"The Seattle Care Pathway for securing oral health in older patients"Pretty, Iain A; Ellwood, Roger P; Lo, Edward C M; Macentee, Michael I; Muller, Frauke; Rooney, Eric; Murray Thomson, William; Van der Putten, Gert-Jan; Ghezzi, Elisa M; Walls, Angus; WOLFF, MARK S
There is a need for a structured, evidence based approach to care for older dental patients. The following article describes the development of the Seattle Care Pathway based upon a workshop held in 2013. An overview is provided on the key issues of older persons dental care including the demography shift, the concept of frailty, the need for effective prevention and treatment to be linked to levels of dependancy and the need for a varied and well educated work force. The pathway is presented in tabular form and further illustrated by the examples in the form of clinical scenarios. The pathway is an evidence based, pragmatic approach to care designed to be globally applicable but flexible enough to be adapted for local needs and circumstances. Research will be required to evaluate the pathways application to this important group of patients..
"Delivering the evidence - skill mix and education for elder care"WOLFF, MARK S; Schenkel, Andrew B; Allen, Kenneth L
OBJECTIVES: To review the current status of dental curricula on elder care, and the current curricula regarding elder care, and it's effect on altering practitioner behaviors while addressing the needs of a growing North American elder population. BACKGROUND: An impending crisis is looming over the oral healthcare of our aging population. At the same moment that life expectancy is being extended through increasingly complex healthcare improvements, the numbers of trained dental providers capable and interested in delivering the needed care is failing to grow at an adequate rate. DISCUSSION: The skills necessary to manage these increasingly complex patients require an interprofessional approach capable of delivering care to sicker patients, in a variety of living accommodations, while managing a variety of care givers. The dental skills necessary to treat these elderly are modifications of skills students routinely learn in dental school. As a matter of fact, the skills students acquire to treat an adult patient population may be contrary to the basic skills necessary to manage the elderly dependent adult patient. Teaching students the nuance differences needed to properly diagnose and care for this population is a difficult task that must be taught in a contextual environment. CONCLUSION: Significant changes in the teaching of dental management of the elderly are critical within much of the education community. Just as teaching students to care for the pediatric population as general dentists, the clinical education must involve a sufficient number of quality experiences to address issues of both competency, that of the graduate to perform care independently, and attitudes, the actually willingness to treat the elderly..
"In vivo effects of a new dentifrice containing 1.5% arginine and 1450 ppm fluoride on plaque metabolism"WOLFF, M; Corby, P; Klaczany, G; Santarpia, P; Lavender, S; Gittins, E; Vandeven, M; Cummins, D; Sullivan, R
OBJECTIVE: This paper presents the results of a clinical study assessing the in vivo effects on plaque metabolism of a new dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride compared to a commercially available dentifrice containing 1450 ppm fluoride alone. METHODS: A four-week, parallel, randomized, double-blind clinical study using 54 subjects was conducted at the New York University College of Dentistry Bluestone Center for Clinical Research. Two study groups used the following products for two weeks: 1) a dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride as sodium monofluorophosphate (MFP; test); and 2) a commercial silica dentifrice with 1450 ppm fluoride as sodium fluoride (NaF; control). In the following two-week period, all subjects used the control product. The effects of product use on plaque metabolism in vivo were assessed by conducting ex vivo analyses at baseline, after two weeks of assigned product use, and after two weeks of control product use. These plaque analyses comprised pH measurements before and after an in vivo sucrose rinse, and measurements of ammonia production and lactate production. RESULTS: The study showed that subjects using the test dentifrice, containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride, had significantly higher plaque pH values before the sucrose challenge than those using the commercially available control dentifrice (p < or = 0.01). Plaque samples from subjects using the arginine-containing dentifrice also produced significantly higher levels of ammonia (p < or = 0.01). Subjects using the arginine-containing dentifrice also had a directionally higher plaque pH after the sucrose challenge, and their plaque samples produced a directionally lower level of lactate during the two-week treatment period compared to subjects using the control dentifrice. Following two weeks of subsequent use of the control product, there were no significant differences in plaque metabolism measures between groups. CONCLUSION: A new dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride has been shown in this study to modulate plaque metabolism, increasing ammonia production and decreasing lactate production, thereby increasing plaque pH to help restore a pH-neutral environment..
