UCSF Scientists May Have Found Link To Early Childhood Tooth Decay

A two-year-old Latina child’s mouth was aching, and she was quietly crying herself to sleep. But the pain, disease, and enormous costs of treatment for her tooth decay were all preventable, according to scientists at the University of California, San Francisco School of Dentistry.

In a recent study published in the Journal of Clinical Pediatric Dentistry, clinicians and researchers worked together to study bacterial, behavioral, and environmental factors associated with early childhood caries. They found that ECC is a preventable condition characterized by decay of primary teeth that may begin as an infant’s teeth erupt, long before his or her first year. What is also significant is that the 2-year-old was probably infected by her own mother’s mouth bacteria due to lack of dental health care in underserved and poor communities, the study found.

In the UCSF study, researchers assessed salivary levels of the bacteria mutans streptococci and lactobacilli \in underserved, predominantly Hispanic children. One hundred forty-six infants and toddlers aged 3 to 55 months with dental decay were identified and examined. The study demonstrated significant association between relatively low cariogenic bacterial levels and dental caries in infants and toddlers. The same bacteria strain \of the mother or caretaker was found in the infants and toddlers. The study also showed that ECC correlates significantly with the child’s age and lack of dental insurance of the children and that ECC also correlates with both low family income and the less education of the mother of the child.

Francisco Ramos-Gomez, DDS, MSc, MPH, UCSF associate professor of pediatric dentistry in the department of growth and development and director of the Pediatric Dental Services at San Francisco General Hospital Medical Center, is lead author of the study. "This population needs help from all of us; from policy-makers, health care providers, and from those serving the children," Ramos-Gomez said. "The cost of a full-mouth rehabilitation under general anesthesia of a 2-year-old is about $10,000. If we can make an impact on the population by teaching them directly how to care for their infants before the damage is done, we can save the children from the pain and society from the costs of repairing the decay."

Study subjects were recruited from three sites based at the SFGH Medical Center -- the Family Dental Center; the Women, Infant and Children Program; and the Well Child Clinic. All of these sites serve primarily low-income Hispanic and African American families.

The population studied included the following demographics:

* All of the children were from San Francisco.

* 45 percent were female; 55 percent were male.

* The median age was 30 months (range from 3 months to 55 months).

* 137 were of Hispanic origin (Mexican, Mexican-American, Central American or from Puerto Rico).

* Two were African American and four were non-Hispanic whites.

* 15 percent of the children were from single-parent families.

* 95 percent of caregivers were mothers; 4 percent were fathers and 1 percent were other relatives.

* Median age of the mothers was 27 years.

* Median age of the fathers was 28 years.

* 73 percent of parents had less than a high school education.

* 71 percent of families earned less than $15,000 per year.

The majority of parents (55 percent) had not seen a dentist in the previous two years, but 79 percent reported they currently had tooth decay.

Dental caries in preschool children remain a significant health problem in the United States. The prevalence of caries is especially high among low-income children, particularly Native Americans, Mexican-Americans and African Americans.

"There was a statistically significant correlation between ECC and lack of dental insurance of the children," Ramos-Gomez said. Children without dental insurance were more than twice as likely to have ECC as children with dental insurance.

"The most striking finding of our study was the low levels of MS bacteria associated with ECC in very young children," Ramos-Gomez said. "This finding may put these infants and toddlers at higher risk than previously thought." In these young children, threshold levels of both bacteria associated with caries were lower than in older children and adults, meaning that infants and toddlers are more at risk.

Efforts to reduce ECC should include improving dental education and access to dental care for adult caregivers. The UCSF research suggests that these two factors could significantly reduce transmission of MS from adult to child.

"Our study has been validated recently by two papers which confirmed that baby's mouths can be colonized with cariogenic (decay causing) bacteria before their teeth emerge," John D.B. Featherstone, PhD, said. Featherstone, UCSF professor and chair of the department of preventive and restorative dental sciences, added that the UCSF study found that the levels of bacteria for infants that cause the beginnings of decay are very low compared to older children and adults. "Unfortunately," he said, "the lack of oral health of the mother or caregiver seems to perpetuate itself with these youngsters."

Benefits of Laser Surgery for Sleep Apnea Deteriorate With Time

Treatment of obstructive sleep apnea with laser-assisted uvulopalatoplasty provides some short-term benefit but results in worsening of snoring and existing apnea over time, according to an article in the April issue of the Archives of Otolaryngology -- Head & Neck Surgery.

Yehuda Finkelstein, MD, from the Meir Hospital, Sapir Medical Center in Kfar Saba, Israel, and colleagues studied 26 patients with obstructive sleep apnea who underwent LAUP to evaluate medium- and long-term results.

LAUP, introduced in 1990, is a popular surgical treatment that controls snoring by removing part of the uvula. This procedure is also being used to treat obstructive sleep apnea, a sleep-related breathing disorder, despite controversy surrounding the use of LAUP for apnea.

