Oral Care repOrt

Need to Reduce the Number

of Antibiotic Prescriptions
T

he development of antibiotics marked

a dramatic advance in the management of
infectious diseases, and one of the most
important advances in modern medicine.
Antibiotics greatly reduced the morbidity and
mortality rates associated with bacterial infections. Nevertheless, over the past 75 years,
the extensive use of antibiotics has resulted
in the emergence of microorganisms that
are resistant to most, if not all, of the major
antibiotics. Further, the development of secondary infections, which represents the overgrowth of other pathogenic microorganisms,
can be life threatening.1
This situation is due in large part to overprescribing of antibiotics in clinical practice
as well as other uses of antibiotics, including
increasing the growth of livestock. A recent
report from the Centers for Disease Control
and Prevention indicates that one third of
the antibiotic prescriptions written by medical providers in outpatient settings were
unnecessary.2 While antibiotic usage by physicians is declining, a disturbing trend is an
apparent increase in antibiotic prescriptions
by dentists.3,4 This practice must be evaluated and corrective action taken. Dentists must
have current knowledge on the appropriate
use of antibiotics.5,6

Antibiotic Prescribing by
Dentists
In the United States, antibiotic prescribing in dentistry represents around 10%
of the total prescribed annually,7 10% of
the total in Spain, and 9% of the total in
Scotland.8,9 In the Czech Republic, dentists
were responsible for 8.5% of all antibiotics
prescribed in 2012 compared with 6.5% in
2006.4 Further, in British Columbia the proportion written by dentists represented
11.3% of the total in 2013 versus 6.7% in
1996; a 62.2% increase.3 In contrast, physicians prescriptions in the same period
decreased by 18.2%.3

Of further concern, more broad-spectrum antibiotics are being prescribed by dentistspredominantly the amoxicillin group
and fewer narrow-spectrum drugs (e.g., penicillin V).10-15 Broad-spectrum antibiotics are
well recognized for an increased risk of antimicrobial resistance.5 In a 2009 survey in the
United States (n = 845), amoxicillin was the
first choice for 37.6% of responding dentists
in 2009 (in the absence of an allergy), up from
27.5% in 1999. In the same period, penicillin
was the first choice for 43.3% in 2009, down
from 61.5% in 1999.10 In the Czech Republic,
amoxicillin with clavulanic acid (Augmentin)
accounted for 31.4% of antibiotics prescribed
by dentists in 2012 compared with 23.1% in
2006, and 19% of all antibiotics used in primary care.4 Similar trends are observed in
other countries3,11-16 (see table on next page).
In addition to the increased use of amoxicillin, the number of unnecessary prescriptions written by dentists for clindamycin and
cephalosporins is of concern, given their association with Clostridium difficile-associated disease (i.e., pseudomembranous colitis).1

Inappropriate Prescribing
Inappropriate antibiotic prescribing by
dentists has been reported for dry sockets,
third molar extractions, localized swelling,
and periodontal and endodontic treatment.3,5,17
In one retrospective chart review, 70% of antibiotic prescriptions were inappropriate, the
majority given for acute pulpitis.5 Antibiotics
are not required for most properly managed
endodontic infections.18 Routine use of antibiotics is not required for apical periodontitis
(AP), chronic/acute apical abscesses (CAA/
AAA),18 and clearly not indicated for irreversible pulpitis (IP). Antibiotics should be
prescribed when there is diffuse facial swelling
or systemic involvement (fever, malaise, lymphadenopathy),10,18 and when indicated by a
patients medical status.18
Click here to continue to next page

In This Issue
Need to Reduce the Number of
Antibiotic Prescriptions

CLINICAL PRACTICE - Diagnosis of

Acute Endodontic Lesions

TECHNOLOGY - Fixed Orthodontic

Appliances or Clear
Aligner Treatment
5
DENTISTRY AND HEALTH CARE Obesity and Periodontitis

PREVENTIVE DENTISTRY Dental Management of

Patients with Autism

HEALTHCARE TRENDS Methamphetamine Abuse and the

Role for the Dental Profession
11

Educational Objectives
After reading this issue of the Colgate
Oral Care Report and correctly answering the questions in the Continuing
Education Quiz, you will
1. understand the problems associated
with antibiotic over-prescribing and
see the necessity for practicing good
antibiotic stewardship;
2. learn the latest techniques designed
to assist dental professionals in
determining the diagnosis of pain of
endodontic origin;
3. become familiar with the relative
benefits of clear retainer-like appliances vs. brackets and arch wires
for certain orthodontic treatments;
4. know the latest evidence supporting
obesity as a risk factor for periodontal disease; and
5. recognize the challenges associated
with treating autistic patients and
the suggested means to provide
effective care.