"Residual stresses in porcelain-veneered zirconia prostheses"Baldassarri, M; Stappert, CF; WOLFF, MS; Thompson, VP; Zhang, Y
GRANTS:2R01 DE017925/DE/NIDCR NIH HHS/United States
OBJECTIVES: Compressive stress has been intentionally introduced into the overlay porcelain of zirconia-ceramic prostheses to prevent veneer fracture. However, recent theoretical analysis has predicted that the residual stresses in the porcelain may be also tensile in nature. This study aims to determine the type and magnitude of the residual stresses in the porcelain veneers of full-contour fixed-dental prostheses (FDPs) with an anatomic zirconia coping design and in control porcelain with the zirconia removed using a well-established Vickers indentation method. METHODS: Six 3-unit zirconia FDPs were manufactured (NobelBiocare, Gothenburg, Sweden). Porcelain was hand-veneered using a slow cooling rate. Each FDP was sectioned parallel to the occlusal plane for Vickers indentations (n=143; load=9.8N; dwell time=5s). Tests were performed in the veneer of porcelain-zirconia specimens (bilayers, n=4) and porcelain specimens without zirconia cores (monolayers, n=2). RESULTS: The average crack lengths and standard deviation, in the transverse and radial directions (i.e. parallel and perpendicular to the veneer/core interface, respectively), were 67+/-12mum and 52+/-8mum for the bilayers and 64+/-8mum and 64+/-7mum for the monolayers. These results indicated a major hoop compressive stress ( approximately 40-50MPa) and a moderate radial tensile stress ( approximately 10MPa) in the bulk of the porcelain veneer. SIGNIFICANCE: Vickers indentation is a powerful method to determine the residual stresses in veneered zirconia systems. Our findings revealed the presence of a radial tensile stress in the overlay porcelain, which may contribute to the large clinical chip fractures observed in these prostheses..
"Effect of an 8.0% arginine and calcium carbonate desensitizing toothpaste on shear dentin bond strength"Canares, G; Salgado, T; Pines, M S; WOLFF, M S
OBJECTIVE: The objective of this study was to determine the effect of an 8.0% arginine and calcium carbonate desensitizing toothpaste (Colgate Sensitive Pro-Relief) on shear bond strength of composites to bovine incisor dentin. METHODS: Bovine incisors were sectioned and prepared into 27 dentin specimens. The experimental group had 13 specimens treated for 10 sessions of two-minute brushing with an 8.0% arginine and calcium carbonate desensitizing toothpaste, followed by a 30-second agitated water wash. The control group had 14 specimens treated with flour of pumice only. Each specimen was dried, etched with 35% phosphoric acid for 15 seconds, and washed clean. A bonding agent was applied and polymerized. A 2.38 mm diameter column of Filtek Supreme A2 was bonded to the surface and polymerized as per manufacturer's instructions. Specimens were stored in water for at least 48 hours, subjected to a shear force at a crosshead speed of 0.5 mm/minute on an Instron mechanical testing device, and force at failure was recorded. A one-sided t-test was used to evaluate significant differences among the groups as measured by mean shear strength. RESULTS: Mean shear force was 19.6 +/- 9.4 (SD) for the experimental group and 15.4 +/- 6.0 for the control group with p = 0.0291. CONCLUSION: No significant differences were found for bond strength to dentin treated with an 8.0% arginine and calcium carbonate desensitizing toothpaste or pumice. Dentists can still achieve optimal dentin bonding results if a patient is using Colgate Sensitive Pro-Relief to manage dentin hypersensitivity..
