Dental Practice Patterns Add to Oral Health Disparity

There is a growing chasm between the practice of dentistry in the United States and the oral health needs of the nation, according to a recent study "The Growing Challenge of Health Care in America" published in the Sept. 5 issue of Health Affairs.

The researchers report that, while the dental professions have flourished, there is "abundant evidence that a sizable segment of the population does not have access to oral health care" and that the dental safety net is "poorly defined and underdeveloped." The article examines the oral health workforce and trends in dental care delivery in relation to the physician workforce and trends in medicine.

"The practice of dentistry has improved, becoming more lucrative and less time-consuming," said Elizabeth Mertz, MPA, lead author and project director at the UCSF Center for Health Professions. "In comparison to physicians, dentists work more independently, have a higher rate of solo practice, and in some cases their earnings have surpassed the net income of physicians," Mertz explained.

"But, while dentistry appears to remain a ‘cottage industry’ fighting incorporation into larger systems of managed care and capitated payments that have permeated medical groups," she said, "our study found that both the dentist-to-population ratio and the average number patient care hours of dentists have been declining," Mertz said.

There are approximately 150,000 clinically active dentists in the United States. Although the number of dentists has been increasing for the past 20 years, the growth has leveled off in comparison to the growth in the U.S. population, resulting in a decreasing dentist-to-population ratio: 58.41 per 100,000 in 1996. (In 1990, there were nearly 60 dentists per 100,000 population.) The physician-to-patient ratio currently stands at 286 per 100,000, and between 1960 and 1998, the physician population grew by 198.6 percent. In addition, the dentist workforce is aging, and a good portion of them will reach retirement age in the next decade. There are fewer young dentists in practice and few dentists working past the age of 65.

In addition, the study found that gender, age, and racial composition of the dental workforce does not match that of the general population and is even more misaligned than the physician workforce. For instance, in a contrast of the racial composition of the U.S. population in 2000 with the dental and physician practice community and the entering dental and medical student population in 1999, the racial/ethnic distribution of the dental workforce is among the least diverse of health professions. Approximately 13 percent of dentists are nonwhite, compared to 22 percent of physicians and 28 percent of the population. African Americans, Hispanics, and Native Americans are generally considered to be underrepresented minorities in the health professions. Dentistry is made up of 6.8 percent underrepresented minorities compared to 8.5 percent of physicians and 24.8 percent of the population. First-year dental students in 1999 were 34 percent nonwhite. However, just 10.2 percent of the students in the entering class were underrepresented minorities. In medicine, 36 percent of the first-year students in 1998 were nonwhite and 14 percent were underrepresented minorities.

The study found that on average, 63.7 percent of patients are covered by private insurance, 5.7 percent by public insurance, and 30.6 percent are uninsured. In 1998, $53.8 billion in private money was spent on dental services, nearly 50 percent as out-of-pocket payments.

"Despite much recent activity at the federal level documenting disparities in oral health and access to care, we have found that the dental public health system provides little funding for prevention or oral health care of the underserved," said co-author Edward O’Neil, MPA, PhD, director of the UCSF Center for the Health Professions and professor of family and community medicine and dental public health.

The authors conclude that only by moving beyond the existing systems of finance, reorganizing systems of dental practice, and utilizing dental professionals in new and innovative ways will the system be able to address the unmet health needs of underserved populations. The UCSF study recommends the following alternatives:

* Expand alternative organization structures for providing care such as public dental clinics or through the use of dental vans and mobile dental services;

* Educate the underserved populations about new programs in oral health to boost participation in existing and new programs;

* Expand and integrate oral health care services within primary health care facilities to reach a broader population base;

* Develop a multidisciplinary approach to oral health through the use of the public health system professionals and social workers;

* Expand independent practice for hygienists and assistants;

* Develop new dental school strategies for recruitment and retention of professionals from the underserved communities;

* Focus more effort on program evaluation, concentrating on cost-effectiveness and patient outcomes.

Funding for the study was provided by the California HealthCare Foundation and the Bureau of Health Professions. For more information, visit the Web site for the UCSF Center for Health Professions at http://futurehealth.ucsf.edu.

