentoutcomes.

ImmediatePhase

Immediatecareinvolvesemergencymeasurestomanageacute conditionsandgivethepatientreliefofpain.Amongthetreatmentsprovidedinthisphaseareextractions,drainageofinfections,medication,smoothingsharpteeth,andrestorations.It reflectsthepatient’stopprioritiesandisessentialforpatient comfortandsafety.Sometimessubsequentreferralisneeded toaccomplishfurthercare.

ControlofDisease

Oncethepatient’spainisrelievedandnofurtherdamageislikely, patientscanreceivepreventivecareandstabilization.Often

RiskassessmentGreen

c/oAresymptomspresentedbypatientorcarerclear?

Isthereaclearpatientorcarerrepottedproblem?

Arepatientwantsandwishesachievable?

HPCArethereconcernswithsleeping,eating,acfivitiesorbehaviour?

MHIsthereamedicalcomplexity,whichmaybedetrimentallyaffectedbyprovidingdentaltreatment?

Isthereamedicalcomplexitythatprecludesordinarydentaltreatment?

ConsentDoesthepatienthavecapacitytoconsent?

Ifthepatientcannotconsentisthetreatmentintheirbestinterestandleastrestrictive?

DiagnosisIsexaminationandradiographspossible?

Whatisthediagnosis,severityandextentofdentaldisease?

TreatmentWoulddeferringtreatmentworsenthefutureforthepatient?

Usefulnesstopreservedentalconditionasitis?

Isthepatientabletoco-operatewithconventionaltreatmentandLA?

Isaminimalinterventionapproachpossible?

Complexityofthetreatment

DependencyIsthepatientabletoattendwithnodependencyissuesandcompleteacourseoftreatment?

MaintenanceDoesthepatienthaveareasonableabilitytomaintain?

(CourtesyofTarnowskiA,EmanuelR:Wavingthe red or green flagforpragmatictreatmentoptionsinolderadults. BDJTeam 12:24-28,2025.)

standardclinicalinterventionsandminimallyinvasiveapproaches tocareareappropriate.

RehabilitationofFunctionandAesthetics

Therestorativephasefocusesonrestoringfunctionandtooth appearance.Olderadultsmayvaluethislessthanprevious phases.Thepersonalizedcareplanshouldbereviewedtoensure itisachievableandagreedtobeforeproceeding.

OngoingCare

Thedentistusesthismaintenancephasetosupportoralhealth andensurelong-termsuccessoftheprevioustreatments.Asdependencyincreases,deteriorationismorelikely,sorestorative careshouldnotfocusondiligentdailycare.Dentalpractitioners shouldconsiderwhetherdeferringtreatmentwouldadversely impactthepatient’scondition,ifthecurrentdentalcondition shouldbepreservedoriffunctionalimprovementsareneeded, andifminimallyinvasiveapproachesareadvisable.Thepatient’ s abilitytocooperatewithtreatmentunderlocalanesthesiaand thecomplexityofanytreatmentrelativetotheclinician’ sscope ofpracticeandexperienceshouldalsobeconsidered.

RedandGreenFlagsforTreatments

Red flagsindicateapatientwhocan’tmanagetreatmentinthe dentalcareorwhocan’tmaintainthetreatmentoutcome.If thetreatmentdoesn’timprovefunctionoraestheticsand improvequalityoflifeforthepatient,ared fl agisappropriate. Green flagsareissuediftheclinicianandpatientcanagreeona

MANAGINGTMD

pragmaticvisionforwhatcanbeaccomplishedandwhenthe planisunderstoodandthepatienthasagreedtoitandiswilling toberesponsibletomaintainitorplanforfailureifthepatient’ s conditiondeteriorates.

ClinicalSignificance

Withagreaternumberofolderandpossiblyfrailadult dentalpatientsinthefuture,dentalpractitionersneed toplanforhowtomanagecomplexrestorativetreatmentsandcomplicationsrelatedtothepatient’sgeneralandpsychologicalhealth(Table2).The personalizedcareplansforthesepatientsshouldbe brokendownintotheircomponents.Thenthedental practitionercanevaluateifthereareobviousenablers, leadingtogreen flags,orbarriers,denotedbyred flags.Basedonthisevaluation,thedentalcareprovidercanchoosehowtoproceedandnegotiatethe situationwitheachpatientmoreaccurately.

TarnowskiA,EmanuelR:Wavingthe red or green flagforpragmatictreatmentoptionsinolderadults. BDJTeam 12:24-28,2025

Reprintsnotavailable

IdentifyingandFacilitatingCareofTMD

BACKGROUND

TMDreferstomusculoskeletaldisorderscommonlycausing non-odontogenicorofacialpain.Qualityoflifeisdiminishedin affectedpatients,whoareoftenthoseage20to40years,and thereisanadverseimpactontheeconomycausedbythesepatients’ reducedproductivity.OftenTMDisassociatedwithand exacerbatedbystressandanxiety,andmanypatientsareseen ingeneraldentalpractices.DentistsshouldunderstandtheinvestigativeanddiagnosticprocessforTMD,befamiliarwiththeconservativemanagementoptions,andknowwhentoreferpatients forsecondarycareservices.

INVESTIGATIONSANDDIAGNOSISOFTMD

TypesofTMD

Morethan12disordersareconsideredTMD,causingpainand dysfunctionofthejoint,masticatorymuscles,orassociatedstructures.ThemyogenousTMDgroupconsistsofmyalgia,local

myalgia,myofascialpain,myofascialpainwithreferral,andheadache.ThearthrogenousTMDgroupincludesdiscdisplacement withreduction,withreductionandintermittentlocking,without reductionwithlimitedopening,orwithoutreductionorlimited opening;osteoarthritis;subluxation,andarthralgia.

Thepatientsmostoftenaffectedarethoseintheir20sand30s. Biological,psychological,andsocialfactorscombinetoproduce thesymptoms,butTMDismorecommoninthosewithjaw injuryortraumaand/orparafunctionalhabits.Possiblemedical comorbiditiesincludeirritablebowelsyndrome,insomnia, depression,and fibromyalgia.

SYMPTOMS

ThemostcommonsymptomsofTMDarenoise,pain,andmovement.Thenoisecanbeclicking,popping,orcrepitusintheTMJ thatcanbereproducedwithjawmovementssuchaschewingor

Figure1. Noticethecondylemovesduringopeningandcanbeeasierto locatetheTMJ.(ReproducedwithpermissionfromCampbellV,Mehmet T,HeffernanA:Toptipsforthemanagementoftemporomandibulardisorders. BrDentJ 238:14-17,2025.)

openingthemouthwide.ThepaincaninvolvetheTMJ,ear, temple,and/ormusclesofmastication.Occasionallyitcanextend intotheneck.PalpationoftheTMJ,masseter,ortemporalismusclecanproducethepain,andjawmovementorfunctioncan exacerbateit.Themovementisdescribedasreducedmouth opening,intermittentlocking,and,rarely,subluxationonexaminationorduring flare-upsinpatientswithchronicconditions.In addition,TMDpatientsmayalsohavesymptomsofsystemicconditions,suchasrheumatoidarthritis.

ObservationsRelatingSymptomstoDiagnosis

Patientsshouldprovideathoroughhistoryandundergoaclinical examination,butcliniciansmaynoticepossibleTMDsymptoms duringthepatient’sinitialvisit.Thedentistshouldbeableto linktheseobservationstoadiagnosisofTMD.Findingsrelated topain,noise,andmovementlistedhereshouldpromptthecliniciantoconsideraTMDdiagnosis:

Forpain:

Myalgiaispainofthemasticatorymusclesandcanbefeltonlyat thepalpationsite.Itmayalsoinvolvethemyofascialmuscleand befeltatthesiteofpalpation,withintheboundariesofthat muscle,orreferredtoareasbeyondthemuscleboundaries. PatientswitharthralgiaexperiencepainintheTMJ. TheTMDisthesourceforheadachepain.

Fornoise:

Clicking,clunking,popping,orgrindingnoisescanbeexperienced.Mostaremorecommonwitheatingbutsomeaccompanyyawning.Allseemveryloudtothepatient.

Figure2. Measuringmouthopeningfromincisaledgeswithplasticruler. (ReproducedwithpermissionfromCampbellV,MehmetT,HeffernanA: Toptipsforthemanagementoftemporomandibulardisorders. BrDentJ 238:14-17,2025.)

Discdisplacementwithreductioncausesaclicking/popping soundasthediscsitsanteriortothecondylewhenthemouth isclosedandonopeningthecondyletranslatesforward (Figure1).

Forlimitedmotion:

Patientsmaymentionhavingdif ficultyopeningtheirmouth, withasenseofrestrictionorfeelingliketheirjawislocked openorclosed.

Patientsmayalsobeabletomanuallyreducethejawbackto itsnormalposition.

Discdisplacementcaninvolvereductionandintermittent locking,butreductionmaybeabsent. Subluxationcanoccur.

History

UsingtheSOCRATESmnemonic,clinicianscanchecksite,onset, characteristic,radiation/referral,associations,timecourse,exacerbatingorrelievingfactors,andseverityofthepain.Three screeningquestionnairescanbeusedtofacilitatediagnosis, notetheimpactofanxietyanddepression,andassesspainintensityquantitatively.

Examination

Athoroughextraoralandintraoralexaminationisrequiredand addressesthefollowing:

Palpatethemusclesofmasticationforenlargementor tenderness. PalpatetheTMJ. Notenoises,associatedpain,andtenderness. Investigatewherethepainiscentered,whetherinthemuscles ofmasticationorthejointitself. Measuremouthopeningandanatomicalreferencepointsusingadisposablepaperorplasticruler(Figure2)oran

Figure3. Mirrorhandleillustratingwheretopalpatethemedialpterygoid muscle.(ReproducedwithpermissionfromCampbellV,MehmetT,Heffernan A:Toptipsforthemanagementoftemporomandibulardisorders. BrDentJ 238:14-17,2025.)

autoclavablemetalone.Ifnoneareavailable,thenumberof fingerbreadthsthepatient’sopeningmeasurescanbeclassifiedasnormal(3to4 fingers)orabnormal(2orfewer fingers).

Intheintraoralexamination, thecliniciancanpalpatethe medialpterygoidmusclebyinsertinga fi ngermediallyto theramusofthemandibleandinferiorlytothemaxillarytuberosity( Figure3 ).Heorsheshouldalsoobserveforsignsof toothsurfaceloss,tonguescallo ping,andridgesonthebuccal mucosaorbilaterallineaalba.T hesewillindicateparafunctionalhabitssuchasgrindingandclenching.

CONSERVATIVEMANAGEMENT

ManagingPatientExpectations

TheclinicianshouldclearlycommunicatetothepatientthatTMD isachronicconditionbut fluctuatesinitsexpression.Nocureis possible,butsymptomscanbemanagedsotheimpactonthepatient’squalityoflifeisminimized.Withthisapproachandproper education,patientscanbecomeexpertsatmanagingtheirown symptoms.It’salsoessentialthattheyunderstandthattheconditionisbenignandwon’tprogress.

Abiopsychosocialapproachisideal,whichmeansbeginningwith conservativemeasuresandhavingpatientsconsiderpossible sourcesofstressintheirlivesandtakemeasurestomanagethese proactively.Cognitivebehaviortherapy(CBT)reducestheintensityofpaininTMD,buthavinglessstresswillalsobebene ficial.

Self-managementPlans

Between75%and90%ofTMDpatients’ symptomsimprovewith conservativemeasuresalone.Amongthesemeasuresareeducationandpainrelief,self-exercisetherapy,thermalmodalities,selfmassage,dietmodi fication,andcurbingparafunctionalhabits.

Painreliefgenerallyisachievedwithoralnonsteroidalantiinflammatorydrugs(NSAIDs),withibuprofengelappliedto theskinatthecondylesorcoupledwithwarmorcoldcompressestomanageextra-oralpain.Jawexercisesandphysiotherapyhelptorelaxthemusclesandallowadisplaceddiscto bereturnedtoitsnormalposition.Eatingasoftdiet,avoiding openingthemouthtoowidely,andreducingchewingbycutting foodupforeaseineatinghavebeenhelpful.Patientscanalsodiscontinuerepetitivehabitssuchasnailbitingorchewinggumand learntostifleorsupportayawntoavoidstressingtheTMJ.Some patientsrespondtosplints,buttheyaregenerallynotconsidered theprimarytreatmentmodality.Thesplintsneedtobecomfortableforthepatientandareusuallywornatnighttocounteract grindingandclenchingduringsleep.Somepatientswithawake bruxismmayalsowearthesplintduringthedaytime.

REFERRALFORSECONDARYCARE

Whenconservativemeasuresdon’tachievepainrelief,it’ s likelythatarestrictionlimitingmouthopeningoraclosed lockispresent.Becausethisaffectsqualityoflifeandnutritionalintake,areferralforsecondarycareisappropriate. Thereferralshouldincludealistoftheconservativemeasures thathavebeentaken.

Varioustreatmentscanbedoneinsecondarycarefacilities. Theseincludemagneticresonanceimaging(MRI)oftheTMJto identifydiscdisplacement;pharmacotherapysuchasduloxetine, cyclobenzaprine,oroff-labelneuromodulatordrugssuchastricyclicantidepressants,selectiveserotoninreuptakeinhibitors, benzodiazepines,andgabapentin;botulinumtoxintypeAinjections;TMJsurgery;TMJmeniscopexy;orcompleteTMJreplacementandsubsequentreplacement.

ClinicalSignificance

TMDtreatmentrequiresthedentalpractitionertobe cognizantofthecausativefactors;thepossiblestructuresinvolved;thepain,noise,andmotioneffects;and factorsthatexacerbatethepatient’scondition.Conservativetreatmentsaregenerallyabletomanage mostpatients’ symptomsandimprovetheirquality oflife.PatientsshouldbeawarethatTMDischronic andhasnocure,butismanageableinmostcases withlifestylechangestominimizestressandanxiety andprotectthestructuresthatareinvolved.

CampbellV,MehmetT,HeffernanA:Toptipsforthemanagementoftemporomandibulardisorders. BrDentJ 238:14-17,2025

Reprintsnotavailable

MSDPREVENTION

AssumingtheBestPostureforDentalCare

BACKGROUND

Dentalprofessionalsareathighriskfordevelopingmusculoskeletaldisorders(MSD),withtheneck,back,shoulder,and wristthemostcommonsitesofpain.Clinicians,whetherdentists,dentaltherapists,ordentalhygienists,adoptstaticpositionsandholdthemforanextendedperiodoftimesothat theycanseewellandgainproperaccesstothepatient ’sworking site.Oftentheseposturesandthelengthoftimetheyareheld canleadtothedevelopmentofMSD,producediscomfortin deliveringcare,andshortenthedentist’scareer.MSD-related paincausesreducedproductivity,frequentabsences,andsometimesevenearlyretirement.Dentalprofessionalsneedtoequip themselveswiththetoolstopreventandmanageMSDand therebyavoidlong-termconsequences.Sometoptipsare offeredtoaddressstandingandseatedposture,sittingata screen,adjustingthepatient,useoflightingandsharpinstruments,purchasingasaddleseatandloupes,andmovingand stretchingregularly.

POSTURE

Posturereferstohowyouholdyourbody,whethermoving(dynamic)oratrest(static).Posturediffersdependingonwhether youarestanding,operating,orsitting.

StandingPosture

Thespinehas3curvesthatneedtobemaintained.Ifyou’ ve developedpoorpostureovertheyears,youneedtoretrain yourbodytoachievegoodposture.Weightdistributionisan essentialpartofposture,withthebodybuilttodistributeits weightacrossyourjointstoreducestrainandstress.Toachieve agoodweightdistribution,youshouldstandwiththefeethip widthapartandtheanklebonesunderthehipbones.Keepthe kneessoftandnotlocked.Gentlytiltthepelvisbackwardandforward,thenallowittosettleinaneutralposition.Shrugtheshouldersafewtimes,thenbringthemdownandbacksotheshoulder jointsareoverthehipjointsandhorizontal.Relaxthearmsdown atyoursides,letyourneck,jaw,andeyesrelax,andfeelthe crownofyourheadlift.Thesemovementswillmakeyoufeel tallerandmoreevenlybalanced.