"Caries management by risk assessment"Takulla, Nisreen F; WOLFF, MARK S; Schenkel, Andrew B
New York University College of Dentistry utilizes a protocol for caries management by risk assessment. It includes guidelines for determining several indicators and factors that are used to identify whether a patient is at high, moderate or low risk for dental caries. This case report presents an assessment of a patient with high caries risk and the system used to treat the disease process and lower the patient's risk for future lesions..
"Smile design and treatment planning with the help of a comprehensive esthetic evaluation form"Calamia, John R; Levine, Jonathan B; Lipp, Mitchell; Cisneros, George; WOLFF, MARK S
Even if a clinician possesses basic knowledge in esthetic dentistry and clinical skills, many cases presenting in modern dental practices simply cannot be restored to both the clinician's and the patient's expectations without incorporating the perspectives and assistance of several dental disciplines. Besides listening carefully to chief complaints, clinicians must also be able to evaluate the patient's physical, biologic, and esthetic needs. This article demonstrates the use of a smile evaluation form designed at New York University that assists in developing esthetic treatment plans that might incorporate any and all dental specialties in a simple and organized fashion.
"Translating the caries management paradigm into practice: challenges and opportunities"Fontana, Margherita; WOLFF, MARK
In an era of evidence-based care, the question of how much evidence is needed to implement changes into practice becomes central to dentistry's recognition that dental caries management must change to a focus on risk-based, patient-centered disease management rather than just restorative care. This article reviews some of the opportunities, needs, and challenges involved in the adoption and implementation of caries management strategies into everyday clinical practice..
"A geriatric patient: age is not a factor"Klodnitskaya, Lisa; Harutunian, Michele M; Mareque Buenos, Santiago; Estafan, Denise; WOLFF, MARK S
Objective. A patient presented to the dental office expressing dissatisfaction with the appearance of his teeth, and as a result, of his smile. Our objective was to satisfy his initial chief complaint: "I don't like how my teeth look when I smile." Methodology. Upon completing all initial exams and consultations, an esthetic dental treatment plan was formulated and agreed upon by both the practitioners and the patient. Results. The patient received periodontal treatment first to create esthetic gingival margins. Anterior ceramic crowns followed. Conclusion. The results surpassed all patient's expectations..
"Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations"Rethman, Michael P; Beltran-Aguilar, Eugenio D; Billings, Ronald J; Hujoel, Philippe P; Katz, Barry P; Milgrom, Peter; Sohn, Woosung; Stamm, John W; Watson, Gene; WOLFF, MARK; Wright, J Tim; Zero, Domenick; Aravamudhan, Krishna; Frantsve-Hawley, Julie; Meyer, Daniel M
BACKGROUND: In this article, the authors present evidence-based clinical recommendations regarding the use of nonfluoride caries preventive agents. The recommendations were developed by an expert panel convened by the American Dental Association (ADA)Council on Scientific Affairs. The panel addressed several questions regarding the efficacy of nonfluoride agents in reducing the incidence of caries and arresting or reversing the progression of caries. TYPES OF STUDIES REVIEWED: A panel of experts convened by the ADA Council on Scientific Affairs, in collaboration with ADA Division of Science staff, conducted a MEDLINE search to identify all randomized and nonrandomized clinical studies regarding the use of non fluoride caries-preventive agents. RESULTS: The panel reviewed evidence from 50 randomized controlled trials and 15 nonrandomized studies to assess the efficacy of various nonfluoride caries-preventive agents. CLINICAL IMPLICATIONS: The panel concluded that certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at higher risk of developing caries. These recommendations are presented as a resource for dentists to consider in the clinical decision-making process. As part of the evidence based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences..
"Technological advances in caries diagnosis"Rochlen, Glenn K; WOLFF, MARK S
Understanding the nature of the caries lesion, disease activity, and the patient's caries risk are all used in determining the nature of dental care to be delivered. An examination should include a health and social history and clinical examination using appropriate technologies. This allows proper assessment and suggests a logical management intervention. Minimally invasive dentistry is a concept based on an assessment of a patient's caries risk and the application of the current therapies to prevent, control, and treat the disease. The history of the dental examination and the variety of current technologies are discussed.