Volume 26, Number 3, 2016

Providing Continuing Education as a Service to Dentistry Worldwide

Oral Care repOrt

2
Antibiotic Prescribing by Dentists4,10-15
2004

Belgium

75.1% of prescriptions were amoxicillin or amoxicillin with

clavulanic acid

2009

Spain

1st choice amoxicillin for 44.3%, amoxicillin with clavulanic

acid for 41.8%

2009

USA

1st choice penicillin VK for 43.3%, amoxicillin for 41.2%

2010

Spain

1st choice amoxicillion with clavulanic acid for 61%,

amoxicillin for 34%

2012

Czech Rep.

31.4% prescribed amoxicillin with clavulanic acid (Augmentin)

2013

Jordan

62.9% most often prescribed amoxicillin, 33.4% amoxicillin

combinations (with clavulanic acid and/or metronidazole)

2013

Turkey

61.8% often prescribed amoxicillin with clavulanic acid,

46.5% amoxicillin

2015

Saudi Arabia

45.2% prescribed amoxicillin with clavulanic acid,

33.7% amoxicillin and 15% amoxicillin with metronidazole

In one retrospective chart review,

70% of antibiotic prescriptions
were inappropriate, the majority
given for acute pulpitis.
Nonetheless, prescribing antibiotics for
endodontic conditions is a widespread practice. Inappropriate prescribing is reported
for IP, acute apical periodontitis (AAP), chronic apical periodontitis, AAA, and other conditions.3-5,8,10,11-15 Antibiotic prescribing for AAP
(with no swelling) was reported by 28.3%,
59%, and 71% of clinicians in surveys from
the United States, Saudi Arabia, and Spain,
respectively10,12,15 (see figure).

Percentage of clinicians prescribing

antibiotics for AAP (no swelling)
28%
59%
71%

n United States n Saudi Arabia n Spain

Antibiotics are also prescribed to manage endodontic flare-ups10 and to relieve pain
between treatments,10 yet there is no evidence
to support this practice.3 Furthermore, they
are given in lieu of proper treatment;5,10,14 an
antibiotic prescription without any definitive
treatment was provided to 54% of patients
receiving care in an after-hours dental clinic.19 In other research, differences in the pat-

tern of antibiotic use have resulted in significant differences in the level of antibiotic resistance, with one study finding increased antimicrobial resistance for periodontal pathogens.20

The most important initial

decision is not which antibiotic to
prescribe, but whether to use one
at all.
Other Factors
Additional reasons given for inappropriate prescribing include the need to delay definitive treatment, an uncertain diagnosis, the need
to avoid problems if the patient/clinician will
be on vacation, and lack of resources to pay
for care (no dental insurance).10,11,21 Excessive
antibiotic prescribing may also be associated
with the increase in implant treatment and associated complications, and with routine extraction of third molars.3
Patient expectations are a driver.10,11,21 In separate patient and dentist surveys in the UK, 23%
of patients (n = 156) expected an antibiotic and
8% of dentists reported being influenced by such
expectations.21 In the United States, 19% of clinicians gave antibiotics if patients asked for them,
or out of fear of losing referrals if requested by
the referring dentist.10

Patient expectations are a driver

for over-prescribing of antibiotics
by dentists.