SeatedPosturefortheDentist

Beginbysittinginastable,upright,symmetricalposition,withthe lowerlegsvertical.Lookperpendiculartothesurfaceyouare workingonbydirectvisionorinamirror.Theoralcavityshould beatmid-sternumheight.Placetheforearmshorizontalorno morethan25degreesupfromhorizontalandtucktheelbows in.Don’ttilttheheadmorethan20degreesinanydirection.

Maintainthispositionfor80%ofyourworkingtime,moving thechairorthepatientsoyoucanrestinthisposture.Theother 20%ofthetime,youcanworkonpatientswhocan’tliesupine (pregnantwomenorbariatricpatients).Keepthedeliveryunit atelbowheighttoavoidreachingtoofar.Toavoidprolonged staticposturing,getupandmoveregularly.

SeatedPosturefortheDentalNurse

Situprightandhigherthanthecliniciansothatyoureyesare about10cmabovethedentist’seyes.Standupifyouneedto.

SITTINGATASCREEN

Adjusttheheightofthedesk,chair,table,orscreentoachieve optimalseatedposition(Figure4).Withbothfeet flatonthe floor,lowerlegsvertical,maintaina90-degreeanglebehind theknees.Situpstraightbutrelaxtheshouldersandallowthe backofthechairtosupportyou.Ensureyourshoulderjoints areaboveyourhipjoints,andkeepyourarms fl atonthedesk ortable.Thetopofthescreenshouldbelevelwithyoureyes, andthescreenshouldbeaboutanarm’slengthaway.

ADJUSTINGTHEPATIENT

Oncethepatientissupine,getintogoodpostureyourself.Ensure thepatienthasplacedhimselforherselfintotheangleofthe chair.Adjustthedoublearticulatingheadrestcorrectly.This maytakepracticewithacolleaguetodeterminethemost comfortableposition.Theheadrestshouldsupportthepatient’ s headonthemastoidboneatthebackoftheskull.Insertawipeablecushionorfoldedtowelifthereisalonggapbetweenthe chairandheadrest.Adjusttheheadrestsothepatient’schinis upwhentreatingupperteethanddownwhentreatinglower teeth.Havethepatientadjusthisorherheadasneededto achievethebestposition.

LIGHTANDSHARPINSTRUMENTS

Theproperuseoflightingrequiresthatyoupositiontheoperatinglightsothelightisparalleltoyourlineofsight.Usethe mirrortoreflectthelightintotheoralcavitywithoutcreating shadows.Ifthelightisonyourloupes,don’tforgettousethe operatinglightsothatthedentalnursecanseeaswell.

Sharp,ergonomicallydesignedinstrumentsarebestfordental work.Theyshouldhavealargediameterandatexturedgrip. Thetexturingmakesiteasiertograspandisbene fi cialduring scaling,reducingtheamountofforceneeded.Minimizehandfatiguebyensuringtheinstrumentsarekeptsharp.

Figure4. Howtositatascreen.ContainspublicsectorinformationpublishedbytheHealthandSafetyExecutiveandlicensedunderthe https:// www.nationalarchives.gov.uk/doc/open-government-licence/version/3/ (CourtesyofRobinsonC,MysoreD,McCollE,etal:Toptipsforpreventing musculoskeletaldisordersandoptimisingposturefordentalprofessionals. BDJTeam 12:10-13,2025.)

SADDLESEATANDLOUPES

Ergonomicseatsandmagnificationloupesareagreatinvestment thatcanhelpinachievinggoodposture.Ergonomicseats,especiallysaddleshapedones,allowyoutositwithacorrectlyaligned spine,soit’simportanttotryseveraloutuntilyou findtheright seatforyou.Tilttheseat5to15degreestoachieveacloserpositiontothepatientwithoutstrainingtheback.Ifthechaircan’t betilted,youcaninsertawedge-shapedcushion.

Magni fi cationloupeswithadirectlightsourcehelptoprovide bettervisionandimproveposturewhilereducingmusculoskeletalpain.Youshouldchooseloupesthatsuityourdailyneeds, havea40-degreeangleofdeclination,andhavealightthat goeswiththem.Generaldentistryneedsnomorethan3.5x magni fi cation,withhighermagni fi cationreservedforspecialty dentistry.Refractiveloupeshelptoensureyourneckwillstay upright.

MOVINGANDSTRETCHING

Staticmusclepainoccurswhenaconstantloadonthemusclesis maintainedforalongperiodoftime.Youshouldstandupand movebetweenpatients.Walkingorbikingtotheof ficeorgoing forashortwalkatlunchtimehelpstocombatstaticmusclepain. Stretchingoftheneck,shoulders,lowerback,hands,andwrists shouldbedoneregularly,especiallybetweenpatientsandat theendoftheday.Duringlongprocedures,takeafewseconds toevaluateyourpostureandthestatusofanymusclestrain. Evenwhennotattheof fice,youcando10minutesofstretching eachdayorjoinaPilatesoryogaclasstostretchtheentirebody. Youmayalsoseekadvicefromaphysiotherapist,osteopath, chiropractor,ormassagetherapist.

ClinicalSignificance

Takingafewminutestoensureyourbodyisrelaxed andreadytoassumeahealthyandstablepostureso youcanworkwithoutpainisapracticalwaytokeep fromdevelopingMSD.Thetipsgivenwillhelpin assumingthecorrectpostureforthetaskathand andcancontributetoahealthierwaytoperform dentistry.Thebenefitsde finitelyoutweightheminor adjustmentsneeded.

RobinsonC,MysoreD,McCollE,etal:Toptipsforpreventing musculoskeletaldisordersandoptimisingposturefordental professionals. BDJTeam 12:10-13,2025

Reprintsnotavailable

PEDIATRICFIRSTPERMANENTMOLARS

AddressingCariesandHypomineralizationofFirst PermanentMolars

BACKGROUND

Thehealthofthe firstpermanentmolar(FPM)isanessential considerationbecausethistoothcanbecomecompromised andcausesignificantnegativeimpactsforthechild,thefamily, andthehealthcaresystem.Thepreventionorarrestofdental diseasessuchasdentalcariesormolar-incisorhypomineralization(MIH)requiresanunderstandingoftherisksFPMsface, sharingthedecisionforcarewithbothpatientandparents,and selectingthebestcourseoftreatmentthatminimizesthechance thatfurtherinterventionswillbeneededinthefuture.

RISKSFORFPMCOMPROMISE

AcompromisedFPM(cFPM)ismostofteninvolvedwithdental cariesorMIH.Thesedisorderscanhaveasigni ficantimpact, bothdirectandindirect,onthepatient,family,andsociety.

DentalCaries

FPMsarethepermanentteethmostsusceptibletodentalcaries. Byage15years,aboutaquarterofFPMteethwillhaveobvious caries,comparedtojust9%ofthesecondpermanentmolar. BecausetheFPMisthe fi rstpermanenttoothtoerupt,itspends

thelongesttimeinthemouthandthereforeismorelikelyto developdentalcariescomparedtotheadjacentpermanentteeth.

MIH

MIHisadevelopmentalabnormalitythatcausesreducedmineral contentintheenamelofFPMsandsometimesalsoofincisors.Evidenceappearstoindicatethatepigeneticchangesinthegenome, causedbyenvironmentalfactors,maybethemostlikelycauseof MIH.About27%ofchildrenwhoarediagnosedwithMIHwillneed clinicalinterventionsbecausethepoormineralcontentleadstoa lackofstructuralintegrity,causingmechanicaldeteriorationof toothstructureandpost-eruptivebreakdown.Themacroscopic appearanceoftheteethiscompromised,makingthemharderto treatandincreasingtheirsusceptibilitytodentalcariesbecause theyaccumulateplaqueandbacteriapenetratetheirenamel.

ADDRESSINGFPMVULNERABILITY

Variousmeasurescanbetakentopreventthedevelopmentof cFPMsduringtheperiodswhencompromisesaremostlikely tooccur.Thesemeasuresincludeoralhygieneandtoothbrushing, fluorideapplications, fissuresealants,andtheuseofsilverdiamine fluoride.Inaddition,publichealthmeasurescanhelp topreventdiseaseatapopulationlevel.

OralHygieneandToothbrushing

Preventionofplaqueaccumulationcanbeachievedbyfocusingon cleaningaroundtheeruptingtooth.Dentalprofessionalsshould teachthechildandparentstochangethetoothbrushposition fromamesial-distalplacementtoabuccal-lingualdirectionwhen thetoothispartiallyerupted,thenreverttothenormalpositionafterit’sfullyerupted.Parentsshouldalsoassistthechildwithtoothbrushinguntilthechildcomprehendstherightapproachandhasthe manualdexteritytobrushindependently.Plaquedisclosurehelps bothchildandparenttounderstandthescopeoftheproblem andmaymotivatethemtoachieveoptimalplaqueremoval.

Fluoride

Fluorideexposuremaintainsaconcentrationintheplaquebiofilmthatencouragestheremineralizationofthetoothsurface. Fluoridedeliverycanbeintoothpaste,water,milk,mouthrinses, toothgels,orvarnish.Fluoridatedtoothpasteisoneofthemost effectivemethods,withtwicedailybrushing,supervisedbyparentsifneeded,therecommendedpractice.Fluoridevarnishcan beappliedtoFPMsandadherestothesurface,providingslow releaseof fluoridetovulnerableareas.DryingtheFPM fi rstincreasesadherence.

FissureSealants

Aresin-based fissuresealanthasbeenassociatedwithareduction intheabsolutecariesriskof11%to51%forupto48months. Whenadhesivesystemsareusedbeforeapplyingthe fissure sealant,increasedpenetrationandretentionrateshaveoccurred. Cavitatedenamelandmicrocavitiesindentincariouslesions bene fitfromresin-bonded fissuresealants.Childrenwithmild

hypomineralizationoftheFPMcanalsoreceive fissuresealants. Patientsshouldundergoregularclinicalandradiographicexaminationstorevealanylesionprogression.

Thesesealantsaresuperiortoglassionomersealantsintermsof clinicaleffectiveness,sotheirplacementshouldbea first-line choice.However,childrenwithlimitedcomplianceorwho havecompromisedmoisturecontrolmaybenefitfromaglass ionomersealantasaninterimoption,reservingtheresin-based sealantforlater.

SilverDiamineFluoride

Silverdiamine fluoride(SDF)maybeconsideredwhentheFPM hasbecomecavitatedandthechildisuncooperativeorthetooth isinavulnerableposition,suchaspartiallyerupted,sothata restorationcan’tbeplaced.SDFusebuysthedentalprofessional sometimebeforede finitivemanagementstrategiesmustbeemployed.ThedrawbackswithSDFincludetheblackdiscoloration ofthetooth,whichshouldbediscussedwiththepatientandparentsbeforeusingtheSDF.Ifit’sdeterminedthatthechildneeds anFPMrestoredwithSDF,thedentalprofessionalshouldusea total-etchapproachtoovercomereducedbondstrengthsbetweencompositeandSDF-treatedenamelanddentin.

PublicHealthInterventions

Communitywater fluoridation,supervisedtoothbrushingprograms,andtaxationofsugar-sweetenedsugarbeveragesaremeasurestakenatapopulationleveltopreventoraldisease. Adopting,implementing,andencouraginguseofamultifocused preventiveapproachisawaytosigni ficantlyreducehavingyoung patientsenteracontinuouscycleofrestorativetreatmentthat wearsawayatthenaturaldentition.

SHAREDDECISION-MAKING

ItcanbechallengingtodeterminethebestinterventionforprotectingFPMsfromcompromiseortomanageatooththathas becomecompromised.Alldecisionsshouldbemadejointly withthepatient,theparents,andtheoralhealthcareprofessional.Youngpatientstendtofavorthisapproachifatrusting relationshiphasbeenformedwiththeclinician.Oralhealthpractitionersshouldbetrustworthy,sharealltheneededinformation,andevidencetheirconcernforthepatient’swell-beingto gaintheconfidenceofayoungperson.Parentsandguardians mustalsobeincluded.Theseindividualscanencouragetheirchildrentoexpresstheiropinionsandpreferencesratherthan dictatewhattheyassumearetheirchild’sviews.

TREATMENTCHOICES

Beforemakinganychoice,thedentalcareprofessionalmustfully assessthechild’sdevelopingdentitionaswellasevaluatethepatient’sandparents’ abilitytounderstandandcomplywithtreatmentneeds.Thepossibletreatmentsshouldbediscussed,with considerationsatthepatientlevel,themouthlevel,andthetooth level(Table1).

Table1. FactorstobeConsideredWhenTreatmentPlanningcFPMs

PatientlevelMouthlevelToothleve

PatientpreferencesNumberofaffectedcFPMsSizeandlocationofdefect

RelevantmedicalhistoryOveralldentalhealthNumberofsurfacesinvolved

Ageandlevelofco-operationDentaldevelopmentalegbifurcationofsecond permanentmolars

Presence/absenceofsymptomsOrthodonticneed,suchaspresence/absence crowding,hypodontiaetc

Presence/absenceofpost-eruptivebreakdownin hypomineralisedtooth

Pulpalinvolvement

CurrentaccesstogeneraldentalservicesPresenceofthirdpermanentmolarsHistoryofdentalabscess/facialcellulitis Accesstospecialistcare (paediatricdental/orthodontic)

(CourtesyofTaylorGD,BulmerV:Advancesinknowledgeandpracticebenefitingthehealthandmanagementof firstpermanentmolarsinchildren. BrDentJ 238:92-98,2025.)

Condition-dependentCare

DentalcariesandMIHaredifferentconditions,sothereare differentinterventionsthatmustbeconsideredbasedonthe conditionpresent.InMIH,mostoftheotherposteriorpermanentteethareunaffected,sotheoptiontoextracttheFPMis moreoftenfavored.However,recentresearchindicatesrestorationandretentionofhypomineralizedmolarsismoreinlinewith minimalinterventiondentistryandfavoredbypatientsinparticular.Indentalcaries,allthepermanentteethareatrisk,withthe

choiceofinterventionbasedonthepatient’sandparents’ engagementinthepreventivestrategies.Thediseaseburdenmaybe minimalandfavorarestorativeapproachtomanagement.

Strategies

The3generalmanagementstrategiesforcFPMsareactivemonitoring,restoration,andextraction.Itshouldbenotedthatlittleclinicalevidencefavorsrestorationorextractionovertheother option.

Figure4.A-D, Ahypomineralizedlowerleft firstmolar(36)withpost-eruptivebreakdown (A) whichhasundergonepartialhypomineralizedenamel removal (B) andthencompletehypomineralizedenamelremoval (C) leavingthemarginsoftherestorationonsoundenamel (D).(CourtesyofTaylorGD, BulmerV:Advancesinknowledgeandpracticebenefitingthehealthandmanagementof firstpermanentmolarsinchildren. BrDentJ 238:92-98,2025.)

ActiveMonitoring

Inactivemonitoring,it’sacceptedthatthetoothislikelyto worsenwithoutintervention.Therisksassociatedwiththis approachincludeahighchancethatdentalpainandsubsequent infectionorsepsiswilloccur.Thisoutcomeshouldbediscussed withthepatientandparents.Anyfuturetreatmentwillhaveto dealwithamoredif ficultcompromisedFPM,aremoreexpensive,andwillbeassociatedwithlesscertainresults,eventually leadingtoextractionofthetooth.

Restoration

Withtheadvancesinrestorativematerialsandtechniques, restorationisoftenaviableoptionforFPMswithdentalcaries. Extendedetchingandapre-restorationrinsewithsodiumhypochloritehavebeensuggestedtoovercomedecreasedbond strengthsandhigherfailureratesinhypomineralizedenamel comparedtorestorationstosoundenamel.Totalremovalof allhypomineralizedenamelhasalsobeensuggested,ashasaselectiveremovalofthecompromisedenamel.Theseoptions reducetheriskofiatrogenicpulpexposurethatcouldmitigate againstbondingproblems(Figure4 ).Theymayalsoovercome structuralissuesrelatedt ohypomineralizedenamel.