The researchers found that despite favorable short-term results, the apparent benefits of LAUP diminished with time. "A significant decline in snoring improvement from 88 percent (23/26) to 65 percent (17/26) was recorded; furthermore, the state of snoring worsened from 4 percent (1/26) to 12 percent (3/26)," wrote the researchers.

"Re-evaluation of the five other sleep-related symptoms after completion of LAUP uncovered a 50 percent improvement rate (13/26), and a 15 percent (4/26) worsening rate. Overall, satisfaction from the procedure was 58 percent (15/26)," the authors continued.

The authors attribute the late decline in snoring improvement, aggravation of apnea symptoms, and the overall failure of the study’s objective measures to progressive fibrosis caused by thermal damage from the laser beam. They explain that the LAUP procedure consists of cutting and vaporizing palatal tissue, which leaves raw tissue that eventually scars. Heavy scarring can lead to progressive fibrosis. Eventually, the area of the back of the throat may narrow, become rigid and lose some of the distendability needed during inhalation.

Refunds Should Be Given Only After Release Signed

If patients are unhappy with treatment, most of the time all they want is a refund, wrote Eric Ploumis, DMD, JD, in the January 2002 New York State Dental Journal.

Rightly or wrongly, a patient may feel the treatment didn’t measure up to expectations. Providing a refund is fine, Ploumis wrote, but it’s essential to get a release.

He cited many reasons dentists should have patients sign a release before any money is refunded. Simply put, he said, by signing a release in exchange for money, a patient gives up the right to sue the dentist. Ploumis said it doesn’t matter how much money is returned, a release is necessary.

The lure of a refund will prompt most patients to sign a release, but if the release is too formal or frightening, they may balk. Ploumis advised tailoring a release to suit the situation. Once signed, refund the money promptly, he wrote.

Even if a dentist feels the patient deserved a refund and senses no breakdown in the doctor-patient relationship, get a release, he said. Situations change rapidly; and once a refund is given, a patient can simply pocket the money and take any and all actions available unencumbered by the legal shackle of a valid release.

According to Ploumis, except for a simple overpayment refund, dentists should never return money to a patient without a release.

Ploumis said a release should consist of the following elements:

* The names of both the releasor (the patient) and the releasee (the dentist). If the patient is a minor, a parent or legal guardian must sign the release.

* A specific dollar amount the dentist intends to return to the patient. Avoid "fuzzy" language such as the dentist will return "one-half of the treatment fee."

* A statement that in returning the fee, the dentist admits to no liability. If this clause is not included, the patient may assume the dentist is refunding money because he or she did something wrong.

* An indemnification clause. Clearly state that the patient, by accepting a refund, waives the right to any future actions against the dentist and his or her associates, partners, employees, corporation, and heirs.

* Termination of the doctor/patient relationship. Even though this may seem obvious, make sure the patient knows that by accepting the refund, he or she is no longer a patient.

* Confidentiality agreement. This should stipulate that the terms of the release are confidential and not to be revealed to any outside parties.

* Signature of the releasor, releasee and at least one witness. Along with the necessary signatures, make sure the release is dated.

Dental Teaching Positions Going Unfilled

The dental profession is losing faculty due to retirement or entry into private practice, creating a vacuum that is not being filled, wrote Janet Walzer in the Winter 2001 Tufts Dental Medicine.

According to a report in the September 2000 Journal of Dental Education, the number of vacant faculty positions in U.S. dental schools stands at 400 full-time faculty, Walzer noted.

Those retiring in the next 10 years could number between 820 and 1,300, and younger dentists are not following in their footsteps, Walzer wrote. The number of dental students who plan to pursue an academic career has remained between 0.5 percent and 1.3 percent since 1980.

While 36 percent of those leaving the teaching profession stated it was due to retirement, 23 percent left to enter private practice. According to Walzer's article, the numbers say much about the issues that characterize the dental teaching crisis: the "graying" of dental school faculty, the lack of enthusiasm for teaching by younger dentists and the financial appeal of private practice.

Dr. Jackson Brown, associate executive director for health policy resources for the American Dental Association, and Dr. Richard W. Valachovic, executive director of the American Dental Education Association and co-author of the September report, believe the profession must address faculty compensation in its broadest sense, highlighting the perks of an academic life in addition to reexamining salaries and benefits.

Some things could make it (teaching) more appealing, Brown noted, such as more time for research and intellectual pursuits as well as for clinical activities.

Dentists who choose academia have always had to make financial compromises in contrast to their peers who enter private practice, Walzer noted in her article. Even if dentists have a love of teaching, the reality of skyrocketing tuition and the resulting student debt have the potential to turn love into ambivalence, Walzer wrote.

Pet-Assisted Therapy Comes to the Dental Office

One thing one might not expect to see in a dental office is a dog. But for one Portland, Ore., dentist, a dog is "normal" in the office, according to an article in the January 2002 issue of Membership Matters, the newsletter of the Oregon Dental Association.