Lack of awareness and knowledge of current guidelines and an unwillingness to change

are additional factors in antibiotic over-prescribing by dental professionals. Furthermore,
differences between past and current guidelines (e.g., regarding antibiotic prophylaxis,
lack of clarity, and minor differences between
sets of guidelines) may result in confusion.18,21
As an example, revised guidelines were provided by the American Dental Association on
antibiotic prophylaxis for patients with prosthetic joints and for prophylaxis against infective endocarditis.22 In contrast to prior recommendations, there are now relatively few
patient subpopulations for whom antibiotic
prophylaxis may be indicated prior to certain
dental procedures.22

Current Guidelines and

Antibiotic Stewardship
Antimicrobial stewardship programs are
intended to optimize the use of antimicrobials through appropriate use, dosing, duration, and selection.23 Guidelines include (1)
prescribing the shortest effective dose; (2)
only prescribing when necessary and providing a delayed prescription that a patient can
fill later if needed; (3) discussing alternatives
with patients and educating them about antibiotic use and risks; (4) avoiding repeat prescriptions whenever possible; and (5) auditing healthcare facilities for antibiotic prescribing patterns.24

Improving Antibiotic
Stewardship
A concerted effort is required to improve
antibiotic prescribing. In a review of interventions with providers, there was moderate evidence supporting communication skill training.23 The evidence for effectiveness of provider
or patient education, guidelines, delayed prescribing, and computer-aided decision making was weak. However, the relative efficacy of
individual interventions was not provided in
most studies where several were used.23 In a
separate review, the most effective outcome
was achieved using a combination of interventions involving providers, patients, and the public.25 Interactive educational meetings were
found to be more effective than didactic ones,
and patient education was also effective. Printed
educational materials or audit/feedback alone
were of limited value.24
Intensive training has proven effective
in changing prescribing behaviors, at least in
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Oral Care repOrt

the short term. In one prospective two-cycle
audit of 60 patients, clinicians and students
received intensive training between the audits,
which were held two months apart. Significant
improvements in prescribing were observed,
with 80% of antibiotic prescriptions meeting
the guidelines versus 30% at the first audit.5
Research-based audit and feedback mechanisms are now being investigated in a clustered, randomized, stratified trial. The control group is the audit group, while each dentist in the intervention group received
individualized feedback regarding his/her
antibiotic prescribing rate for the prior 14
months. Some dentists also received feedback
at 9 months, text-based interventions, and a comparator. This trial will provide further information on interventions and their efficacy.9
Computer-aided clinical decision making also shows promise as a guide for improved
antibiotic prescribing.26 In five of seven randomized or cluster randomized trials, a statistically significant improvement in antibiotic prescribing was observed using this tool;
greater improvements were observed when
computer-aided clinical decision making was
used. More research is required to determine
which aspects of computer-aided clinical decision making would best drive appropriate
antibiotic prescribing.26

3
3.

4.

5.

6.

7.

8.

9.

Conclusions
Over-prescribing of antibiotics by dentists is observed globally, including both the
clinical scenario and selection of an inappropriate drug or dose. Recent studies are helping to determine required changes and which
interventions will be most effective. In order
to combat antimicrobial resistance, it is essential that dental professionals understand and
adhere to the guidelines for antibiotic use and
practice good antibiotic stewardship. O
C

10.

References

12.

1.

2.

Beacher N, Sweeney MP, Bagg J. Dentists,

antibiotics and Clostridium difficile-associated disease. Br Dent J 2015;219:275-9.
Fleming-Dutra KE, Hersh AL, Shapiro DJ,
Bartoces M, Enns EA, File TM, Jr., Finkelstein
JA, Gerber JS, Hyun DY, Linder JA, Lynfield
R, Margolis DJ, May LS, Merenstein D, Metlay
JP, Newland JG, Piccirillo JF, Roberts RM,
Sanchez GV, Suda KJ, Thomas A, Woo TM,
Zetts RM, Hicks LA. Prevalence of inappropriate antibiotic prescriptions among US
ambulatory care visits, 2010-2011. J Am Med
Assoc 2016;315:1864-73.

11.

13.

14.

15.