Ifthepulpisexposedorthepatientdevelopssymptoms,endodontictreatmentsuchasvitalpulptherapiescanbeusedfor cariousaswellashypomineralizedmolars.Vitalpulptherapieshaveasuccessrateofabout91%forpartialaswellas coronalpulpotomies.Thedrawbackistheperpetuationof therestorativecyclewithincreasinglylargerrestorationsuntilnotoothsubstanceremainstorestoreandextraction mustbedone.

Extraction

Ifthetoothisextracted,thereisnoneedtomaintainarestoration,whichsomepatientswillprefer.Youngpatientsandadults tendtoperceiveextractionasmoreinvasivethanrestoration. Extractioninayoungchildoftenrequiresrepeatedadjunctive treatments,includingsedationandgeneralanesthesiafortreatment.Theseareassociatedwithclinicalrisksandcosts.

SEPSIS

Ifextractionistheonlyfeasibleoption,spontaneousclosureof thespacecouldoccur,negatingtheneedfororthodonticspace closureorprostheticreplacement.Theoralcarepractitioner shouldbeawareofradiographicprognosticfactorsthatimprove thechancesofspontaneousclosure,althoughthesefactorsdon’t guaranteeitandunfavorabletoothmovementortippingofadjacentteethcanstilloccur.

TheextractionofanupperFPMmightbedonetocompensatefor extractionofthelowercFPM.Thisshouldbedonewithcautionand reservedforpatientswhohaveaclearocclusalrequirementor whentheupperFPMwillbeunopposedforasignificanttimeperiod.

RemovalofcFPMswilllikelyhaveanimpactonthirdpermanent molarposition.It’sbeennotedthatthirdmolarsofpatients whosecFPMswereextractedbetweenages8and11years havemovedsignificantlymoremesiallythanthemolarsofpatientswhohadnoextraction.Asaresult,thethirdmolarmay eruptintoamorefavorablepositionandreducebothimpaction andassociatedmorbidities.

ClinicalSignificance

WhenFPMsareatriskorcompromised,thedental careprofessionalmustinstitutemeasurestoprotect themaswellasintervenetokeepthesituationfrom progressing.Throughouttheprocess,thepatient andparentsshouldbeapartofthedecision-making process,withtheoptionsselectedbasedoneachindividualcase.

TaylorGD,BulmerV:Advancesinknowledgeandpractice bene fitingthehealthandmanagementof firstpermanentmolars inchildren. BrDentJ 238:92-98,2025

Reprintsavailablefrom GDTaylor;e-mail: Greig.taylor@newcastle.ac.uk

RecognizingSignsandSymptomsofSepsis

BACKGROUND

Sepsisdevelopswhenthebodyhasanabnormalresponseto aninfection.Forunknownreasons,thebody’simmunesystem occasionallydealswithaninfectionbyattackinghealthyorgans andothertissues.Asaresult,sepsisistheleadingcauseof deathintheworld,withamortalityofmorethan20%,but

morethan40%ofsurvivorsalsosuffersigni ficantconsequences,suchaspost-traumaticstressdisorder(PTSD),amputations,failureofmajororgans,braindamage,chronicpain, andchronicfatigue.Thosewhosesepsisiscaughtearlyand treatedcanmakeafullrecovery,butthesegoodoutcomes couldbeimprovedbygreaterpublicandprofessional

Figure1. Signsandsymptomsofsepsis.UsedwithpermissionfromFirstAidforLife www.firstaidforlife.org.uk and www.onlinefirstaid.com.(Courtesyof HammettE:Sepsis acompleteguide. BDJTeam 12:80-82,2025.)

awarenessofthesignsandsymptomscharacteristicofsepsis. Unfortunately,theearlysignalsofsepsisareoftenmissed, evenbyprofessionalhealthcareproviders.Sepsisfactswere shared,includingitscauses,possibledamageproducedinthe body,andthepatientsmostcommonlyaffected.Thekeysto recognizingandtreatingthesignsandsymptomsofsepsisin adultsandchildrenwereoutlined.

SEPSISFACTS

Sepsisbeginswithaninfectioninthebody.Thisinfectionmay occuraftersurgeryortraumaandcanmayaffectstructuresin anyareaofthebody.Theinfectionsseenmostofteninclude pneumonia,urinarytractinfections,intra-abdominalinfections, skininfections,woundscausedbytraumaorsurgery(including dentalinfections),andsofttissueinfectionssuchasalegulcer.

Figure2. Signsandsymptomsofsepsisinchildren.UsedwithpermissionfromFirstAidforLife www.firstaidforlife.org.uk and www.onlinefirstaid.com (CourtesyofHammettE:Sepsis acompleteguide. BDJTeam 12:80-82,2025.)

Thebacteriainvolveddon’tnormallycauseillness.Between2% and3%ofcasesoccuraftertrauma.Meningitiscausesabout1% ofcasesinadultsbutabout10%ofcasesinchildren.Viralmeningitisisn’tusuallylife-threatening,butbacterialmeningitis,which ismuchlesscommon,canleadtosepsis.However,bothtypesof meningitisareserious,andcommonearlysignsandsymptoms shouldberecognizedsotreatmentcanbestarted.

Theinflammationrelatedtosepsisinjuresthebody’stissuesand organs,withitsspreadinvolvingthebloodstream,sothesepsis cantravelthroughoutthebody.Thebreakdownincirculation canaffectalltheorgansofthebody,includingthebrain,lungs, heart,skin,andkidneys.Ifcirculationtotheextremitiesis compromised,amputationcanberequired.

Sepsiscandevelopinanyoneandnosinglespeci ficsignordiagnostictestcanidentifyit.Themostcommonpatientsarevery youngchildren,olderadults,andthosewithunderlyinghealth conditions,buteven fitandhealthypersonscandevelopsepsis. Personswhohavedentalworkcanhavebleeding,whichallows theingressofbacteriaandthedevelopmentofinfections.Dental professionalsmaygivepatientswhoaresuspectedtohavean infectionacourseofantibiotics,especiallyiftheyhaveacompromisedorweakenedimmunesystem.Patientsshouldbeurgedto completethecourseofantibioticstoensurethebestresponse.If theinfectionissevere,itmayrequiredrainagetoreducepainand swelling.

RECOGNIZINGANDTREATINGSEPSIS

EducatingPatients

Healthcareprofessionalsshouldexplaintopatientswhatthe earlysignsofinfectionareandadvisethemtointervenewith earlytreatmentorseekprofessionalcare.Patientsshouldalso bemadeawareofthemoreserioussignsandsymptomsofsepsis sotheyknowwhattolookforandwhenurgentmedicalcareis required.Somepatientsmayneedtotakeprophylacticantibioticsbeforeanyinvasivedentaltreatmenttoguardagainst infection.

SignsandSymptoms

Adults

Theinitialsymptomsofsepsisinadults(Figure1)canresemble the fluandfeelingseriouslyunwell.Theindividualmayhavesigns offeverwithcoldhandsandfeetorevenanabnormallylowtemperaturebutfeelingveryunwell.Amongthecommonsignsand symptomsarethefollowing(occurringinnoparticularorder):

Dislikeofbrightlights

Stiffneck

Vomiting

Severemusclepain

Drowsiness,withdifficultystayingawake

Pale,blotchy,orspottyorrash-coveredskin

Convulsions/seizures

Feverwithcoldhandsandfeet

Confusionandirritability

Children

Inchildren(Figure2),thesignsandsymptomsofsepsiscan includehavingthefollowingconditions:

Abnormallycoldtothetouch

Mottled,bluish,orverypaleskin

Rashthatdoesn’tfadewithpressure

Breathingveryfast

Convulsions

Extremelethargyordif ficultywakingup

Forchildrenunderage5years,thereshouldbeconcernifthe childisn’tfeeding,isvomitingrepeatedly,andhasn’turinatedor hadawetdiaperfor12hours.

Anyofthesesignscanindicateaseverelyillchildwhoshouldbe takenurgentlytothedoctor,withtheadultmentioningaconcern thatthechildmayhavesepsis.

CONCLUSIONS

Sepsisisaseriousproblemthatcanhavelifelongconsequencesor resultindeath.Boththepublicandhealthcareprovidersshouldbe awareoftherangeofsignsandsymptomsthatmayindicatethata simpleinfectionhastriggeredthebodytooverreactandbecome septic.

ClinicalSignificance

Sepsiscanaffectanyone,withmorethan240,000 peopledealingwithsepsiseachyear.IntheUnited Kingdom,anestimated5peopledieofsepsisevery hour.Becausetheearlysignsandsymptomscanbe difficulttoconnecttosepsis,everyoneshouldbe educatedaboutwhattolookfortodetectitasearly aspossible.Dentaltreatmentoftencausesbleeding, whichcanopenthedoortobacteriaenteringthe bodyandultimatelycausesepsis.Dentalcare providersarediligenttotakemeasuresthatensurea cleanfacilityandcleanlinessamongthoseproviding care,butpatientswhohaveanyofthesignsof possiblesepsisshouldbecarefullymanagedto ensurethebestpossibleoutcomes.

HammettE:Sepsis acompleteguide. BDJTeam 12:80-82,2025

Reprintsnotavailable

SUGARYMEDICINES/CHILDREN

AddressingSugaredMedicationsforChildren

BACKGROUND

Bittermedicinesaren ’tunusualtreatmentsforchildren,but themostcommonwaytohelpthemedicinegodownisto usesugar-basedsyrupsratherthanpillsortogivethechild asugarydrinktowashthecapsuleortabletdown.Sucrose isthemostcommonsugaraddedtomedicationsandhas theadvantagesofbeinginexpensive,non-hygroscopic,and easytoprocess.Thedownsideofsucroseisitspotentialto contributetothedevelopmentofdentaldecay.Dentalcaries, themostprevalentdiseaseoftheoralcavity,anduntreated dentalcariesinpermanentteeth,themostcommonhealth conditionintheworld,arewidelyfoundandrequire concertedeffortstominimizetheirdamage.Untreatedcaries causespain,leadstoinfection,andcanrequireextractionsof teethundergeneralanesthesiainchildren.Schooldaysare missed,parentshavetotaketimeoffworktovisittheir child ’sdentist,andtoothextractionsareexpensive,sodental cariesaffectsmuchmorethanthechild ’soralhealth.The cariesprocess,howtoreducecariesriskorsusceptibility, theadvantagesanddisadvant agesofsugar-containingand sugar-freemedicines,andrecommendationstoreducethe dentalriskofsugar-containingmedicineswerediscussed.

THECARIESPROCESS

Thecauseofdentalcarieshasmultiplecontributingfactorsbut essentiallyinvolvestheinteractionofatooth,bacteria,fermentablecarbohydrates,andtime.Theseinteractionsofthesecomponentscaneventuallydestroytoothsubstanceiftreatment isn’tinitiated(Figure1).

Thehost-microbialinteractioninvolvesseveralsteps.Itbegins withdentalplaqueformation,inwhichbacteriaattachtotooth surfacestoformplaque.Acidisthenproducedasthebacteria fermentsugarsandothercarbohydratesinfood.ThepHofthe environmentbecomesloweredasaresult.Thisacidicenvironmentdissolvesordemineralizestoothenamel.Remineralization canoccuriftheacidicenvironmentisneutralizedandthepHof theoralcavitybecomesstabilized.Duringremineralization,mineralssuchascalciumandphosphate,whicharepresentinsaliva, areredepositedintotheweakenamel.Iftheacidicenvironment isn’tstabilized,thedemineralizationcontinues,eventuallypenetratingtheenamelandattackingthedentin,whichisweaker

thanenamel.Decaythencanreadilyspreadthroughthetooth andcausecavities.

TheStephancurveillustrateshowtheoralpHdipsafter eatinganddrinkingfermentablecarbohydrates(Figure2). HavingapHlessthan5.5allowsdemineralization,making thisthecriticalpHforenamel.Remineralizationrequiresa riseinpHabove5.5.Ifthisrisedoesn ’toccur,thelonger theoralpHremainslessthan5.5,themoresusceptibleteeth aretocariesdevelopment.

REDUCINGCARIES

Effectivetoothbrushingremovesmuchofthesoftdentalplaque, withtheadditionof fluoridetoothpastehelpingtostrengthenthe teeththroughremineralizationofthetoothsurface.However, dietisthemostimportantcomponentinreducingdentalcaries. Bylimitingthefrequencyandamountofsugarconsumedeach day,thetimeteetharesusceptibletodecayisalsolimited.Dentiststrytoeducatepatientstoonlyconsumesugarsatmealtimes andlimitanysugar-containingsnacks.

Ifchildrenaretakingsugar-basedmedicines,especiallyifthemedicinesaregivenatnon-mealtimesmultipletimesaday,thecariogeniceffectisincreased.It’sespeciallyimportanttoavoidsugary medicinesatbedtimebecausesalivaisn’tabletoeffectivelyremineralizethetoothsurfacesatnight.

Figure1. Extensivedentalcariesinachild.(CourtesyofHowardJ,Dave M,ReynoldsL,etal:Thebittertruthregardingsugarymedicinesinchildren. BDJTeam 12:116-120,2025.)

Figure2. TheStephancurve – aftermealsareconsumed,theincreaseinsugarreducesoralpHbelowthecriticalpHofenamel(pH5.5),resultingintooth demineralization.(CourtesyofHowardJ,DaveM,ReynoldsL,etal:Thebittertruthregardingsugarymedicinesinchildren. BDJTeam 12:116-120,2025.)

SUGAR-CONTAININGVERSUSSUGAR-FREE MEDICINES

Sucrose-containingmedicinescauseadropindentalplaquepH, andlong-termuseofsugaryoralmedicationhasbeenlinkedto rampantdentaldecay.Asaresult,clinicianshaverecommended theuseofsugar-freemedicinesinpatientswithchronicdiseases.Someevidenceindicatesthattheuseofsugar-freemedicationsforpatientsathighbaselineriskforcariesisespecially appropriate,whereastheuseofsugar-freemedicinesforlow caries-riskindividualswhohaveashort-termillnessmaybe lessclinicallyjusti fi ed.

Sugar-freedrinksandsnackscanalsohelpreducetheriskof dentalcaries.It ’simportantthatchildrennotbegivensweet drinksorsugarysnackstomakethemedicinemorepalatable tothem,whichwouldbecounterproductivewithrespectto cariesreduction.

Someevidencepointstothefactthattheprescriptionof sugar-freemedicineslong-termforchildrenwhoaremedicallycompromised,havepoororalhealth,suffersocialdeprivation,havelearningdisabilities,orrequirerestrictedeating patternsisespeciallyimportant.It'sbeenshownthatsocial deprivationisnotonlyariskfactorforpoororalhealth butalsoanindicatorofmoreseveredentaldisease.Having learningdisabilitiescanbeassociatedwithastruggleto

copewithdentaltreatmentwhenitisneeded.Therefore, effectivecariespreventionstrategiesareespeciallyimportant inthesehigh-riskpatients.

REDUCINGTHEDENTALRISKRELATEDTO SUGAR

Family

Parentsandcaregiversshouldbeeducatedregardingtheeffectsofsugarinrelationtotoothdecay.Theyshouldalso betoldwhenamedicationcontainssugarandinstructedto givethemedicationatmealtimes.Medicationsthatareprescribedtobegivenatbedtimeshouldbeadministeredatleast 30minutesbeforethechildgoestobedtoallowtimeforthe oralenvironmenttoregainneutralstatusbeforebrushingthe teeth.Ifthesugar-containingmedicationmustbegivenata timeseparatefrommealtime,thechildshouldusea fluoride-containingmouthwashaftereachdosetominimize theriskoftoothdecay.

Prescribers

Thehealthcarepractitionerswhoprescribemedications, especiallyforchildren,shouldbeawareoftheeffectsof sugar-containingmedicinesonteeth.Thepreferenceshould beforsugar-freemedications.Inaddition,electronicprescribingsystemsshoulddefaulttosugar-freeformulations,if

Table1. CommonlyPrescribedSugar-containingMedicinesforPaediatricPatientsandSugar-freeAlternatives.