Not just any dog, but one who has been trained and certified for "animal-assisted therapy."

Julie Debansky, dental assistant for Dr. Alan R. Pike, a Portland-based pediatric dentist, owns two pet-assisted therapy dogs, Morgan and Madison. On her days off from the dental office, Debansky takes her dogs to a local hospital to visit patients.

She noticed that apprehensive children in the dental office became more relaxed when she showed them pictures of her dogs. One child requested that Debansky bring her dogs to the office.

After checking with Dr. Pike and the appropriate regulatory agencies, she began bringing her dogs to the dental office dressed in their office "Pet-Assisted Therapy" vests.

Pike said the effect on some of the children -- and their parents -- was amazing. Many children focused more on the dogs and worried less about their checkups, he said.

Pike said anecdotal evidence suggests he is able to offer a more homelike environment for his patients who might sometimes be a bit overwhelmed by the dentist’s office. That makes the children and their parents more relaxed, and helps establish a good dentist-patient relationship, Pike said.

Sucralose May Help in Caries Prevention

When used to replace sugar, both sucralose and the tested sucralose-based sweeteners may be useful in the dietary management of caries, wrote Irwin D. Mandel, DDS, and V. Lee Grotz, PhD, in the Journal of Clinical Dentistry, Vol. XIII, No. 3.

Sucralose, a new type of noncaloric, high-intensity sweetener, was recently approved for use by the U.S. Food and Drug Administration. Several studies of the drug show that sucralose is noncariogenic, the authors wrote.

Sucralose-based sweeteners that contain bulking ingredients, which allow them to pour and measure more like sugar, do have cariogenic potential due to the presence of added fermentable carbohydrate. Mandel and Grotz said, however, that the data suggest that both the currently marketed sucralose granular and packet products are less cariogenic than sugar.

Mandel and Grotz noted that diet modification to reduce the intake of sugar-containing foods is a widely accepted approach for the prevention of dental caries.

They wrote that the most significant dental-related studies of sucralose were conducted in the 1990s. The authors noted that the basic study of the effects of sucralose on bacterial metabolism was done by Young and Bowen on 10 strains of oral bacteria, including S. mutans and other acidogenic plaque organisms that can play a contributory role in the initiation and progression of caries.

Investigators found that sucralose, as a sole carbon source, was unable to support the growth of any strains tested.

Their article reviewed six studies that show that sucralose does not promote dental caries. The authors said the in vitro study established the inability of sucralose to be utilized by cariogenic bacteria.

Scientists Find Gene Involved in Gum Overgrowth

Dental researchers have known for decades that some people are born with gums that grow abnormally over their teeth. What they have never known is why.

In a recent issue of the American Journal of Human Genetics, dental researchers have their first clue. An international team of scientists reported that it has identified the first gene that, when altered, triggers hereditary gingival fibromatosis, the most common of these rare, inherited gum conditions.

The researchers noted that the gene, called SOS1, encodes a protein that is known to activate the "ras" pathway, one of the key growth signals in \ cells. The authors say this finding suggests that, when the SOS1 gene is not mutated, its protein and the "ras" pathway likely are involved in the normal growth of healthy gums, or gingiva, an idea that was previously unknown.

If confirmed, they said, learning how to turn on relevant portions of the pathway, like flipping a biological switch, might help dentists one day regenerate the gingiva naturally in people with receding gums or advanced periodontal disease. Conversely, by switching off the growth signal, dentists could prevent gingival overgrowth, meaning people with HGF might not need to have the excess tissue surgically cut away, now the standard treatment.

Honors

Peter S. Young, DDS, of Arcadia, Calif., has been installed as the first Chinese American president of the Arcadia Chamber of Commerce. Dr. Young is an assistant professor at Loma Linda University School of Dentistry and maintains a family and cosmetic dental practice.

Upcoming Meetings

2002

July 4-7 Academy of General Dentistry Annual Meeting, Honolulu, (888) 243-3368, Ext. 4339, www.agd.org.

July 19-21 Second Annual Dental Materials and Technology Update 2002, Universal City, Calif., (818) 716-1791, www.estheticprofessionals.com.

Aug. 16-23 Fun in the Sun, Costa Rica, (818) 716-1791, www.estheticprofessionals.com.

Sept. 26-28 American Society for Dental Aesthetics, 26th International Conference on Aesthetic Dentistry, Las Vegas, (813) 264-2772, www.asdatoday.com.

Sept. 27-29 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470.

Oct. 11-13 National Association of Filipino Dentists in America Annual Meeting, San Francisco, (818) 988-3910.

Oct. 19-23 ADA Annual Session, New Orleans, (312) 440-2500.

Nov. 7-9, Excellence in Dentistry, Las Vegas, (800) 337-8467.

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.