Marra F, George D, Chong M, Sutherland S,

Patrick DM. Antibiotic prescribing by dentists has increased: Why? J Am Dent Assoc
2016;147:320-7.
Pipalova R, Vlcek J, Slezak R. The trends in
antibiotic use by general dental practitioners in the Czech Republic (2006-2012). Int
Dent J 2014;64:138-43.
Chopra R, Merali R, Paolinelis G, Kwok J. An
audit of antimicrobial prescribing in an acute
dental care department. Prim Dent J 2014;
3:24-9.
Johnson TM, Hawkes J. Awareness of antibiotic prescribing and resistance in primary dental care. Prim Dent J 2014;3:44-7.
Cherry WR, Lee JY, Shugars DA, White Jr. RP,
Vann Jr. WF. Antibiotic use for treating dental infections in children: a survey of dentists
prescribing practices. J Am Dent Assoc
2012;143:31-8.
Robles Raya P, de Frutos Echaniz E, Moreno
Milln N, Mas Casals A, Snchez Callejas A,
Morat Agust ML. Im going to the dentist:
antibiotic as a prevention or as a treatment?
Aten Primaria 2013;45:216-21.
Prior M, Elouafkaoui P, Elders A, Young L,
Duncan EM, Newlands R, et al. Evaluating
an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol. Implement Sci 2014;9:50.
Pye K. Antibiotic Use by Members of the
American Association of Endodontics: A
National Survey for 2009. A follow up from
the report in 1999. Available at: http://scholarscompass.vcu.edu.
Dar-Odeh NS, Al-Abdalla M, Al-Shayyab MH,
Obeidat H, Obeidat L, Abu Kar M, AbuHammad OA. Prescribing antibiotics for pediatric dental patients in Jordan; knowledge
and attitudes of dentists. Int Arabic J Antimicrob
Agents 2013;3(4):1-6.
Iqbal A. The attitudes of dentists towards the
prescription of antibiotics during endodontic treatment in North of Saudi Arabia. J Clin
Diagn Res 2015;9:ZC82-4.
Mainjot A, DHoore W, Vanheusden A, Van
Nieuwenhuysen JP. Antibiotic prescribing in
dental practice in Belgium. Int Endod J
2009;42(12):1112-7.
Kaptan RF, Haznedaroglu F, Basturk FB,
Kayahan MB. Treatment approaches and
antibiotic use for emergency dental treatment
in Turkey. Ther Clin Risk Manag 2013;9:
443-9.
Segura-Egea JJ, Velasco-Ortega E, Torres-

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

Lagares D, Velasco-Ponferrada MC, MonsalveGuil L, Llamas-Carreras JM. Pattern of antibiotic prescription in the management of
endodontic infections amongst Spanish oral
surgeons. Int Endod J 2010;43(4):342-50.
Rodriguez-Nez A, Cisneros-Cabello R,
Velasco-Ortega E, Llamas-Carreras JM, TrresLagares D, Segura-Egea JJ. Antibiotic use by
members of the Spanish Endodontic Society.
J Endod 2009;35(9):1198-203.
Jaunay T, Sambrook P, Goss A. Antibiotic prescribing practices by South Australian general dental practitioners. Aust Dent J
2000;45:(3):179-86.
American Association of Endodontists.
Endodontics: Colleagues for excellence. Use
and abuse of antibiotics. Winter 2012.
Tulip DE, Palmer NO. A retrospective investigation of the clinical management of patients
attending an out of hours dental clinic in
Merseyside under the new NHS dental contract. Br Dent J 2008;205(12):659-64.
Ardila CM, Granada MI, Guzmn IC.
Antibiotic resistance of subgingival species
in chronic periodontitis patients. J Periodontal
Res 2010;45(4):557-63.
Cope AL, Chestnutt IG. Inappropriate prescribing of antibiotics in primary dental care:
reasons and resolutions. Prim Dent J
2014;3(4):33-7.
American Dental Association. Antibiotic
prophylaxis prior to dental procedures.
Available at: http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis.
Drekonja DM, Filice GA, Greer N, Olson A,
MacDonald R, Rutks I, Wilt TJ. Antimicrobial
stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol
2015;36:142-52.
National Center for Biotechnology
Information, U.S. National Library of
Medicine. Guidelines set to tackle over-prescribing of antibiotics. 2015. Available from:
http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2015-0818-guidelines-set-to-tackle-over-prescribing-ofantibiotics/.
Arnold SR, Straus SE. Interventions to
improve antibiotic prescribing practices in
ambulatory care. Evid Based Child Health
2006;623-690.
Holstiege J, Mathes T, Pieper D. Effects of
computer-aided clinical decision support systems in improving antibiotic prescribing by
primary care providers: a systematic review.
J Am Informatics Assoc 2015;22:236-42.