MedicationwithsugarPrescribedfor

Sugarcontent g/5ml*

Sugar-freesubstitution

Loratadine5mg/5mloralsolutionAllergicconditions3.0gLoratadine5mg/5mloralsolutionsugar free

Piritonsyrup(chlorphenamine2mg/5ml oralsolution)

Amoxicillin125mgand250mg/5mloral suspension

Allergicconditions2.4gChlorphenamine2mg/5mloralsolution sugarfree

Bacterialinfections2.7gAmoxicillin125mgand250mg/5ml sugar-freeoralsuspension

Azithromycin200mg/5mloralsuspensionBacterialinfections3.7gAzithromycin200mg/5mloralsuspension sugarfreeavailablebyspecialorder

Cefalexin125mgand250mg/5mloral suspension

Ciproxin(ciprofloxacin250mg/5mloral suspension)

Clarithromycin125mgand250mg/5ml oralsuspension

Co-amoxiclav250mg/62mg/5mloral suspension

Co-trimoxazole80mg/400mg/5mloral suspension

Bacterialinfections

3.0gCefalexin125mgand250mg/5mloral suspensionsugarfree

Bacterialinfections1.4gConsiderprescribinganalternativesugarfree fluoroquinoloneantibiotic

Bacterialinfections3.1gConsiderprescribinganalternativesugarfreemacrolideantibiotic

BacterialinfectionsUnknownCo-amoxiclav250mg/62mg/5mloral suspensionsugarfree

Bacterialinfections2.5gCo-trimoxazole40mg/200mg/5mloral suspensionsugarfree

Flucloxacillin125mg/5mloralsolutionBacterialinfections3.2gFlucloxacillin125mg/5mloralsolution sugarfree

Metronidazole200mg/5mloral suspension

Phenoxymethylpenicillin125mgand 250mg/5mloralsolution

Bacterialinfections1.7gConsiderprescribinganalternativesugarfreeantibiotic

Bacterialinfections2.9gPhenoxymethylpenicillin125mgand 250mg/5mloralsolutionsugarfree Lactulose3.1-3.7g/5mloralsolutionConstipationUnknownLactulose10g/15mloralsolution15ml sachetssugarfree

Lansoprazole15mgorodispersibletabletsGastrointestinalulceration,GORD,H. Pyloriinfection 13.8mgConsiderprescribinganalternativePPI

Morphinesulfate10mg/5ml oralsolution

Pain2.3gMorphinesulfate10mg/5mloralsolution sugarfreespecialorder

Brufen(ibuprofen100mg/5mlsyrup)Painandinflammation3.3gIbuprofen100mg/5mloralsuspension sugarfree

Paracetamol120mgand250mg/5mloral suspensionpaediatric

Painandpyrexia3.0gParacetamol120mgand250mg/5mloral suspensionpaediatricsugarfree

*These figuresrelatetoatleastoneUKlicensedproduct.

(CourtesyofHowardJ,DaveM,ReynoldsL,etal:Thebittertruthregardingsugarymedicinesinchildren. BDJTeam 12:116-120,2025.)

possible.Ifnosugar-freealternativeisavailable,themedicationsshouldbeprescribedtobegivenwithmealsiffeasible.

Pharmacists

Sugar-freemedicinesshouldbepromotedinpharmacies.Inaddition,pharmacistsshouldbegiventheauthoritytodispensesugarfree-preparationsasappropriate.

PharmaceuticalCompanies

Sugar-containingmedicationsshouldhavelabelswarningabout theriskoftoothdecayandadvisingthatthesemedicationsbegiven atmealtimes.Noncariogenicsweetenersshouldbepreferred oversucrosefordrugs.Thesecompaniesshouldalsoexplore developingsmallertabletsandcapsulesformedicationsthatchildrenwillbetakingtohelpthemhandlesolidformulations.

ClinicalSignificance

Pain,infections,andtroubleeating,sleeping,andsocializingcandevelopinchildrenwhohavedental caries.Usuallythetoothdecaycanbeprevented, withdietbeingthemostimportantriskfactorthat canbemodifiedtopreventcaries.Onecomponent thatcanbeaddressedissugar,withmodificationsof thediettokeepingestedsugarstoaminimum.Dental andotherhealthcarepractitionerscanhelpbyprescribingmedicationsthataresugarfreeaswellasinstructingthatsugar-supplementedmedications shouldbetakenwithmealsifthesugarcan’tbeeliminated.Manycommonlyprescribedsugar-containing medicationshavesugar-freealternatives(Table1).

HowardJ,DaveM,ReynoldsL,etal:Thebittertruthregarding sugarymedicinesinchildren. BDJTeam 12:116-120,2025

Reprintsavailablefrom MDave,DivofDentistry,Coupland3Bldg, TheUnivofManchester,OxfordRd,Manchester,M139PL;email; manas.dave@manchester.ac.uk

VAPINGANDORALHEALTH

CounteractingMisinformationAboutVaping

BACKGROUND

E-cigarettesandothertypesofvapingdeviceswereinitiallyintroducedaswaystohelpsmokersquitusingcigarettesandothertobaccoproducts.Thesevapingdevicesweretoutedasasafe alternativetosmoking,buttheirreceptionbyyouthandyoung adultsledtotheirwidespreaduseasrecreationalproducts.Innovationsindesignsand flavorshaveincreasedtheappeal.Despite thesupposedsafetyofvaping,ithasbeenlinkedtoanincreased riskforasignifi cantspectrumofhealthrisks.Thehealthimplicationsofvaping,prevalentmisconceptionsaboutthispractice,and proposedpublichealthinterventionsthatareneededtoaddress therisksofvapingwerepresented.

HEALTHIMPLICATIONS

Non-oralHealthEffects

Vapinghasbeenassociatedwithanincreaseinlunginjuries,the exacerbationofasthma,chroniccoughing,andotherrespiratory systemdisturbances.Inaddition,severalcardiovascularsystem problemshavebeennoted,includinganincreasedriskfor myocardialinfarctionrelatedtotheexposuretonicotineand otherchemicalsduringvaping.Thecentralnervoussystemhas alsobeenaffected,withincreasedmooddisordersandnicotine addictiondevelopingwithuse.Eventheimmunesystemhassufferedsuppressionoftheimmuneresponseandanincreaseinthe riskofcancer.

OralHealthEffects

Multipleoralhealthproblemsarerelatedtovaping,asfollows (Table1):

Thepropyleneglycoline-liquidscandecreasesalivary flow, causingdrymouthanddiscomfort.

Propyleneglycolalsoresultsintheproductionofdiacetyland methylglyoxal,whichhavedetrimentaleffectsonoralhealth. Salivaisreducedandwhenthisiscombinedwithsugarye-liquids,anenvironmentfavorabletodentalcariesdevelopment results.

Chemicalssuchasnicotine,glycerol,volatileorganiccompounds,and flavoringagentshavebeenlinkedtoperiodontitis. Thediminishedsalivaandaccumulatedresiduescausepersistentbadbreath.

Theoralmicrobial floraisaltered,increasingtheriskofinflammationandmakingusersmoresusceptibletoinfectionssuch ascandidiasis.

Gumdisordersandtoothlossareassociatedwithchronic usage.

Enamelandtoothstructureareweakenedbytheacidicagents usedine-liquids.

Nicotineexposureimpairsblood flowandslowsthehealing processoforalwounds.

Prolongedexposuretonicotine-containingliquidscancause teethtodiscolor.

Table1. OralHealthImplicationsofVaping

Sr.noOralimplications

1Increasedriskofperiodontitis

2Guminflammationandbleeding

3Reducedsalivary flow

4Drymouth(Xerostomia)

5Irritationoforaltissues

6Alteredoralmicrobiome

7Erosionofdentalenamel

8Toothdecay

9Developmentoforalulcers

10Increasedriskoforalinfections

11Increaseinriskoforalcancers

12Flavor-inducedcytotoxicity

(Courtesyof.ShrivastavaSR,BobhatePS,BadgeA:Counteringoral healthimplicationsandmisconceptionsofvaping. JIntOralHealth 17:82-84,2025.)

Overheatingcausesburnsofthelips,gums,andpalate. Thechemicalsinvapeaerosolscanimpairtastebudfunction. Long-termexposuretocarcinogenicsubstancesinaerosols canincreasetheriskfororalcancer.

MISCONCEPTIONS

Mostpeoplebelievethatvapingonlyaffectsthelungsanddoesn’t causeoraldiseases,althoughawholelistofconditionsareactuallycausedbyvapingtosomedegree.Vapinghasalsobeenpromotedasahealthysmokingalternativebutevenaerosols generatedbythevapingcancauseoralcancerandperiodontal disease.

Someclaimthatvapingisn’taddictive,butthenicotine-containing flavoredliquidsusedareactuallyhighlyaddictive.Astudyinthe UnitedStatesreportedthat44%ofrespondentsquitsmoking andtookupvapingbecausetheybelieveditwassafe.About 12%sawvapingasnotbadforone’shealth.Amongadolescents age13to19years,asignificantproportionbelievethate-cigarettesarelessaddictivethanothertobaccoproducts.Wearing bracesorotherdentalapplianceswhilevapingcanincreasethe riskforinflammationintheoralcavityanddiscolorthegums.

PUBLICHEALTHINTERVENTIONS

Spreadingthetruthaboutvapingandhealthwillrequirevarious approaches.It’svitaltocreateawarenessaboutthespeci fic oralhealthrisksassociatedwithvapingusingavarietyofoutreach

campaigns.Theseincludesocialmediaplatforms,whichiswhere themisconceptionsabouttheuseofvapingareoftenspread. Peoplewhousevapingdevicesshouldalsobeencouragedto attenddentalcheckupsregularlytodetectanyoralhealthissues. Userscanalsobetaughttoperformself-examinationsperiodicallytodetectorallesions,ulcers,orotherearlylesions,then reportthemtotheirdentalcarepractitioner.

Thosewhovapeneedtoconsumeplentyofwatertooffsetthe reducedsalivaryproduction,thetendencytodevelopdental caries,andtheoraldiscomfort.Brushingand flossingatleast twiceadaycanpreventtheaccumulationofresiduesandbacteria inthemouth,combatinggumdiseaseandtoothdecay.Those whovapeshouldalsoconsumeadietrichinantioxidants,vitamins,andmineralstopromotepositiveoralhealthandprevent bothgumdiseasesandoralcancers.Supportandresources shouldalsobemadeavailabletothosewhovapetohelpthem quitthehabitandminimizetheriskforcompromisesoftheir oralhealth.

ClinicalSignificance

Aquestionnairefoundthat29%oftherespondents werewillingtoquitvapingusingmedications.Inaddition,35%werewillingtoquitusingmobileapplications.Theseresultsindicateadditionalwaysthat publichealthinitiativescanreachpeoplewhoarevapingwiththemessageabouthowdangerousandunhealthyvapingactuallyis.Gettingthemessageout andprovidingsupportforthosewhowanttoquitvapingandhavebetteroralhealthinthefutureareimportantwaysdentalcareproviderscanhelptocounteract themisinformationaboutthesafetyandvalueofvaping.

ShrivastavaSR,BobhatePS,BadgeA:Counteringoralhealth implicationsandmisconceptionsofvaping. JIntOralHealth 17:82-84,2025

Reprintsavailablefrom SRShrivastava,DeptofCommunity Medicine,DattaMegheMedicalCollege,Off-CampusCtrof DattaMegheInstofHigherEducationandResearch,Hingna Rd,Wanadongri,Nagpur – 441110,Maharashtra,India;e-mail: drshrishri2008@gmail.com

INQUIRY

COMPLETEDENTURES/TASTE

EffectofDenturesonTastePerception

BACKGROUND

Tasteisdetectedthroughthetastebuds,whicharelocated throughoutthemouth,althoughmostarepresentonthetongue. Adultshaveabout14,000tastebudsintheoralcavity.Thesensationoftasteoccurswhenthesubstancethathasa flavorandsaliva interactwiththespecificreceptorforthat flavoronthetastebuds. Tasteperceptionguidestheacceptanceorrejectionoffoodand theresponsetostimulito flavor.Tastedisorderscanproduce nutritionaldeficienciesandstressinindividualsandcaninfluence theirmentalhealth.Adiminishedawarenessoftaste(hypogeusia) hasbeenreportedbypatientswhowearconventionalcomplete dentures.Thesedentalaidscovertheentirepalateandobliterate thetastebudsandmechanoreceptorsinthatstructure,whichdetractsfromthestimulationofafferentsomaticnervesandalters sensorystimuli,sothat flavorsaren ’tperceivedcorrectly.Taste changescanalsoresultfromhyposalivationanddifficultyswallowing,whichcanchangeeatinghabits,leadingtopreferencesfor sweetandcreamysubstances.Thenewhabits,especiallyinelderly patients,cancausenutritionalandmetabolicdisorders,masticatorymuscleatrophy,anddecreasedchewingability.Theliterature hasconflictingoutcomesforstudiesoftheeffectofconventional completedenturesontastesensations.Asystematicreviewwas conductedtoclarifywhethertasteperceptionisalteredinedentulouspatientswearingcompletedentures.

METHODS

AsearchofthePubMed/MEDLINE,CochraneLibrary,andScopusdatabasesuntilJune2022wasdone,alongwithamanual searchinthereferencelistsofincludedarticlesandthemainjournalsonoralrehabilitationandotolaryngology.Sevenarticles wereincludedinthereview,with3randomizedclinicaltrials and4nonrandomizedclinicaltrials.

RESULTS

Atotalof287participants(meanage60years)wereincludedin thereview.Onehundred fifty-sixhadonlymaxillarycomplete

dentures.Only1studyinvestigatedtheeatinghabitsandnutritionalproblemsoftheincludedpatients.

Measurementsofsalivary flow,volume,andpHinpatientswith andwithoutcompletedenturesshowedsalivary flowincreases whendentalprosthesesareworn.Theunstimulatedsalivary flowwasmorebasic.

Nostatisticallysignifi cantdifferenceswerenotedinthetime requiredfor flavoridenti fication,whethercompletedentures wereorweren ’twornin2studies.Athirdfoundthatwearing completedenturesincreasedthe flavoridenti ficationtime.

Tasteperceptionthresholdwastestedinseveralstudiesusingsolutionswithdifferentconcentrationsof flavors.Themost commonlyusedsolutionsforsalty,sweet,sour,andbitter were,respectively,sodiumchloride,sucrose,citricacid,andquinine.Differentstudiesfoundthatdifferent flavorswerethemost difficulttoidentify.

Somestudiestestedtasteperceptionusingpaperstripssoaked inthe fl avorsolutionincontactwiththeoralmucosa.Dif ficultyin fl avoridenti fi cationwasreportedforhardpalate andbackofthevestibulesites.Dentureswerenotedto reduce fl avorperception,withbittertastethemostdif fi cult toidentify.

CONCLUSIONS

Thehypothesisthatcompletedenturesdidn’tinterferewithtaste perceptionwaspartiallyaccepted,with4ofthestudiesnotingthe useofcompletedenturesinterferedwithtasteperception.In addition,mostofthecompletedenturewearerswereelderly, withphysiologicalandbiochemicalchangesrelatedtoagingthat interferedwithtaste.Thisincludedafewertastebuds,adecrease inretronasalandorthonasalsmellandtaste,andareductionin theperceptionofsaltyandsweet flavors.

ClinicalSigni

ficance

Conventionalcompletedenturesmayinterferewiththe perceptionofthe4primarytastes(sweet,salty,sour, andbitter)inedentulouspatients.When flavorisn’t wellperceived,thepatientmayexperiencepoorfood acceptanceandreducedsatietyprocesses.Older adultstendtoalsoexperiencechangesintheirability totasterelatedtoage-relatedfactors,suchastheeffectsofmedicationontheirabilitytodistinguish flavors.