Mammalian Teeth Successfully Regenerated

For the first time, researchers have been able to successfully regenerate teeth.

According to the October 2002 issue of the Journal of Dental Research, researchers from the Forsyth Institute found that when cells obtained from immature teeth of 6-month-old pigs were seeded onto biodegradable polymer scaffolds and placed in rat hosts, small, recognizable tooth crowns formed within 30 weeks.

The researchers are the first to report using dissociated tooth tissues (tooth buds enzymatically digested into single cells) combined with polymer scaffolding (a technique used to form a pattern for human tissues and organs) to regenerate teeth. Researchers from other laboratories had previously used alternative approaches to form partial tooth structures including dentin and pulp, but none had grown complete structures that included enamel.

The research also suggests the existence of dental stem cells, which could be key to bioengineering human teeth. "The ability to identify, isolate, and propagate dental stem cells to use in biological replacement tooth therapy has the potential to revolutionize dentistry," said Dominick P. DePaola, DDS, PhD, president and chief executive officer of the Forsyth Institute.

Scientists Identify Key Gene Involved in Cleft Lip and Palate

Scientists report in the October 2002 issue of Nature Genetics that they have discovered the gene that causes Van der Woude syndrome, the most common of the syndromic forms of cleft lip and palate.

The term "syndromic" means babies are born with cleft lip and palate, in addition to other birth defects.

According to the scientists, the discovery could direct them to genes involved in "nonsyndromic" cleft lip and palate, one of the most common birth defects in the world. Among Caucasians, nonsyndromic cleft lip and palate occurs in an estimated 1 in every 1,000 live births, and the frequency seems to be even higher in some Asian countries, such as China and the Philippines.

"Since there is so much clinical overlap between the two, we expect that similar genes and maybe even the same genes will be involved in the nonsyndromic form," said Jeff Murray, MD, a scientist at the University of Iowa and an author of the paper.

Murray noted that the gene, called IRF6, seems to play a key role in the normal formation of the lips, palate, skin, and genitalia. He said further study of the gene should provide precise molecular clues into normal human development and suggest specific biological strategies to prevent birth defects, such as cleft lip and palate.

First described in the 1860s, Van der Woude syndrome is involved in about 2 percent of all cases of cleft lip and palate, occurring in approximately 1 of every 33,000 live births. Children with the syndrome are born with any of four characteristic birth defects: Pits, or small indentations, in the lower lip; cleft lip; cleft palate; and undeveloped tooth buds.

The research was supported by the National Institute of Dental and Craniofacial Research.

Treating Oral Candidosis in Purview of Dental Professional

Dentists must be prepared to play a central role in the recognition, diagnosis, and treatment of oral candidosis, the most common fungal infection of the oral cavity, according to an article in Quintessence International, Vol. 33, No. 7, 2002.

Navy dental researchers report that dental practitioners must be familiar with antifungal treatment strategies and patient management guidelines.

Candidosis is caused by an overgrowth of the fungal organism Candida. Colonization by Candida in the oral cavity does not necessarily equate to infection, they said. Studies have shown that a significant proportion of healthy individuals continuously harbor Candida albicans.

Many factors can increase susceptibility to oral candidosis. They include immunosuppression, endocrinopathies, nutritional deficiencies, medications, malignancies, dental prostheses, epithelial alternations, salivary changes, a high-carbohydrate diet, age, poor oral hygiene, and a history of smoking.

Prompt treatment of candidosis with an appropriate antifungal agent can eliminate infection, prevent systemic dissemination, and prevent potentially debilitating sequelae.

The diagnosis of oral candidosis is often based on clinical signs and symptoms and can be supported by adjunctive tests such a exfoliative cytology, biopsy, and culture.

According to the article, oral candidosis is often asymptomatic, but patients may periodically describe a burning sensation, dyphasis, or an altered sense of taste.

The primary line of treatment of mild, localized oral candidosis usually consists of topical antifungal therapy. Systemic antifungal agents are generally reserved to treat severe, localized, disseminated oral candidosis or infections in immunosuppressed individuals.

