Faculty Bibliography

OBJECTIVE:To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults. BACKGROUND:Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States. METHODS:We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies. RESULTS:Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives. CONCLUSIONS:Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.

BACKGROUND:In this paper, we describe the design, program details, and baseline demographics and oral health of participants in ForsythKids, a regional, comprehensive, school-based mobile caries prevention program. METHODS:We solicited all Massachusetts elementary schools with greater than 50% of students receiving free or reduced-price meals. Six schools initially elected to participate, ultimately followed by over 50 schools. Interventions were based on systematic reviews and randomized controlled caries prevention trials. Participating students received semiannual dental examinations, followed by comprehensive preventive care. Summary statistics regarding oral health indicators were derived from individual tooth- and surface-level data. RESULTS:Over a 6-year period, data were collected on 6927 children. The number of students per school ranged from 58 to 681. The overall participation rate was 15%, ranging from 10% to 29%. Overall, 57% of the children were younger than 8 years at baseline. Approximately, 54% of children experienced dental decay on any tooth at baseline; 32% had untreated decay on any tooth, 29% had untreated decay on primary teeth, and 10% untreated decay on permanent teeth. CONCLUSIONS:Untreated dental decay was double the national average, even in schools within several blocks of community dental clinics. These data demonstrate the need for caries prevention beyond the traditional dental practice.

BACKGROUND:Globally, children's caries prevalence exceeds 30% and has not markedly changed in 30 years. School-based caries prevention programs can be an effective method to reduce caries prevalence, obviate traditional barriers to care, and use aerosol-free interventions. The objective of this study was to explore the clinical effectiveness of a comprehensive school-based, aerosol-free, caries prevention program. METHODS:The authors conducted a 6-year prospective open cohort study in 33 US public elementary schools, providing care to 6,927 children in communities with and without water fluoridation. After dental examinations, dental hygienists provided twice-yearly prophylaxis, glass ionomer sealants, glass ionomer interim therapeutic restorations, fluoride varnish, toothbrushes, fluoride toothpaste, oral hygiene instruction, and referral to community dentists as needed. The authors used generalized estimating equations to estimate the change in the prevalence of untreated caries over time. RESULTS:The prevalence of untreated caries decreased by more than 50%: from 39% through 18% in phase 1, and from 28% through 10% in phase 2. The per-visit adjusted odds ratio of untreated caries was 0.79 (95% confidence interval, 0.73 to 0.85). CONCLUSIONS AND PRACTICAL IMPLICATIONS/UNASSIGNED:This school-based comprehensive caries prevention program was associated with substantial reductions in children's untreated caries, supporting the concept of expanding traditional practices to include office- and community-based aerosol-free care.

OBJECTIVE:To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health. MATERIALS AND METHODS/METHODS:An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers. RESULTS:The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered. CONCLUSION/CONCLUSIONS:In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

Credible, reliable and consistent information to the public, as well as health professionals and decision makers, is crucial to help navigate uncertainty and risk in times of crisis and concern. Traditionally, information and health communications issued by respected and established government agencies have been regarded as factual, unbiased and credible. The U.S. Centers for Disease Control and Prevention (CDC) is such an agency that addresses all aspects of health and public health on behalf of the U.S Government for the benefit of its citizens. In July 2020, the CDC issued guidelines on reopening schools which resulted in open criticism by the U.S. President and others, prompting a review and publication of revised guidelines together with a special "Statement on the Importance of Reopening Schools under COVID-19." We hypothesize that this statement introduced bias with the intention to shift the public perception and media narrative in favor of reopening of schools. Using a mixed methods approach, including an online text analysis tool, we demonstrate that document title and structure, word frequencies, word choice, and website presentation did not provide a balanced account of the complexity and uncertainty surrounding school reopening during the COVID-19 pandemic. Despite available scientific guidance and practical evidence-based advice on how to manage infection risks when reopening schools, the CDC Statement was intentionally overriding possible parent and public health concerns. The CDC Statement provides an example of how political influence is exercised over the presentation of science in the context of a major pandemic. It was withdrawn by the CDC in November 2020.

Dental teams and their workplaces are among the most exposed to airborne and bloodborne infectious agents, and therefore at the forefront of pandemic-related changes to how dental care is organized and provided to patients. The increasing complexity of guidelines makes is challenging for clinicians to navigate the multitude of COVID-19 guidelines issued by different agencies. A comparative analysis of guidance issued for managing COVID-19 in dental settings leading U.S. agencies was conducted, including documents of the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Secretary of Labor, and of the U.S. Centers for Disease Prevention and Control (CDC), an agency of the U.S. Secretary of Health and Human Services. Details of infection control and other risk mitigation measures were reviewed for consistency, overlaps and similarities, then clustered according to thematic areas covering all domains of managing a dental healthcare setting. The analysis revealed five distinct areas of pandemic control, comprising (1) planning and protocols, (2) patient screening, (3) preparation of facilities, (4) PPE and infection control, and (5) procedures and aerosol control; thereby covering systematically all aspects requiring adaptation in a pandemic context. The "Pandemic-5 Framework for COVID-19 Control in Dentistry" provides an opportunity to simplify comprehensive decision-making from a clinical practitioner perspective. The framework supports a comprehensive systems-driven approach by using dental clinics as a setting to integrate pandemic clinical responses with the implementation of appropriate infection control protocols. Traditionally these two aspects are addressed independently from each other in separate concepts.

The coronavirus disease 2019 (COVID-19) pandemic revealed a lack of consensus on the concept of essential oral health care. We propose a definition of essential oral health care that includes urgent and basic oral health care to initiate a broader debate and stakeholder alignment. We argue that oral health care must be part of essential health care provided by any health system. Essential oral health care covers the most prevalent oral health problems through an agreed-on set of safe, quality, and cost-effective interventions at the individual and community level to promote and protect oral health, as well as prevent and treat common oral diseases, including appropriate rehabilitative services, thereby maintaining health, productivity, and quality of life. By default, essential oral health care does not include the full spectrum of possible interventions that contemporary dentistry can provide. On the basis of this definition, we conceptualize a layered model of essential oral health care that integrates urgent and basic oral health care, as well as advanced/specialist oral health care. Finally, we present 3 key reflections on the essentiality of oral health care. First, oral health care must be an integral component of a health care system's essential services, and by implication, oral health care personnel are part of the essential health care workforce. Second, not all dental care is essential oral health care, and not all essential care is also urgent, particularly under the specific risk conditions of the pandemic. Third, there is a need for criteria, evidence, and consensus-building processes to define which dental interventions are to be included in which category of essential oral health care. All stakeholders, including the research, academic, and clinical communities, as well as professional organizations and civil society, need to tackle this aspect in a concerted effort. Such consensus will be crucial for dentistry in view of the Sustainable Development Goal's push for universal health coverage, which must cover essential oral health care.

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.