AvelinoMEL,Vila-NovaTEL,CostaRTF,etal:Doestheuseof conventionalcompletedenturesinfluencetasteperception?A systematicreview. JProsthetDent 133:438-444,2025

Reprintsavailablefrom SLDMoraes,UnivofPernambuco(UPE), RectoryS/NGovernadorAgamenonMagalhaesAve,Santo Amaro,Recife,Pernambuco50100010,Brazil;e-mail: sandra. moraes@upe.br

COSTEFFECTIVENESS/ROOTCANAL TREATMENT

DeterminingTreatmentBasedonCost-Effectiveness

BACKGROUND

InSweden,signi fi cantimprovementshavebeenmadeinoral health,includingafallinedentulismandpartialedentulism. Theoralhealth relatedqualityoflifeisnegativelyimpacted bymissingteeth,whicharealsolinkedtoincreasedcardiovasculardiseaserisk.Withthisinmind,patientsoftenchoose nottoacceptextractionforseverelydecayedteethwithpulp necrosis,butmaychoosetohaverootcanaltreatment(RCT) beforerestorationwithanindirectpostandcore(PC).The SwedishNationalBoardofHealthandWelfare recommends RCTbasedonitslowcostinrelationtoitsgainedeffect. RCTplusPChassurvivalratesbetween86%and93%,but thisapproachpresentsatechnicallychallengingtask,with generaldentalpractitionersoftenfeelinginsuf fi cientlyequippedtoperformit.Inaddition,about22%oftheRCTsinmolarsarereportedtoendinextractionbeforetreatmentis completedwithapermanentroot fi lling.Analternative approachisextractionandreplacementwithanimplantsupportedsinglecrown(ISSC).Systematicreviewsshow ISSCstohavehighsurvivalrates,butthistreatmentiscomplexbiologicallyandtechnica lly,withalossofimplantsoccurringinsomecases.Ifthisoccurs,the fi nalsolutionistaking advantageofneighboringteethtoserveasabutmentsfora fi xeddentalprosthesis.ISSCsalsohaveahighinitialcost, makingitimpracticalforsomepatients.Expectedutilitytheory(EUT)hasbirthedtheprocessofclinicaldecisionanalysis, inwhichmodelssuchasdecisiontreesareusedtovisualize thevariousoutcomesofasituation.Whenadecisionistobe basedoncost-effectiveness,theoutcomesincludecostsand probabilities,whichareusuallybasedonpublishedhigh-

qualityscienti fi cliterature.Thesecostsandprobabilitiesare usedtocalculatetheexpectedcostsfortheoutcomes, thentheoutcomewiththelowestexpectedcostisconsideredthemostcost-effective.Asensitivityanalysiscanbe usedtodeterminethethresholdvaluesforwhen1option becomesmorecost-effectivethantheother.Adecisionanalyticapproachwasusedtocomparethecost-effectivenessof RCT+PCwiththatofISSCina fi ctionalseverelydecayed fi rstmandibularmolarwithanecroticpulp;Swedishgeneral dentalpracticeservedasthecontextforthismodel-based undertaking.

METHODS

Nopatientsorpatientdatawereused,withthemodel-based cost-effectivenessstudyusingdataonoutcomesbasedonSwedishsources,whenavailable.Costswereliftedfromthereference pricelistestablishedbythe SwedishDentalandPharmaceutical BenefitsAgency.

Adecisiontreemodelwasusedtovisualizethetreatmentscenarios.The2modelsdevelopedbeganwitha firstmandibular molarwithadeepcarieslesionanddentalpulpnecrosis.The first treatmentoptionwasRCT+PC,andthesecondwasextraction andimplantplacement(EI), finishingwithanISSC(EI+ISSC). Applyinganewtreatmentstepwasconsideredanactivechoice, withsurvivalorlossofatoothorimplantbasedonprobabilities. Theoutcomewasmeasuredafter1and5yearspostoperatively. Thesensitivityanalysisillustratedhowmuchtheprobabilityvalue couldbechangedbefore1treatmentoptionwouldbecome morecost-effectivethantheother.

RESULTS

DecisionTreeforRCT þ PC

The5-yearsurvivalprobabilityforRCT+PCwas70%,whereas thecorrespondingprobabilityforEI+ISSCwas98%.Thecostfor thedifferentbranchesafterchoosingRCTwasbetween15,860 Swedishkrona(SEK)and33,105SEK.Expectedcostforchoosing RCTwas17,400SEK,butexpectedcostforchoosingEIwas 18,800SEK.

DecisionTreeforEI þ ISSC

The5-yearsurvivalprobabilityforRCT+PCwas69%,withthe probabilityforEI+ISSCremainingat98%.TheRCTbranchcost variedfrom15,860SEKto54,290SEK.ExpectedcostforRCT was19,500SEK,butthatforEIremainedat18,800SEK.

SensitivityAnalyses

Indecisiontree1,thelowestestimatedcostforchoosing RCT+PCwas15,860SEK,andthehighestexpectedcostwas 33,105SEK.AllofthepossibleexpectedcostsofRCTwerebetweenthese2points.

TheexpectedcostofISSCwas18,800SEK.ForRCTtocostless thanthat,theprobabilityvalueforRCTwouldhavetobeatleast 83%.

Indecisiontree2,thelowestcostforRCTwouldstillbe15,860 SEK,butthehighestcostwouldbe54,290SEK.ForRCTtobe morecost-effectivethanISSCinthisscenario,theprobability valueofRCTsurvivalwouldneedtobeatleast93%.

DENGUEFEVER

CONCLUSIONS

Themodelanalysisgivesasimplifiedversionofrealitytoillustrate thecost-effectivenessdifferencesbetweenchoosinganRCTfollowedbyPCoranextractionandISSC.Basedonthecurrent stateofevidence,RCTanddentalimplantsprovidenearlyequivalentalternativesbasedoncost-effectiveness.Theprobabilityof toothsurvivalafterRCTandPCmustbeintherangeof83%to 93%tobemorecost-effectivethanextractionandISSC.

ClinicalSignificance

Theprognosisofthe2optionscouldbechangedby evenasmalldeteriorationinthepreoperative,intraoperative,orpostoperativeconditionsforRCTand PC,shiftingtoextractionandISSCbecomingamore cost-effectiveoption.ItshouldbenotedthattheresultsofthisstudyarebasedonSwedishstudiesand thecostsandeconomicsonSwedishdentalcare, meaningtheycannotbedirectlyuniversalized.

SavolainenN,FriskF,KvistT:Isrootcanaltreatmentandanindirectcoronalrestorationofamandibular firstmolarcost-effective comparedtoextractionandanimplant-supportedcrown?Adecisionanalyticapproach. ActaOdontolScand 84:95-103,2025

Reprintsavailablefrom NSavolainen;e-mail: nikki.savolaine@rjl.se

OralManifestationsofDengueFever

BACKGROUND

Denguevirus(DENV)infectionistransmittedbymosquitosusuallyinendemicareas,withmostcasesbothasymptomaticand self-resolving.However,denguefevercancausemild flu-like symptoms,includingfever,nausea,muscleandjointpain,and headaches.Complicationscandevelopinaminorityofpatients, includingreducedplateletcount,whichcanevolveintodengue hemorrhagicfeveranddengueshocksyndrome,bothofwhich canbefatalbecauseofthecoagulationabnormalities,plasma leakage,severebleeding,respiratorydistress,and fluidloss. Thesemoreseriousformscanleadtohypovolemicshockand multi-organfailure.OralmanifestationsofDENVinfectionare uncommon,butdentalhealthcarepractitionersshouldbeaware oftheoralsymptomssothediseasecanbeidenti fiedearlyinpatientshavingdentalprocedures.Theoralsymptomsinclude gingivalbleeding,oralulceration,lingualhematoma,andbilateral

inflammatoryswellingoftheparotidglands.Theclinicalimplicationsfordentalpractice,thepossibleoraloutcomesrelatedto DENVinfection,andmanagementoptionsforaffectedpatients werediscussed.

METHODS

Ascopingreviewwasdone,withsearchesconductedintheMedline,WebofScience,Scopus,Embase,CochraneLibrary,andLILACS/BBOdatabases.Forty-onestudieswereincludedinthe review,covering42,817patients(meanagerange8to44years).

RESULTS

EpidemiologyandVectors

Thestudiescamefrommostlytropicalandsubtropicalregions (Figure2),withAsiaaccountingfor61%ofthem,SouthAmerica

Figure2. GlobalmapshowingthedistributionofDENVstudies.Search flowchartaccordingtothePRISMA2020statement.(CourtesyofdeAraujoLP, WeisshahnSK,doCarmoET,etal:Oralmanifestationsofdenguevirusinfection:Ascopingreviewforclinicaldentalpractice. BMCOralHealth 25:138, 2025.)

22%,NorthAmerica7%,CentralAmerica5%,andOceaniaand Europe2%each.Themostcommonlyrepresentedcountries wereBrazilandIndia.

The Aedesaegypti mosquitowastheprimaryvectorin78%ofthe studies,with Aedesalbopictus in5%.Acombinationofbothvectorswasdocumentedin17%.

OralManifestations

Themostfrequentlyreportedoralmanifestationwasgingival bleeding(51%),whichwasfoundin21studiesacrossseveral countries.Oralulcerationsoccurredin10%andwereoftensevere,causingsignificantdiscomfortorcomplications.Pharyngitis wasseenin10%andoral/oropharyngealpseudomembranous candidiasisin7%.Othersymptomsincludedbilateralinflammationoftheparotidglands,lingualhematoma,hemorrhagicplaques,bluemucosa,submucosalhemorrhageofthehardpalate, pinkspotsonthesoftpalate,andLudwig’sangina.Comprehensiveoralexaminationsareneededtodetectosteonecrosisof thejawandangularcheilitisinthesepatients.

CONCLUSIONS

TheoralclinicalpresentationofDENVinfectioncanrangefrom mildsymptomstoseveremanifestations,illustratingthe complexityoftheinvolvement.Dentalprofessionalscandetect oralmanifestationsinearlydiseaseandimprovepatient outcomes.

ClinicalSignificance

Dentalprofessionalsneedtobetrainedtobecome awareofpossibleDENVinfectionintheirpatients, especiallyiftheypracticeinendemicareas.When patientsaresuspectedtohavedengue,dentists shouldbeawareofthemeasuresassociatedwithearly diagnosisandmanagementandavoidtheuseof nonessentialmedications,especiallyantiinflammatoryagents,antibiotics,andmedications thathaverenal,hepatic,orhematologictoxicity. Furtherresearchisneededtoidentifythepathogenesisoforalmanifestationsofdengueandtodevelop standardizedprotocolsfortheclinicalassessment andmanagementofinfectedpatients.

deAraujoLP,WeisshahnSK,doCarmoET,etal:Oralmanifestationsofdenguevirusinfection:Ascopingreviewforclinical dentalpractice. BMCOralHealth 25:138,2025

Reprintsavailablefrom LPdeAraujo,SchoolofDentistry,Catholic UnivofPelotas(UCPel),CampusdaSaude,AvFernandoOsorio, 1586-PelotasPelotas,RS,Brazil;e-mail: lucas.araujo@ucpel. edu.br

DENTALANXIETY

DentalTreatmentUnderGeneralAnesthesia

BACKGROUND

Dentalanxietyaffectsabout15%oftheworld ’spopulationand canexistaloneoras1ofmultiplemorbidconditions.Someindividualsexperiencenegativedentaltreatmentandsubsequentlydevelopdentalanxiet y,whereasothersexperiencea traumaticeventofsometypethatleadstotheiranxiety.Those whoexperiencesexualabusemaybetriggeredbydentaltreatmentsituationstorelivefeelingsreminiscentoftheabuse.Asa result,theymayavoidevenurgentlyneededdentaltreatment, leadingtoadeteriorationoftheirdentitionandbothfunctional andsocialconsequences.Ifthepatientsuffersfromsevere dentalanxiety,dentaltreatmentmayonlybeaccomplishedby usinggeneralanesthesia(GA) .Thedentalinterventionsare neededtoavoidthedangerofallowingodontogenicinfections toremainuntreated,whichcancausetheinfectiontospread toothersites,resultinginsofttissueabscesses,sinusitis,or osteomyelitis.Thesepatientsmayalsoovermedicatethemselveswithanalgesics,andthepersistentuseoftheseagents canhavenegativeeffects.Providingdentaltreatmentunder GAisoftenpracticedtomanagefearfulchildren,butanypatient withseveredentalanxietycouldreceivedentalcareunderGA. Unfortunately,manycountrieshavealimitedsupplyofGAfor dentalpatients,withlongwaitinglists.Astudywasundertaken todescribethedentalstatusofpatientswithseveredentalanxietyradiologically,todepicttheirmentalandgeneralsomatic healthpro fi le,andtoevaluatepossibledifferencesinoral,generalsomatic,andmentalhealthstatusbetweenpatientswithand withoutareportedhistoryofabuse.

METHODS

Panoramicx-rayswereobtainedforthe56participants,and theirgeneralhealthvariableswerecollectedfromtheirpatientrecords.Ofthe38womenand18men(meanage 37.9years)whoparticipated,27hadareportedabuseexperience(RAE).

RESULTS

RadiographicDentalFindings

Alloftheimagesexhibitedatleast1variablethatcouldn’tbeassessedforeachtoothorrootremnant.Thesuboptimalimage qualitywasmostprevalentintheareafromcaninetocaninein bothjaws.Thiswasseenmostofteninaninabilitytoassessapical radiolucenciesandcarieslesions.Anaverageof71%oftheteeth ineachimagecouldbeassessedforcaries,withabout55%ofthe teethorrootremnantsassessableforapicalradiolucencies.

Ofthe14patientswithfewerthan20teeth,13(93%)hadatleast 1apicalradiolucency.Twelve(86%)hadevidenceofatleast1 toothwithcaries.Ofthe42patientswith20ormoreteeth,apicalradiolucencieswerenotedin64%anddentalcariesin81%.

MentalandGeneralSomaticHealth

Seventy-fivepercent(42)ofthepatientshadatleast1mentalor generalsomaticdisorder.Psychiatricdisordersotherthansevere dentalanxietywerereportedbyabout55%(32)ofthepatients. Nonspecificpsychiatricdisorderwasreportedbyabout21%, withfewerpatientsreportingpost-traumaticstressdisorder (PTSD),anxiety,anddepression.Mixedsomaticconditions(about 36%),oralconditionsandhabits(about21%),anddevelopmental anomaliesorgeneticconditions(about16%)werealsofound. About63%ofpatientsreportedusingatleast1classofmedication, withthemostcommonlyusedbeingpsychopharmacologicalagents (about36%)andanalgesics(about34%).About57%ofpatientstook painmedicationstomanagethedentalpaintheywereexperiencing.

EffectofaHistoryofAbuse

Ageandgenderweresimilarbetweenthepatientswithand withoutRAE.Inaddition,the2groupsweresimilaronnumber ofteeth,missingteeth,rootremnants,teethwithrestorations, root- filledteeth,teethwithcarieslesions,andteethwithapical radiolucencies.

Table4. PredictiveContributionofReportedAbuseHistoryandGenderonReportedPsychiatricDisorders,OtherDisorders,andUseof AnalgesicMedications

Abuse1.500.014.48(1.42,14.16)1.360.033.91(1.19,12.85)1.670.015.32(1.54,18.41) Gender0.520.401.68(0.50,5.65)0.830.232.29(0.60,8.77)-0.210.750.81(0.22,2.97)

OR, Oddsratio; CI, confidenceinterval.

Note: Binarylogisticregressionincluding2dummycodedindependentvariables:Abuse(1, reportedabuseexperience, 0, noreportedabuseexperience) andGender(1, female, 0, male).Dependentvariablesforallmodelswerecodedas 1 =yesand 0 =no.Themodelsexplain18.4%A/17.4%B/18.0%C (NagelkerkeRsquare)ofthevarianceobservedinthedependentvariable.

(CourtesyofAardalV,HolC,RønnebergA,etal:Whorequiresdentaltreatmentundergeneralanesthesiaduetopainandseveredentalanxiety? FindingsfrompanoramicX-rayimagesandanamnesis.ActaOdontolScand84:78-85,2025.)