Therapeutic management should be based on the patient’s medical history, clinical presentation, and symptoms, the researchers said. Practitioners must monitor the patient’s response to antifungal therapy, educate the patient to improve treatment compliance, and provide appropriate follow-up to maximize therapeutic effectiveness.

Watch Out for Seven Deadly Leadership Sins, Experts Warn

The greatest investment dentists will make in their practices will be the investments made in their dental teams, said Steve Anderson and Walter Hailey in Dental Practice Management, summer 2002.

There are some basic rules to follow that will create the best environment in which a team can succeed, they said; and the best way to relate to the rules is to be aware of the sins that make the rules necessary.

Sin No. 1: No vision. Most dental teams get their motivation and enthusiasm from the hope that problems will be addressed or that their personal situation will improve. But without a clear vision, this hope does not exist.

Sin No. 2: No accountability. The authors said this is a common complaint of dental team members. Definitive solutions to problems must be reached, and someone must be given the specific assignment to carry out the decision.

Sin No. 3: No recognition. According to the authors, this ranks as the biggest complaint team members have about their dentist. Anderson and Hailey say that even simple things such as a kind word, a short note, or a quick thank you can build loyalty and harmony.

Sin No. 4. Too much control. A common complaint of team members is that they wish the dentist would get out of the way and let them do what they know how to do. Anderson and Hailey said that, as consummate perfectionists, most dentist think they have to manage and look over every detail in the office with as much attention as they give to doing a crown prep.

Sin No. 5: No open ears. Anderson and Hailey said that according to a recent survey of loyal team members who had been with the same office for 10 years or more, one of the consistent factors that contributed to employees’ longevity was the feeling they had that the leaders in the practice listened to them and that their opinions mattered.

Sin No. 6: Gossip. It crops up everywhere unless there’s a way to control it. Gossip can tear an office apart. The authors said the solution is easy: Make sure all team members agree to take all problems back to the source. If an employee has a problem with another person, it should be his or her responsibility to go to that person and get it resolved.

Sin No. 7: Bad attitudes. The authors said that it is a lot easier to hire people with great attitudes and train them in the needed technical skills. But if some employees have attitude problems, the solution is to clarify what is expected. They said, too, that dentists should lead by example, not asking their dental team to do anything they are not willing to do themselves.

Antidepressant Shows Results in Helping Spit Tobacco Users Quit

An antidepressant that has been shown to help smokers quit may also prove effective in helping spit tobacco users kick their habit, according to preliminary research results from the Mayo Clinic.

In a study of 68 spit tobacco users randomly assigned to take either bupropion or a placebo for 12 weeks to aid in quitting their habits, 44 percent of the bupropion group were still abstinent at the 12-week mark, compared to 26 percent of the placebo group.

In addition to finding greater success in cessation, participants who took bupropion gained less weight -- an average of 1.54 pounds -- during the 12 weeks than those who took the placebo, who averaged 9.7 pounds.

However, the researchers said that spit tobacco users may benefit from talking bupropion longer than 12 weeks, since abstinence rates for both groups were even, at about 29 percent, at a 24-week follow-up.

"The results are good news for spit tobacco users trying to quit," said Lowell Dale, MD, a Mayo Clinic specialist in nicotine dependence and lead researcher on the study. "None of the other agents that help smokers quit -- patches and gum -- have been shown to be as effective for spit tobacco users."

The Mayo Nicotine Research Center plans to launch a large double-blind study on bupropion for spit tobacco users.

Occlusal Vertical Dimension on Face Height Not Visually Distinguishable

Attempts to alter face height by changing the occlusal vertical dimension may not produce visually distinguishable results, reports a study in the International Journal of Prosthodontics, Vol. 15. No. 4.

Researchers at the Department of Prosthodontics, Tel Aviv University, Israel, evaluated the effect of increasing occlusal vertical dimension on 22 young adults. A common belief in fixed and removable prosthodontics, they said, is that an increase or decrease in the occlusion vertical dimension significantly affects the lower face height and facial esthetics. Some believe that an altered occlusal vertical dimension can improve dentofacial esthetics and create improved visual proportions in facial height.