Oral Care repOrt

CLINICAL PRACTICE
Diagnosis of Acute Endodontic Lesions
One of the most challenging aspects of
clinical dentistry is the accurate diagnosis of
acute pain, often due to endodontic involvement. Typically, the diagnosis of pain of
endodontic origin relies on clinical symptoms,
some simple physical tests, and radiographic
findings. These alone may not; however, accurately provide a diagnosis. Acute apical abscesses (AAA) are usually obvious, however a definitive diagnosis of symptomatic apical periodontitis (SAP) and/or of symptomatic irreversible pulpitis (SIP) for a tooth can be difficult when relying on clinical symptoms, basic
physical tests, and radiography.
New approaches have also been introduced to improve the accuracy of diagnosis
of endodontic lesions. These include ultrasound imaging and color Doppler (USCD),1,2
as well as cone beam computed tomography
(CBCT)3. These too have their limitations,1,4
including the static nature of the information obtained. As acute, emergent situations
are often stressful for both the provider and
patient, a decision tree has been introduced
to help guide the clinician to the proper
endodontic diagnosis.5 Use of the decision
tree is a dynamic approach to diagnosis.

CBCT
CBCT provides images free of distortion
and without the possibility of superimposition that is inherent for PAs.4 In a recent study
(n = 130) comparing the diagnosed prevalence of SAP and asymptomatic AP in 307
paired roots representing 138 teeth,11 AP
lesions were observed in 3.3% and 13.7% of
roots when using PAs and CBCT, respectively (p < 0.05). A greater number of lesions was
observed for SAP vs. asymptomatic AP using
CBCT, and 22 affected roots were identified
that were not detected on PAs.11 In another
study involving 340 paired roots of 161 teeth,
15 previously unidentified affected roots were
found using CBCT.8
In comparing the accuracy of CBCT and
PAs in detecting root anatomy and anomalies
in 250 roots, as referenced to the benchmark
(transverse sections of teeth; TS), significantly more root canals were identified with CBCT
(294 of 295 vs. 230 of 295 with PAs; see Figure
1).4 Additionally, CBCT detected 10 of 16 accessory canals (with no false positives) and 4 of
5 transverse fractures.4 The quality of CBCT
is, however, impacted by metallic restorations,
pins, and root fillings.4

Radiographs
Peri-apical radiographs (PAs) are standard practice when assessing acute dental pain,
and treatment is often based on the observed
findings. Digital radiography permits rapid
acquisition and manipulation of images,
including magnification and digital subtraction applications.6 However, since PAs are twodimensional, not all details are visible. PAs
may not detect early periapical changes associated with SAP, appearing normal or only
showing a thickening of the periodontal ligament.7 In one study, PAs detected periapical radiolucencies in just 15% of roots in teeth
with SAP.8 In addition, PAs usually detect periapical lesions only after the cortical plate has
been perforated.9

PAs may not detect early

periapical changes associated
with SAP, appearing normal or
only showing a thickening of the
periodontal ligament.
USCD
Ultrasound technology allows threedimensional (3D) visualization of structures
deep within the tissues.2 The diagnostic capabilities of ultrasound are enhanced by color
Doppler technology, which detects and measures blood flow in the tissues.10 Studies have
compared the sensitivity, specificity, and accuracy of USCD and PAs in the differential diagnosis of periapical granulomatous, cystic, and
mixed lesions, and to track post-surgical healing. Results from these studies have been
promising, with one (n = 30) finding 100%
concurrence in a diagnosis of anterior granulomatous lesions (n = 16) with USCD and
the histology gold standard.2
Nonetheless, there is currently a paucity
of USCD data for SAP. In addition, in comparing USCD with PAs and histology samples
from periapical lesions in anterior, bicuspid,
and molar teeth (n = 30),1 USCD was found
to be accurate only when the mean bone thickness was < 1.6 mm (p = 0.03).1 This limits the
potential use of this technique to areas where
cortical bone is thinner, such as the anterior
maxilla.