Figure1. Numberofparticipantswithspecificradiological findingsandtheircombinations. AR, Apicalradiolucencies; RR, rootremnants.(Courtesyof AardalV,HolC,RønnebergA,etal:Whorequiresdentaltreatmentundergeneralanesthesiaduetopainandseveredentalanxiety?Findingsfrom panoramicX-rayimagesandanamnesis. ActaOdontolScand 84:78-85,2025.)

Differenceswerestatisticallysigni fi cantbetweenthosewith andwithoutRAEintherateofpsychiatricdisordersother thanseveredentalanxiety,mix edconditions,andincreased useofanalgesicmedications.Evenwhenadjustedforgender, statisticalanalysiscon fi rmedthatpatientswithRAEhad greateroddsofhavingpsychiatricdisorders,mixedsomatic

conditions,andusinganalgesicmedicationthanthosewith nohistoryofabuse( Table4 ).

CONCLUSIONS

Patientswithseveredentalanxietywhowerereceiving dentaltreatmentunderGAhadpoordentalhealth,with

dentalpathologyanddentalpain.Theyalsohadhigherrates ofreportedpsychiatricconditionsotherthandentalanxiety andevidencedmixedsomaticconditions.Havingahistoryof abusewasalsolinkedtoahigherlikelihoodofhavingpsychiatricorsomaticconditionsandahigheruseofanalgesics.

ClinicalSignificance

Abouthalfoftheparticipantsinthisstudyreportedan abuseexperience,whichledthemtoavoiddental care.Asaresult,theirdentalhealthwaspoor.Inaddition,thesepatientsweremorelikelytodeveloppsychiatricproblems.Thesepatients,whoarealready sufferingfromseveredentalanxiety,areatan increasedneedforthedeliveryofdentalcareunder GA,especiallysincetheirdentalproblemstendtobe seriousandotherwiseunmanageable.

AardalV,HolC,RønnebergA,etal:Whorequiresdentaltreatmentundergeneralanesthesiaduetopainandseveredentalanxiety?FindingsfrompanoramicX-rayimagesandanamnesis. Acta OdontolScand 84:78-85,2025

Reprintsavailablefrom VAardal,OralHealthCtrofExpertisein RogalandNorway,Postboks130Sentrum,4001,Stavanger, Norway;e-mail: vilde.aardal@throg.no

ENDODONTICS/RESTORATIVEDENTISTRY

RestorationsforEndodonticallyTreatedTeeth

BACKGROUND

Endodonticallytreatedteeth(ETT)oftensuffertoalossof toothstructurethatweakenst heirresistancetomechanical stressandmakesthemmoresusceptibletofracture.Restorationsarefocusedonprotectingtheremainingtoothstructure andpreventingfurtherfailure.OptionsforrestorationforposteriorETTincludefull-coveragecrownsorothercuspal coverage,whichrequiresfewerrepeatinterventionsthanthe optionofdirectrestorations.Bothcoronalleakageandcoronal fracturesarelesslikelywithfull-coveragecrowns,althoughthe supportforcrownsoftenfailstoconsidertheremainingtooth structure,whichispositivelycorrelatedwithfractureresistanceforETT.Atoothlackingbothmarginalridgesisathigher riskforfracturethanatoothwithonlyanocclusalcavity.Fullcoveragecrownsalsorequirethe removalofsoundtoothstructureinmanycasesanddon ’t fi twellwiththeprinciplesofminimalbiologicalcostandconservativemanagement.Direct restorationspreservetoothstructure,costlesstoperform, reducetreatmenttime,andpotentiallyallowforendodontic repeatinterventionsandchairsiderepairs.Theevidencesupportingthelong-termsurvivalofETTthatreceiveddirectrestorationsislacking.Arandomizedclinicaltrialwasdoneto assessthesurvivalandsuccessofdirectcompositeresinrestorationscomparedtometal-ceramiccrownstorestoreETTwith minimalstructuralloss,speci fi cally,forteethhavingatleast3 intactaxialwalls.

METHODS

The53participantshadcomeforrootcanaltreatmentof molarteeththathadatleast3remainingaxialwallsmeasuring 2mmthick.Inonegroupofpatients,theteethwererestored withdirectcompositeresinrestorations.Intheothergroup, theteethwererestoredwithadirectcompositeresinrestoration,followedbyafull-coveragemetal-ceramiccrown.Evaluationsweredoneatbaselineandannuallyfor3years.The assessmentincludedclinicalandradiographicevaluations, includingbitewingandperiapicalradiographstodetectmarginaldefects,recurrentcaries,andsignsofinfection (Figure1).Athoroughperiodontalexaminationwasalsoperformed,includingbleedingonprobingandpocketdepth measurements.

RESULTS

Thesurvivalcurvesafter3yearsshowedthesurvivalrateforthe crowngroupwas93.3%andthatforthedirectrestorationgroup was76.7%.Thesesurvivalratesdidn’tdiffersigni ficantlyfromone another.

Sevendirectrestorationsfailed,4ofwhichinvolvedfractures. Twoparticipantswithfractureswerebruxers.The2failuresin thecrowngroupshowedsymptomaticandradiographicsigns ofapicalpathologyrequiringendodontictreatment.

Figure1. Bitewingandperiapicalradiographstakenatthe36-monthfollow-upappointment.Image A showsanendodonticallytreatedmolarrestoredwithan occlusalcompositeresinrestoration;image B showsandendodonticallytreatedmolarrestoredwithanocclusal-proximalcompositeresinrestoration;and image C showsanendodonticallytreatedmolarrestoredwithametal-ceramiccrown.(CourtesyofAbu-AwwadM,HalasaR,HaikalL,etal:Directrestorationsversusfullcrownsinendodonticallytreatedmolarteeth:Athree-yearrandomizedclinicaltrial. JDent 156:105699,2025.)

Statisticalanalysisshowedparafunctionalhabits(bruxism)was theonlysignificantpredictoroffailure.Parafunctionwasassociatedwitha12.8-foldincreaseintheriskofaneventcomparedto noevent.

Signi fi cantdifferenceswerenotedbetweentherestorationand crowntreatmentswithrespecttoseveralUSPublicHealthService(USPHS)criteriaafter3years.Restorationsperformed worsethancrownsintermsofcaries,surfacetexture,and

marginalintegrity,withborderlinesigni fi canceformarginal discoloration.Crownsperformedworsethanrestorations withrespecttoperiodontalassessment,withmoreteeth receivingcrownsshowingincreasedbleedingonprobing,a slightincreaseinpocketdepth,andthepresenceofperiapical infection.Overtime,directrestorationsdeterioratedsigni ficantly,withcaries,margindiscoloration,marginintegrity,and fractureshowingevidenceofthisdecline.Crownsshowedno signi fi cantdeteriorationwithtime.

CONCLUSIONS

ETTwithminimalstructurelosswasmanagedwithcomparable survivalandsuccessratesforthedirectrestorationsandfullcoveragecrowns.Crownstendedtobemorepredictable,particularlyifthepatientdemonstratedbruxism.Directrestorations weremoreappropriatewhentheocclusalloadwasreduced, withendodonticmonitoring,andwhencostwasaconcern.

ClinicalSignificance

The3-yearsurvivalandsuccessratesfordirectcompositerestorationsweresimilartothoseformetalceramiccrownsforendodonticallytreatedmolars withminimalstructuralloss.Directrestorationsare mostappropriateformolarsthathaveminimallossof structure,thosewithreducedocclusalloads,when endodonticmonitoringisdone,andwhen financiallimitationsexist.

Abu-AwwadM,HalasaR,HaikalL,etal:Directrestorations versusfullcrownsinendodonticallytreatedmolarteeth:A three-yearrandomizedclinicaltrial. JDent 156:105699,2025

Reprintsavailablefrom HPetridis,UnivCollegeLondon,Eastman DentalInst,Rm238,RockefellerBldg21UniversitySt,London, WC1E6DE,UK;e-mail: c.petridis@ucl.ac.uk

ORALMICROBIOME

ChangesintheOralMicrobiomeOvertheLifespan

BACKGROUND

Theoralmicrobiomeconsistsofdiversemicrobialcommunities thatdifferbasedonmanyfactors.Somemicrobiotacomefrom theenvironment,somehavetheabilitytoadheretooralsurfaces andobtainnutrientsfromtheecosystem,otherscancompete withorcopewithothermicroorganisms,andstillotherscan resistadverseconditionsandevadehostdefensemechanisms. Theindigenousoralmicrobiomeundergoesrapidphenotypic changesinresponsetoenvironmentalstressors,thencanreturn toanormalstateoncethesestressorsarecontrolled.Signi ficant ecologicaldisruptionscanoccurandresultinthemostcommon oraldiseases:dentalcariesandperiodontaldiseases.Areviewof thecurrent findingsregardingthecompositionandfunctionsof thepredominantmicrobialcomponentsofahealthyoralmicrobiomeatdifferentagesandindifferenthabitatswaspresented.

EARLYORALMICROBIOMES

Theneonate'soralmicrobiomevarieswidelyandissignificantly influencedbythetypeofdelivery,thetypeoffeeding,andthe changetosolidfoodandtootheruption.

TypeofDelivery

Vaginallydeliveredinfantstendtohaveanoralmicrobiome stronglyin fl uencedbytheclosecontactbetweenmother andchild,sothatmaternalskinandgutmicrobiotaarethe primarysources.Cesareansectiondeliveriesintroducemicrobesfromthematernalskinandthehospitalenvironment. Thesalivaofavaginallydeliveredchildhasgreatermicrobial diversityandmorecloselyresemblesthemother'ssalivary microbiotathanthesalivaofachilddeliveredbycesarean section.Vaginaldeliveryalsopromotesearlycolonization withoralyeast,especially Candidaalbicans. Thesedifferences indeliveryaremoreapparentinsamplescollectedshortlyafterbirthandtendtodisappearbyage3months.

Otherfactorsthatin fluencetheearlymicrobiomeinclude maternaluseofantibioticsandcontinuousexposuretoand transmissionofthemother'soraltaxatothechild.Theprofiles ofbiologicalandadoptedchildrenareequallysimilartothose oftheirmothers,indicatingtheroleofasharedenvironment anddirectcontact.

Figure1. Keydifferencesobservedinoralmicrobiotabetweenbabies whoreceivedonlybreastmilkcomparedwiththosewhoreceivedformula.(CourtesyofCorr eaJD,CarlosPPS,FariaGA,etal:Thehealthy oralmicrobiome:Achangingecosystemthroughoutthehumanlifespan. JDentRes 104:235-242,2025.)

TypeofFeeding

Cleardisparitieshavebeenfoundbetweenbreastfedand formula-fedinfants.Breastmilkprovidesessentialnutrientsas wellasanarrayofmicrobes(Figure1).Inaddition,breastmilk componentssuchasimmunoglobulinAandGmaternalantibodiesinhibitthegrowthofsomebacteriaandfostertheattachmentofcommensals.Formula-fedinfantsharborahigher abundanceof Actinomycetota and Bacteroidota,especiallyinthe genus Prevotella ,comparedtobreastfedinfants.Breastfedinfants haveahigherprevalenceof Pseudomonadota andstreptococci speciescomparedtoformula-fedinfants.Overall,thedifferences inoralmicrobiotacompositionbasedontypeoffeedingtendto bemostpronounceduptoage2years.

SolidFoodandToothEruption

Beforetootheruptionoccurs,bacteriacolonizemucosalsurfaces.Withtheintroductionofsolidfoods,whichoftenoccurs aroundthesametimeastootheruption,asignificantchange takesplaceintheoralmicrobiota.Solidfoodscontainnutrients forthemicrobialcommunity,andteethcreatenewnichesfor theaccumulationofplaque.Theinfant'smicrobiomeresembles thatofadultsmorecloselythanthatofotherinfants.Ifsolidfoods areintroducedandbreastfeedingisdiscontinuedbeforeage 12months,theinfanttendstohavehigherbacterialdiversityat age2years.

Aschildrentransitionfrompredentatetohavingaprimarydentition,theoralmicrobiotabecomescolonizedbyobligateanaerobesratherthan Streptococcus.Theearlycolonizersdeplete oxygensothatanaerobicspeciescanthrive.Changescontinue throughthemixedandpermanentdentitionphases.Whenthe permanentteetharrive,therearemore Actinomyces species andhighanaerobeconcentrationscomparedtotheprimary dentitionsituation.Caries-freeoralstatusisassociatedwith highproportionsof Porphyromonascatoniae and Neisseria flavescens

CHANGESWITHADOLESCENCE

Theonsetofpubertybringswithitsigni fi cantshiftsintheoral microbiota,markingadistinctphaseintheoralecosystem. Endogenoushormoneexposuresaffectthecompositionof theoralmicrobiome,alteringtheabundanceofexistingbacteria ratherthanintroducingnewones.Theoralmicrobiomeofadolescentsismorediverseandsharesmoreinterindividualsimilaritiesthanthemicrobiomeinadults.Studieshaveidenti fi ed differinggroupsofmicroorganismsaspredominantatthis time.Althoughnostudiesspeci fi callydealwiththemetabolism oftheoralmicrobiotainhealthyadolescents,themostprevalentbacteriainadolescentssuggestvariousfunctions.Lactate maybeconvertedintoweakeracids,orbacteriacandegrade glycoproteins,proteins,pepti des,andaminoacidsintoshortchainfattyacids,ammonia,an dsulfurcompounds,whichare linkedtooralmalodor.

HEALTHYADULTORALMICROBIOME

Theoralmicrobiomeisin fluencedbymultiplephysical,biological,mental,andpsychosocialstressorsdirectlyorindirectly throughoutadulthood.Itcanbeextremelydif ficulttoidentifya “universal” oralhealthmicrobialprofileforadults.The “normal ” oralmicrobiomevariesbetweenindividualsandbetweenoral samples.Supragingivalplaqueistheleaststablemicrobiotain theoralcavity,butataspecieslevel, Fusobacteriumperiodonticum onthetonguedorsumand Fnucleatum insupragingivalplaque havestrongtime-varyingbehavior.

Acorecommunitydoesappeartopersistentlyinhabitcertain oralniches.Subgingivalplaquehasdemonstratedthehighestdiversity,withkeratinizedgingivahavingthelowest.Streptococci maybefoundinallsites,but Simonsiellamuelleri onlyinhabits thehardpalate. Calbicans isfoundinverylowproportionson thepalate,supragingivalbio film,andoralrinsesamples.Viruses arefoundinmucosalsitesandsupragingivalbio film,withmost beingbacteriophagesthattargetspeciesof Streptococcus and Aggregatibacter.

Youngeradultshavehigherdiversityinthesupragingivalbiofi lm, althoughnodifferencesbetweenagegroupsarefoundforbuccal mucosamicrobiota. Neisseria declinesafterage40years,but Lactobacillus spp, Gemellasanguinis,and Streptococcusangiosus hasbeenfoundtoincreaseinthesupragingivalbiofilmsofthose olderthanage60years.Healthyadultsmayharbormorethan 100species.

Thecoremetabolicpathwaysmaybenichespeci ficorbroadly availableacrossmanymicrobiomes.Forexample,somehealthassociatedoraltaxacanconvertdietarynitratetonitriteinsaliva, whichisthenconvertedtonitricoxide,whichreducesblood pressure,improvesvascularfunction,andhasantimicrobialactivityagainstperiodontalpathogens,thuscontributingtooralas wellassystemichomeostasis.

Figure2. Oralmicrobiotathroughoutlife.Keyfactorsinfluencingthecompositionoftheoralmicrobiotaalongwiththemaincomponentsofthemicrobial communityateachlifestage.Thelineindicatestheincreaseordecreaseindiversity.(CourtesyofCorr^ eaJD,CarlosPPS,FariaGA,etal:Thehealthyoral microbiome:Achangingecosystemthroughoutthehumanlifespan. JDentRes 104:235-242,2025.)

HEALTHYAGINGANDORALMICROBIOTA

Thehumanmicrobiomeisnowknowntobeakeycomponentin thepromotionofhealthyagingandlongevity.Age-relatedchanges inhostbiology,suchaslow-gradeinflammationandcellularsenescence,canchangethemicrobiomeovertime.Oralsenescence alsochangestheoraltissuesandincreasestheirsusceptibilityto drymouth,periodontitis,cancer,androotcaries.Havingpoor oralhealthpredictsthedevelopmentoffrailtyandmaycontribute toagingprocesses.It'slikelythatthereisabidirectionalrelationshipbetweenagingeffectsontheoralmicrobiomeandthemicrobiomethatpromotesahealthylifespan.