The researchers photographed the 22 subjects in a standardized manner in an anterior view. Sequential photographs were taken at the intercuspation and clinical rest positions, with four complete-arch maxillary occlusal overlays increasing occlusal vertical dimension in interincisal increments of 2, 4, 6 and 8 mm.

Objective measurements were made from the photographs using facial reference markers. Ten observers made subjective evaluations of the resulting changes in face height using the sequential photographs randomly presented.

Measurements of the facial markers showed that, on increasing occlusal vertical dimension, a corresponding change in lower face height was 50 percent of the interincisal increase in intercuspation and 40 percent for the clinical rest position. Analysis of variance for repeated measures showed a statistically significant effect of the intraoral increase in occlusal vertical dimension on lower face height. However, the researchers noted, subjective results showed that observers were not capable of detecting changes in face height caused by an intraoral increase in occlusal vertical dimension (2 to 6 mm intrinsically). ANOVA for the difference between dentists and nondentists showed a minimal, but significant, difference between the two groups with dentists erring slightly less.

The researchers noted that the findings of their study apply to young adults. Changes in older patients may be more apparent because of aging-induced soft-tissue alterations. Their findings indicate that changes in vertical dimension in fixed prosthodontics within the range of 2 to 6 mm are unlikely to cause visually apparent changes in the soft tissue face height in the range of normal vertical dimension.

Study Shows Caries in Primary Teeth Predict Future Decay

Children with tooth decay in their primary dentition are nearly three times more likely to have decay in their permanent teeth, according to an eight-year study conducted in China.

In 362 Chinese children age 3 to 5 years at the time of the 1992 baseline study, 85 percent who had had caries in their primary molars showed at least one decayed permanent tooth in a follow-up examination in 2000. In contrast, 83 percent of the children who exhibited no caries in their primary teeth remained decay-free until at least age 12.

The authors of the study suggest that children with caries in their primary dentition should be considered high-risk cases for decay in permanent teeth, increasing the importance of dental sealants and fluoride treatments for decay prevention.

The recommendation is consistent with a recent recommendation from the Centers for Disease Control and Prevention calling for broader community efforts to reduce tooth decay by extending water fluoridation and dental sealants to more children and adults.

The results of the Chinese study were published in the August 2002 issue of the Journal of Dental Research.

Honors

Donald S. Clem, III, DDS, of Fullerton, Calif., has been elected president of the American Academy of Periodontology Foundation.

Paulo M. Camargo, DDS, of Los Angeles, has been named the 2002 recipient of the Bud and Linda Tarrson Fellowship by the American Academy of Periodontology Foundation.

The California Association of Orthodontists has selected Arthur A. Dugoni, DDS, MSD, dean of the University of the Pacific School of Dentistry, as the recipient of its 2002 Distinguished Service Award.

Upcoming Meetings

2003

Jan. 23-25 Metropolitan Denver Dental Society’s Rocky Mountain Dental Convention, Denver, (800) 637-6337, www.rmdconline.com.

Feb. 5-8 American Academy of Dental Group Practice Annual Conference and Exhibition, Miami, (602) 381-1185, www.aadgp.org.

March 5-8 Academy of Laser Dentistry 10th Annual Conference and Exhibition, Destin, Fla., (954) 346-3776, www.laserdentistry.org.

April 24-27 CDA Spring Scientific Session, Anaheim, Calif., (916) 443-3382, Ext. 4470.

April 29-May 4 19th Annual American Academy of Cosmetic Dentistry Scientific Session, Orlando, Fla., (800) 543-9220, www.aacd.com.

June 19-22 OSAP 2003 Symposium, Tucson, Ariz., 800-298-OSAP.

Oct. 25-29, ADA Annual Session, San Francisco, (312) 440-2500.

2004

April 15-18 CDA Spring Scientific Session, Anaheim, Calif., (916) 443-3382, Ext. 4470.

Sept. 8-11 International Federation of Endodontic Associations Sixth Endodontic World Congress, Brisbane, Queensland, Australia, www.ifea2004.im.com.au.

Sept. 10-12 CDA Fall Scientific Session, San Francisco, (916) 443-3382, Ext. 4470.

Sept. 30-Oct. 3 ADA Annual Session, Orlando, Fla., (312) 440-2500.

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.