"Implementing tobacco use treatment guidelines in public health dental clinics in New York City"Shelley, Donna; Anno, Jaime; Tseng, Tuo-Yen; Calip, Greg; Wedeles, John; Lloyd, Madeleine; WOLFF, MARK S
In this study we evaluated the effect of a multicomponent intervention to implement the Public Health Service (PHS) guideline Treating Tobacco Use and Dependence in six randomly selected dental clinics in New York University's College of Dentistry. The main outcome measure-provider adherence to tobacco use treatment guidelines-was assessed by auditing a random selection of patient charts pre (698) and post (641) intervention. The intervention components included a chart reminder and referral system, free nicotine replacement therapy (NRT), and provider training and feedback. The results showed that rates of screening for tobacco use did not change between pre and post test chart audits. However, providers were significantly more likely to offer advice (28.4 percent pre, 49 percent post), assess readiness to quit (17.8 percent pre, 29.9 percent post), and offer assistance (6.5 percent pre and 15.6 percent post) in the post test period. Increases in NRT distribution were associated with booster training sessions but declined in the time periods between those trainings. Research is needed to further define sustainable strategies for implementing tobacco use treatment in dental clinics. The results of this study suggest the feasibility and effectiveness of using a tailored multicomponent approach to implement tobacco use treatment guidelines in dental clinics..
"Changing the face and practice of dentistry: a 10-year plan"Young, Douglas; Ricks, Charles S; Featherstone, John D B; Fontana, Margherita; Fournier, Susan M; Geiermann, Steven P; Hurlbutt, Michelle; Kutsch, V Kim; Loftus, Rolande; Luther, John R; Novy, Brian B; WOLFF, MARK S; Wong, Allen
Jan. 7 through 9, 2011, the California Dental Association Foundation hosted a symposium on caries management by risk assessment in which a diverse range of stakeholders from across the nation gathered to discuss current and future status of CAMBRA. The consensus of the group was to develop a national strategic plan for CAMBRA implementation which will chart the course to improve the standard in caries disease management within the next decade. This paper represents the initial start of this living document..
"Defining dental caries for 2010 and beyond"Fontana, Margherita; Young, Douglas A; WOLFF, MARK S; Pitts, Nigel B; Longbottom, Chris
This introductory article provides an overview of the caries disease process that will help guide readers into the world of evidence-based caries management in the beginning of the twenty-first century and help them understand the ongoing need to update in this field. This issue of Dental Clinics of North America provides clinically relevant reviews, full of chair-side recommendations based on best available evidence, on epidemiology, nomenclature, disease process, and management. A glossary of common terms in cariology is included..
"Chewing variation in lepidosaurs and primates"Ross, C F; Baden, A L; Georgi, J; Herrel, A; Metzger, K A; Reed, D A; Schaerlaeken, V; WOLFF, M S
Mammals chew more rhythmically than lepidosaurs. The research presented here evaluated possible reasons for this difference in relation to differences between lepidosaurs and mammals in sensorimotor systems. Variance in the absolute and relative durations of the phases of the gape cycle was calculated from kinematic data from four species of primates and eight species of lepidosaurs. The primates exhibit less variance in the duration of the gape cycle than in the durations of the four phases making up the gape cycle. This suggests that increases in the durations of some gape cycle phases are accompanied by decreases in others. Similar effects are much less pronounced in the lepidosaurs. In addition, the primates show isometric changes in gape cycle phase durations, i.e. the relative durations of the phases of the gape cycle change little with increasing cycle time. In contrast, in the lepidosaurs variance in total gape cycle duration is associated with increases in the proportion of the cycle made up by the slow open phase. We hypothesize that in mammals the central nervous system includes a representation of the optimal chew cycle duration maintained using afferent feedback about the ongoing state of the chew cycle. The differences between lepidosaurs and primates do not lie in the nature of the sensory information collected and its feedback to the feeding system, but rather the processing of that information by the CNS and its use feed-forward for modulating jaw movements and gape cycle phase durations during chewing..