Mostofthedifferencesbetweenyoungandolderadultsare relatedtoanincreaseinlowabundanttaxa,suggestingthat coredominantbacteriaareresponsibleformaintaininghealth statusduringaging.However,conflicting findingsbetweenyoung andolderadultsareevenmorepronouncedincentenarians, includingdiversityinsalivaandplaqueinGermancentenarians andsigni ficantlylessdiversityinItaliancentenarians.

Themostcommonoraltaxainolderadultsare Streptococcus spp, Veillonella spp, Gsanguinis, Pmelaninogenica, Fnucleatum, Hparainfluenza, Rothia spp, Gemellaadiacens, Prevotelladenticola, Prevotellahisticola,and Neisseria spp.Olderadultshadreduced coloniesof Porphyromonasendodontalis, Lautropiamirabilis, Rothia aerea, Cardiobacteriumhominis,and Gemellamorbillorum .

Thedataonthemetabolismandfunctionalityoftheoralmicrobiomeinhealthyolderadultsremainlimited.However,it's

possiblethatmaintainingcommensalspeciesinvolvedinnitrate reduction,argininemetabolism,anti-in flammatory,andimmunomodulatoryprocessesthroughoutagingismorelikelytopromotebene ficialeffectsintheoralhealthofagingadults(Figure2).

ClinicalSignificance

Ahealthyoralmicrobiometendstoberesilientand relativelystableevenatolderages,butthemain coregenerainindividualsmayevolve.The first2years oflifeseemtodeterminetheoralmicrobiomemakeup thatwilllastforseveralyears.Duringpuberty,the physiologicalchangesfavortheovergrowthofsome microorganisms.Adulthoodisatimeofmoresignificantstabilityuntiltheagingprocessbegins.More notablechangesareseeninaging,suchasanincreaseinraretaxa.Alargearrayofhealth-related pro filesexistsoverthehumanlifespan.

Corr^ eaJD,CarlosPPS,FariaGA,etal:Thehealthyoralmicrobiome:Achangingecosystemthroughoutthehumanlifespan. J DentRes 104:235-242,2025

Reprintsavailablefrom JDCorr^ ea,Ponti ficCatholicUnivofMinas Gerais,AvDomJoseGaspar,500Coraç aoEucaristico,Belo Horizonte,MinasGerais30535-901,Brazil;e-mail: jo_odonto@ hotmail.com

ORTHOGNATHICPSYCHOLOGY

PatientSatisfactionandImprovedQualityofLifeAfter OrthognathicSurgery

BACKGROUND

Patientswithdentofacialdeformitiesoftenexperiencelowselfesteem,alackofself-confidence,socialchallenges,anddistress regardingtheirfacialfeatures.Orthognathicsurgery(OGS)isundertakentoaddresstheskeletal,facial,anddentalabnormalities, withthegoalofimprovingmusculoskeletalfunctionand psychosocialwell-being.Amongtheproceduresperformedare LeFortIosteotomy(LFI),bilateralsagittalsplitosteotomy (BSSO),andgenioplasty.Aftersurgery,patientsmustadjustto theirnewappearance,makingpre-andpost-treatmentevaluations importantinmeasuringthepatient’ssatisfactionandqualityoflife. Acomprehensiveassessmentwillincludepsychologicaleffects, oralhealth,andfacialaesthetics.Thegoalofsurgeryistoofferbenefitsthatoutweightherisks.Clearcommunicationwiththepatient aboutpotentialoutcomesisvital.Aliteraturesearchwasdoneto identifystudiesthatassessedthepatient’spsychologicalfactors indicatingsatisfactionandanimprovedqualityoflifeafterOGS.

METHODS

ThedatabasesofPubMed,GoogleScholar,APAPsychNet,ScienceDirect,Medline,Embase,Cochrane,andothersweresearchedfor relevantstudies.Twenty-ninestudieswereidentified,covering13 prospective,5prospectivecohort,3randomization,4quasiexperimentaldesigns,and5usedpropensityscoremethodsto constructamatchedcomparisongroup.Thetargetpatientswere adolescents(age12to18years)andadults(age18to65years) withClassI-IIIcraniofacialmalocclusionthatrequiredorthognathic treatment.

RESULTS

AssessmentofPatients

Patientswereassessedpreoperativelytoidentifyconditionssuchas bodydysmorphicdisorder(BDD),anxiety,ordepression,allof whichcaninfluenceoutcomes.Postoperativetestswere designedtoaddressconcernsaboutsurgeryandrecovery,as wellasthepatient’sdevelopmentofbetterself-esteem,reduced anxiety,andbetterbodyimage.Thetoolsusedtoevaluatethe patientsincludedthoserelatedtoqualityoflife(QoL)indicators, theOrthognathicQualityofLifeQuestionnaire(OQLQ),the 36-questionShortFormHealthSurvey(SF-36),andtheOralHealth ImpactProfile(OHIP).

StudyCharacteristics

Follow-updatacollectionwasconductedfor3weeksto60months, with25ofthestudies(about86%)indicatingOGSwaseffective basedonpatientsatisfactionscores.Moststudiesshowedapositive

patientoutcomewhentheOQLQ,SF-36,andOHIPscoreswere consideredseparately.Fivestudies(about17%)notednoeffect oranegativeassociationfor2studyoutcomes.Themajorityof studiesshowedOGSpositivelyaffectedQoL,improvedpsychologicalwell-being,andachievedaesthetictransformations.

OutcomesSummary

TheOQLQ,OHIP,andSF-36measuresshowedimprovedoral health,physicalfunction,andreducedlimitationsonroles,giving patientsapositiveexperience.Signi ficantQoLimprovements weremadeinpatientshavingLeFortIosteotomyandBSSO. Themostsigni ficantdifferenceswerenotedintheoralfunction andphysicallimitationdomains.

CONCLUSIONS

Cliniciansmustaddressfactorssuchastheroleofbodyimage, self-esteem,andstressinpatientoutcomesthroughcarefulpatientselection,psychologicalevaluations,clearcommunication, andmanagingexpectationswhenpatientsarecandidatesfor OGS.It’simportantthatsocialandemotionalsupportisoffered before,during,andaftersurgery.

ClinicalSignificance

Thissystematicreviewidentifiedfactorsthatcontribute toapositiveassociationbetweenOGSandpatient satisfactionandimprovedQoL.Thesefactorsinclude enhancedoralandphysicalfunction,improvedfacial aesthetics,andreducedpsychologicaldiscomfort. Theconsistent findingsofthestudiessurveyedshow themultifacetedbenefitsofOGSinmanagingdentofacialdeformities.Conductingapsychologicalevaluation afterOGScanencouragethepatient’sadaptationto newfacialfeatures,changesinself-esteemlevels, andoverallsatisfactionwiththeexperience.

AlkaabiS,AlsabriG,AlyammahiA,etal:Psychologicalandquality oflifeoutcomesfollowingorthognathicsurgery:Acomprehensivesystematicreview. AdvOralMaxillofacSurg 18:100522,2025

Reprintsavailablefrom SAlkaabi,DeptofOralandMaxillofacial Surgery/OralPathology,AmsterdamUMC-locationVUmc,De Boelelaan1118,1081HZAmsterdam,theNetherlands;e-mail: salem.alkaabi@ehs.gov.ae

PERIODONTALTREATMENT

BenefitsofPeriodontalTreatments

BACKGROUND

Periodontaldiseases,suchasperiodontitisandgingivitis,arethe mostprevalentoraldiseasesintheworld.Gingivitisresultsfrom theaccumulationofbacterialbiofilms(plaque),andperiodontitis isachronicinflammationthatprogressivelydestroysthesoftand hardtissuesthatsupporttheteeth.Fourstagesofperiodontitis havebeenidentified,basedonseverityofdisease,with3grades basedonrateofprogressionmodifiedbythepresenceofsmoking anddiabetes.Severeperiodontitisincreasesinadultsage30years andreachesitshighestrateatage40years,withadegreeofstability inolderpatients.Oralhealthcareprovidersaddressthechallenge ofthishighprevalenceofadultperiodontaldiseasethrough periodontaltreatment(PT),buttreatmentmustbedoneatappropriateintervalstoachievethebestoutcomes.Patientstendtohave fewornosymptomsthattranslateintoanurgentneedforcare,so theyoftenmissfollow-upvisits,resultinginprogressionofthedisease.Anobservational,follow-up,register-basedstudywasdone toestimatethebenefitofPTafteranoralhealthexamination (OHE)andafollow-upOHE.

METHODS

Atotalof42,533adults(age18to80years)visitedpublicoralhealth careclinicsinHelsinki,FinlandbetweenJanuaryandDecember 2009foranOHE.TheOHEconsistedofanassessmentofalloral tissues,adiagnosis,atreatmentplan,andtheassignmentofanindividualrecallinterval(IRI).Recallintervalsrangedfrom0to 60months.Thepatient’speriodontalstatuswasrecordedusing theCommunityPeriodontalIndex(CPI),withthemouthineach caseconsideredin6sextants.Atotalof16,040patientsattended afollow-upOHEbetween2010and2015basedontheirIRI (meanfollow-uptime2.2to2.6years),wherethechangeinCPI wasnoted.

RESULTS

Ahealthyperiodontiumwasrecordedfor4.6%ofthe16,040patients.Deepperiodontalpockets(CPIscoresof3or4)wererecordedin24%ofpatients.ThosewithCPIscore4hadthehighest meanage(61years).Thisgroupalsohadthefewestnumberof teethpresent.About91%ofthepatientgrouphadteethpresent in6sextants.ThemostprevalentCPIscorewas2inallsextants inboththeoriginalOHEandinfollow-upOHEs.

IftheCPIscorewas1orhigher,thepatienthad1PTormore,dependingonhowseverethegingivitisorperiodontitiswas.Ten percentofthepatientswhowereidentifiedasneedingPTdidn’t receiveit.SevenpercentofthepatientshadaCPIscoreof1or 2.Sextant2hadthebestresponsetotreatment.Atleast1better sextantwasachievedin56%ofthepatientsduringthefollow-up

OHE,with7%havingallsextantsbetter.DuringPT,thosepatients whoseCPIscorewas4hadmoreextractionsthanpatientswithany otherCPIscore.

ThemodelsconstructedwiththedatashowedthatCPIimproved iftheperiodontaldiseasewasmanagedwithPTdeliveredbyan oralhealthcareteam.PTandchronicdiseasesshowednosignificantinteractions,butdiabetesorseverementaldisorderswere associatedwithapooreroutcomeafterPTinallsextantsduring thefollow-upOHE.MenalsohadpooreroutcomestoPTthan womenwhenallsextantswerecombined.

CONCLUSIONS

PTafterOHEwasanimportantfactorinachievingbetterperiodontalhealth.Havingmoretreatmentswasassociatedwithabetteroutcomethanbeinglimitedtoasingletreatment.Theoutcome waspoorerinpatientswithdiabetesorseverementaldisordersand formen,butchronicdiseasesandPTshowednosignificant interactions.

ClinicalSignificance

Periodontaldiseaserequirestreatmentwithfollow-up visitstomonitortheoutcomeandtodeliveradditional treatmentsifindicated.Inaddition,patientsmustbe committedtobetteroralhygienehabits,including frequenttoothbrushingtwiceadayandinterdental cleaning.Patientsmustalsomakehealthylifestyle changes,suchasquittingsmoking.Theoralhealth careteamshouldmonitorpatientswithperiodontal diseasestomanageanyprogressionofdisease. Thesebehaviorsneedtobetaughttopatientsso thattheyknowtheirresponsibilityintheprocess. Patientsshouldalsosharewiththeiroralhealthcare teamanyriskfactorstheyhave,suchasdiabetes andseverepsychoticmentaldisorders.PTshould beginimmediatelyaftertheoralhealthcareevaluation andbeconductedbytheoralhealthcareteam,which mayrequirereferraltoaspecialistforadvancedcases.

HaukkaA,KailaM,HaukkaJ,etal:EffectsofperiodontaltreatmentonperiodontalstatusinFinland:Aregister-basedstudy. ActaOdontolScand 84:128-136,2025

Reprintsavailablefrom AHaukka,DeptofPublicHealth,POBox 20,FI-00014UnivofHelsinki,Helsinki,Finland;e-mail: anna.k.haukka@helsinki. fi

VERTICALDIMENSION

ControversiesRegardingtheVerticalDimensionof Occlusion

BACKGROUND

Theverticaldimensionofocclusion(VDO)isdescribedasthe distancebetween2anatomicpointswheninmaximalintercuspal position.Thepointsoftenselectedarethetipofthenoseandthe chin.IdealVDOhasbeenconsideredimportantwhenassessing facialaestheticsandprovidingmasticatoryfunction,butseveral mythshavearisenthathavepromotedcontroversyaround VDOdentalconcepts.Forsomepatients,alteringtheVDOis consideredanessentialcomponentoftheirprostheticororthodontictreatmentplan.Otherpatientsareadvisedtoaltertheir VDOforfunctionalreasons,oftenbasedonsupposedly abnormalmorphologicalfeatures.TheVDOtopiccanbe confusingwhenfacedwiththemanyapproachesforregistering theVDO,usingtechniquesthatrangefromtraditionalfaciallandmarkstoadvancedtechnologicalapproaches.It’salsonotuncommonthatclinicianswilldebatewhetheranalteredVDO willaffectTMDsymptoms.FourmythsregardingVDOinrestorativedentistrywereexplored,andguidancerelyingonevidentiary findingswasofferedbasedonthecurrentliteratureplusa surveyof862generaldentistsandprosthodontists.

MYTHONE

YouMustAllowforaProlongedTrialorGradualProcessto AlterVDO

Nearly88%ofthesurveyrespondentstestanewVDObecause ofconcernoverthepatient’sreactiontothenewocclusion, 85%observethatpatientsdowell,and53%worryabout TMDsymptoms.Sixpercentreportedtherewasalegalrequirementtotestthenewbitewithtemporaryrestorationsintheir countries.Only9%believedthatthereisn ’tanyneedtotestthe newVDO(Figure4 ).Inreality,prolongedtrialphasesarerarely needed,withpatientsusuallyadaptingwelltoanewVDOwithin ashortperiodoftime.Noevidenceshowsagradualincreaseis needed.Thestomatognathicsystemhasthecapacitytomake neuroplasticchanges,andthetemporomandibularjoint(TMJ) andmusclesadapttothisprocess.Someevidenceindicate thatsofttissuemanagementorspeechproblemsmayjustify theuseoftemporaryrestorationsforanextendedperiodof time.

Someclinicalscenariosmayjustifycautionandaddedpreparation,suchaspatientswithanactiveTMDorhistoryofTMD, whoshouldbediagnosedcorrectlyandtreatedbeforeprosthetic

measuresareinstituted.Inaddition,theclinicianshouldbeaware thatpatientswhosepsychologicalpro fileindicatesdepression andanxietymaybeatriskforchronicTMD.Thepatient’ spsychologicalhealthcanimpairtheeffectivenessofthetreatment andtheadaptiveresponsestoanincreasedVDO.Insleepapnea patients,anincreasedVDOmayimpacttheupperrespiratory tractandnegativelyaffecttheseverityoftheobstructivesleepapnea.Anotolaryngologicalevaluationisneededtopinpointthe siteofairwayobstructionandidentifythebesttreatments. Finally,anexcessiveincreaseinVDOcanleadtolipincompetence,whichhasadverseeffectsonmasticationandphonetic functions.Orthodontictreatmentmaybeadvisablebeforeprosthetictreatmentcanbedone.

MYTHTWO

ARestoredVDOIsn’tStableOverTime

Almosthalfofthesurveyrespondentsbelievedtherestored VDOisn’tstableovertime,whichlikelyre flectseitherthe fixed musclelengththeoryortheadaptablemuscletheory.The fi rst arguesthatanyVDOchangesaretemporaryandwillrevertto theoriginalstate,whereasthesecondtheorysaystheVDOis flexibleandlong-lastingchangesarepossiblebecausethemuscle willadapt.Researchindicatesthatadultskeletalmusclesadjust theirlengthandareadaptable.Thishasbeenshowninsurgical limblengtheningandtendontransfersandextendstomasticatory muscles,whichadjusttheirlengthwithinamonthafterVDOalterations.Bothresearchandclinical findingsindicatethatamodifiedVDOisverylikelytobestableovertimeaftertheadaptation.

Figure4. Thedistributionofpatients’ adaptivecapacityaftervertical dimensionofocclusion(VDO)elevation.(CourtesyofLassmann Ł,Calamita MA,ManfrediniD:Mythssurroundingverticaldimensionofocclusionin restorativedentistry:Ascopingreview. JEsthetRestorDent 37:94-105, 2025.)

Figure7. Dento-alveolarcompensation.(CourtesyofLassmann Ł,CalamitaMA,ManfrediniD:Mythssurroundingverticaldimensionofocclusionin restorativedentistry:Ascopingreview. JEsthetRestorDent 37:94-105,2025.)

Toothweardoesn’tnecessarilyleadtoVDOlossandisoften accompaniedbysomedegreeofdentoalveolarcompensation. Evenwithsubstantialtoothwear,VDOandfaceheightcan remainconsistentbecauseofthiscompensation(Figure7). ManydentistsassumetheVDOisreducedwhentheyobserve wornteeth.Currently,nopropertoolsexisttopreciselymeasureVDOlossinthesesituations.

MYTHTHREE

MethodstoDetermineVDOforCompleteDenturesAre EquallyEffectiveforWornDentition

ThetechniquesusedtodetermineVDOfordentatepatients differfromthoseforedentulouspersons.Thetraditionalways todetermineVDO,whichinvolvetheuseoffaciallandmarks, phonetics,anddeglutition,maybeusefulformobileprosthodontics,buttheymaynotbedirectlyapplicableforpatientswhose dentitionisworn.Amorepreciseapproachfordentatepatients isneeded.

MYTHFOUR

ChangesinVDOAreaDirectCauseorCureforTMD

Currentliteraturedoesn’tsupportanycausalorcurativerolefor VDOchangesinpatientswhohaveTMDsymptoms.Nodirect linkexistsbetweenVDOchangesandTMD.Evidenceisaccumulatingthatindicatesadiminutionofocclusalfeaturesshouldserve asadeterminingfactorinTMDtreatment.

CONCLUSIONS

ManycommonbeliefsaboutVDOalterationsandtheireffectson patientadaptation,whetheragradualprocessandtrialphaseare

required,thestabilityofmodifiedVDO,andlinksbetweenVDO andTMDwereshowntobeinaccurateandmisleadingbasedon published findingsandtheclinicalwisdomofpracticingdentists andprosthodontists.VDOalterationsarenotonlystablebut thefacialanddentalstructuresarealsoadaptabletothese changes.Inaddition,traditionalmethodsusedtodetermine VDOincompletedenturesaren’tsuitablefordealingwith worndentition.Dentatepatientsrequireatailoredapproach ratherthanrelianceonthetraditionalmethod.

ClinicalSignificance

Evidencesupportstheadaptabilityofthestomatognathicsystem,sonoprolongedtrialphaseisneeded afterVDOalterations.Evidencedoesn’tsupportany linkbetweenVDOandTMD.Alongwiththeother guidanceprovided,it’simportantthatdentalpractitionersrelyoncurrentevidenceandclinicaljudgment andnotnecessarilyontraditionalapproachesor assumptions.

Lassmann Ł,CalamitaMA,ManfrediniD:Mythssurrounding verticaldimensionofocclusioninrestorativedentistry:Ascoping review. JEsthetRestorDent 37:94-105,2025

Reprintsavailablefrom Ł Lassmann,One&OnlyInst,Gdanski, Poland;e-mail: zlassmann@hotmail.co.uk

EXTRACT

ISTHATREALLYTRUE?

Surveysshowthatoursocietyisvulnerabletoacceptingmisinformation,especiallythroughsocialmedia andthatincludeshealth misinformation.Isitpossibletoknowifasourceistrustworthy?Howcanweprotectourselvesfrominaccuratehealth information?

Massmediaandsocialmediadisseminationhelpsinformationtravelfast,whichisgreatforaccessibilitybutnotnecessarilyfor accuracy.Ina2024USconsumerstudy,morethanhalfofrespondentsobtainedhealthinformationfromsocialmediaand 32%reliedonfamily,friends,andcolleagues.Respondentsadmittedthattheydidn’talwaystrustthesesourcesbecausehealth misinformationmaybemisreported,misinterpreted,orotherwiseinaccurate.A2024UKsurveyfoundthat94%ofthepopulation hadwitnessedmisinformationbeingcirculatedonsocialmedia.Howcanweknowiftheinformationisaccurate?

DawnHolfordoftheSchoolofPsychologicalScienceattheUniversityofBristol,UK,isabehavioralscienceresearcherwhospecializesinthepsychologyofcommunicationanddecision-makingandhasstudiedstrategiestopreventandrebuthealthmisinformation.Shehasfoundthattounderstandwhywemightfallforhealthmisinformation,weshouldexamineour “attituderoots.” Thistermreferstothebeliefsandideasthatwehaveconsolidatedinourmindssincewewereyoung.Theyarenowpartofour psychologyandserveasmotivationaldriversofhowweprocessinformation.Theserootsaren’tgoodorbadinthemselvesbut simplymotivateusandareshapedbyourlifeexperiencesandthoughtpatterns.

Emotionscanalsobepartoftheseroots.Anxiety,forexample,maybefeltaboutsomethingwhosemechanicswedon’tunderstand andthatcanincludemedicalexaminations,medications,andvaccines.Holford’steamexamined11differentattituderoots concerningmisinformationaboutvaccination.Theyincludedfearsaboutpossibleadversemedicaloutcomes,variousreligious views,andresistanceaboutbeingtoldwhattodo(reactance).Theteamdeterminedthatpeopletendtoseekandinterpretinformationthatalignswiththeirexistingpatternsofthoughtandinquiry.Beinganxiousaboutgoingtothedoctororhavingmedical procedurescouldmakeusmorelikelytoadoptmisinformationthatconsolidatesthatfear.Andthat’sconsistentwithhowhuman brainswork theyareverypronetoconfirmationbias,whichmeansselectivelyseekingevidencethatsupportsthebeliefsand anxietieswealreadyhave.Thistendencyisextremelystrongandcanbeverydif ficulttodislodge.

Holfordalsoclari fiedwhoismostsusceptibletomisinformation.Shesaid, “Peopletendtobelieveinformationmoreifthatinformationalignswiththeirideology.” Inaddition,certainpsychologicaltraitscanin fluenceoursusceptibilitytomisinformation, suchasactivelyopen-mindedthinking.Shewarnsthat “Whichgroupwouldbemoresusceptibledependsonhowmisinformation iscraftedtocreatealignmentwithpeopleofthatgroup’sbeliefs.”

Whenaskedwhypeoplemightmistrusthealthinformationfromofficialsources,Holfordsuggestedthatfakeinformationspread withmaliciousintentbybadactorscanarisefromreal-lifenegativeexperienceswithinthehealthsystemitself. “Togivesome examples,” sheexplained, “wewouldbemoresusceptible[to]disinformationthatvaccineswereintendedasaforeignplotto sterilizepeoplelikeusifwe’dhadpreviousexperiences mostofthetimelegitimate! thatshapedourattituderootofdistrust ofsay,colonialgovernments.” Thiscouldalsobeseenwithbeingdeniedtimelytreatmentduetogenderbias,orwithexperiences ofracisminhealthcare,orsimplythroughpoorexperienceswithinstitutions,allofwhichcouldamplifyouranxietyandmakeus moresusceptibletofalsehealthinformation.Narrativescanevenbecraftedsotheycouldtargetmorethan1group.

INTERVENTIONSAGAINSTMISINFORMATION

Holfordandhercolleaguesaredevelopingastrategytheycall “jiu-jitsuinterventions” tohelppeopledealwithhealthmisinformation.Holfordexplainshowthisstrategyworks: “Weconceptualize ‘jiu-jitsuinterventions’ as[tryingto]usemisinformation againstitself.[ ]Injiu-jitsu[aBrazilianmartialart],youdon’ttryto fightwithanopponentheadon,butratherletthemattack andleveragethatforceto fightback.Inthisway,weareabletochallengewhatmayseemlikeastrongerandinsurmountablefoe. WhichIthinkisimportantwhenwelookatthescaleofthechallengewithmisinformation.Soourinterventionslookatwhatare

thefeaturesofmisinformation,whatitisthatmakesitsticky,thatmakespeoplesusceptibletoit,andweusethosetobuildpeople’sskillstodefendthemselvesorothersagainstmisinformation.”

Twotypesoftheseinterventionsarepsychologicalinoculationagainsthealthmisinformationandempatheticrefutationofmisinformation.Psychologicalinoculationislikeavaccineinthatitwarnspeopleagainstthetacticsofmisinformation,suchas cherry-pickinginformation,playingonouremotions,orrelyingonfakeexpertstoappearcredible.Whenpeopleexperiencesmall dosesofthesetactics,theyunderstandhowtrickymisinformationcanbeandbuildprotectivemeasuresagainstit.Empathetic refutationinvolvesthedevelopmentofinterventionsthatarealignedtotheindividual’sattituderoots,demonstratingempathy tomakecorrectingmisinformationfeellessthreateningsoit’smorelikelytobereceived.

VERIFYINGACCURACY

It’simportanttocheckanddouble-checkthesourceofinformation.Called lateralreading, thistechniquehelpslookforthecorroborationoffacts.Afterencounteringthehealthinformation,wewouldlookoutsideofthatsiteorplatformforothersources thatwillverifyitscredibilityandseesourcesindependentoftheoriginalsource.Becauseofourtendencyistoacceptincorrect informationthatalignswithwhatwewanttohear,it’svitaltoemploythelateralreadingtechnique.Holfordemphasizesthatthose whodisseminatehealthinformation,suchasmedicalnewswebsites,haveadutytoperformmoreexactingfact-checkingbefore releasinginformationtothepublic.

TRUSTWORTHYSOURCES

Holfordsays, “Ironically,governmentalpublichealthorganizationsareoftentheplaceswheretheinformationisreliable because theyareaccountabletocitizensinawaythatothercontentgeneratorswouldnotbe.Manyalsomakeanefforttoshareinformationusingaccessiblelanguage.Andbecausehealthisaprettybroadarea,it’softengovernmentalorganizationsthathavethe remitandthewherewithaltocoordinatetheexpertiserequiredtocheckinformation.” Sheadmitsthatwedon’talwaystrustour owngovernments.Inthatcase,Holfordrecommendslookingtosourcesthataremoreglobal,suchastheWorldHealthOrganization(WHO).IntheUK,effortstogatherexpertadviceacrossawiderangeofhealthtopicsinclude PatientInfo.

Questionstoaskwhensearchingforatrustworthysourceareasfollows:

Whatdoestheconsensusacrossmultiplecrediblesourcestellus?

DoesthisseemtooalignedwithwhatIalreadybelieve?

Holfordalsorecommendsthatweseekoutatrustedhealthproviderorcommunityhealthrepresentativewecantalktoandask foradviceonwheretolook.

[CohutM:HowDoYouKnowIfAHealthInformationSourceIsReliable? MedicalNewsToday, Feb5,2025]

ANTIDOTETOSTRESS:COZYMAXXING

TikTokofferscozymaxxingasanewself-caretrend.Itfocusesoncreatingacomforting,stress-freeenvironmentthatoffersmentalhealthbene fits.Youcanchangeintopajamas,lightacandle,wrapyourselfina fluffyblanket,enjoyyourfavoritecomfortshows, orlistentogentlemusic.Theself-caretrendfocusesonengagingincozy,comfortingritualsthatpromotestressreliefandcalm. KenFierheller,apsychotherapistatOneLifeCounselling&Coaching,describescozymaxxingas “intentionallycuratingyourhome andhabitstoprioritizerelaxationandcoziness.” Henotesthattheprimaryreasonforitsappealisburnout,whichleadspeopleto seekwaystocreatepocketsofpeaceintheirlives.Toomanystressorsinourlivesalsomakeusdesiremomentsoffeelingsafeso wecanrelaxandde-stress.

RitikaSukBirah,counselingpsychologistandfounderofReflectwithDrRitz,notedthat, “Peopleareincreasinglyrejectingthe glori ficationofbusynessandhustleculture,optinginsteadforself-careandbalance.” Birahnotesthattheaftereffectsofthepandemichaveledpeopletoprioritizetheirmentalhealthand “adeeperappreciationofcomfortandsafetywithinpersonalspaces.” Otherfactorsincludeeconomicstress,climateanxiety,andpoliticalinstability.

MENTALHEALTHBENEFITS

Amongthementalhealthbene fitsofcozymaxxingarereducedstress,improvedemotionalregulation,andbetterqualityofsleep. Birahsays, “Acozy,predictableenvironmentsignalssafetytothebrain,reducingcortisol(thestresshormone)andpromoting relaxation.This,inturn,canleadtoareductioninstressandanxiety.” Consciouslyrelaxingmayallowforre flection,whichhelps

inmanagingemotions.Amongthecomfortingpracticesyoucanincorporateincozymaxxingarejournalingandsippingtea,which supporttheparasympatheticnervoussystem,thebranchofthenervoussystemresponsibleforrestanddigestfunctionsasopposedto fightor flightreactionstostress.Improvedsleepcanberelatedtohavingaclutter-free,invitingspacewhereyoucan winddown.Thatbettersleepqualityhelpswithemotionalbalance.

SELF-CAREWITHINTENTION

Ifcozymaxxingisn’tdonewithinsomeparameters,itcanleadtoavoidancebehavior.Conductingmentalhealthcheck-inswhen practicingself-carecanincludeaskingyourselfifyou’rewithdrawingfromothers,avoidingresponsibilitiesorrecharging,ormovingenough.Birahexplains, “Excessivecozinesswithoutmovementcancontributetophysicalhealthissuesorlethargywhileusing cozinessasanescapecanleadtoprocrastinationordifficultyfacingstressors.” It’swisetosetatimelimitforthecozyritualto avoidbecomingisolatedorengaginginexcessiveescapism.Ifyourstressandanxietybecomedif ficulttomanagealone, finda therapistorconnectwithamentalhealthprofessionaltogetsomeprofessionalsupport.

TIPSFORSTARTINGCOZYMAXXING

Birahadvisesthatyoubeginbycuratingyourspace,addingsoftlighting,blankets,warmcolors,andscentssuchaslavenderor vanillatocreateacalmingenvironment.Thenintroduceacomfortingritual,likeaddingawarmdrink,reading,orstretchingbefore bedtosignalyourrelaxationintention.Takingtimeforabathwithgentlemusicandacandlecanalsobepartofcozymaxxing. Expertsadvocateleavingsmartphonesandotherdevicesoutsidethespacetoavoidaddingorcontinuingthestresstheseitems create.Incorporatinggentlemovementintoyourdaycanalsobecalmingandcozy.Thisincludesyoga,stretching,orashortwalk incomfortableclothes.Thiscozytimedoesn’thavetobesolitary.Beingwithotherscanhelpcreateasenseofrechargingand sharinginthecozyrituals.Itcanbecomeamovienight,asharedteatime,oraslowSundaybrunch.

Cozymaxxingrequireslittleeffortbutisaneffectivewaytosupportmentalhealthandrestoration.Itshouldn'tbeusedtoavoid responsibilitiesordifficultsituations.Cozinessshouldbebalancedwithmovement,connection,andpurposetocreateasustainable,healthy,self-carepracticeforbothphysicalandemotionalhealth.

[StokesV:TikTok’ s ‘Cozymaxxing’ TrendCouldImproveYourMentalHealth,ExpertsSay. Healthline.com,March12,2025]