230
294
295

n PAs n CBCT n Transverse Sections

Figure 1. Number of root canals identified by different

diagnostic techniques.4

Diagnosis Using a
Decision Tree
In a recent study involving patients with
a chief complaint of acute severe dental pain
(n = 221), a decision tree was developed as
an aid to diagnosis.5 The study included 103
patients diagnosed with SAP and 70 diagnosed
with SIP. During development of the decision
tree, the clinical signs and findings and a
checklist with 11 questions on symptoms were
used to identify differentiators for SIP and
SAP. A numeric assessment of the level of pain
in the prior 24 hours (with 0 being no pain
and 10 being the worst pain imaginable) was
included.5
Clinical findings used to differentiate SIP
and SAP included sensitivity to cold using carbon dioxide ice, and the identification of a
widened periodontal ligament on PAs.
However, since PAs may or may not show a
widened periodontal ligament space with SAP,
this is not definitive, and early radiolucencies may also not be apparent.
Of teeth with a pain response to cold,
duration of pain < 1 week and that felt high,
72% were correctly determined to have SAP
(Figure 2). Non-differentiators included the
level, constancy, and reduction of pain spontaneously or upon application of cold,
response to heat, the presence of a sharp or
radiating pain, pain on chewing, and sleep
disturbance. It was determined that the deci69.9%

75.7%

n SIP

45.7%
35.9%

Pain
< 1 Week

Pain
on Cold

n SAP
48.5%

28.6%

Tooth
Felt High

Figure 2. Frequency of a positive response to differentiators

for SIP and SAP.5

sion tree had a positive predictive value of 67%,

though specificity was only 31%.5 This means
that there was a 67% chance that the individual had the condition, but also a high risk of
false negative findings.

Conclusions
The ability to differentiate endodontic
lesions is necessary for an accurate diagnosis
and subsequent treatment. Not only can AAA
develop rapidly, the emergency treatment for
SIP and SAP differ (pulpotomy vs. pulpectomy). Therefore, an accurate definitive diagnosis for SIP and SAP is clinically important.
Currently, there is a paucity of data for
USCD with respect to SIP and SAP. Data on
CBCT is promising, although now limited.
The decision tree described in this article is
an innovation in clinical care. While not a
perfect tool, it provides a logical approach
to arriving at the diagnosis of pain of
endodontic origin. O
C

References
1.

Tikku AP, Bharti R, Sharma N, Chandra A,

Kumar A, Kumar S. Role of ultrasound and
color doppler in diagnosis of periapical lesions
of endodontic origin at varying bone thickness. J Cons Dent 2016;19(2):147-51.
2. Sandhu SS, Singh S, Arora S, Sandhu AK,
Dhingra R. Comparative evaluation of
advanced and conventional diagnostic aids
for endodontic management of periapical
lesions, an in vivo study. J Clin Diagn Res
2015;9(1):ZC01-4.
3. Leonardi Dutra K, Haas L, Porporatti AL,
Flores-Mir C, Nascimento Santos
Mezzomo LA, Correa M, De Luca Canto G.
Diagnostic accuracy of cone-beam computed tomography and conventional radiography on apical periodontitis: a systematic review
and meta-analysis. J Endod 2016;42(3):
356-64.
4. Weber MT, Stratz N, Fleiner J, Schulze D,
Hannig C. Possibilities and limits of imaging
endodontic structures with CBCT. Swiss Dent J
2015;125(3):293-311.
5. Rechenberg DK, Held U, Burgstaller JM,
Bosch G, Attin T. Pain levels and typical symptoms of acute endodontic infections: a
prospective, observational study. BMC Oral
Health 2016;16(1):61.
6. Carvalho FB, Gonalves M, Tanomaro-Filho
M. Evaluation of chronic periapical lesions
by digital subtraction radiography by using
Adobe Photoshop CS: a technical report. J
Endod 2007;33:493-7.
7. Gutmann JL, Baumgartner JC, Gluskin AH,
Hartwell GR, Walton RE. Identify and define
all diagnostic terms for periapical/periradicular health and disease states. J Endod
2009;35(12):1658-74.
8. Abella F, Patel S, Durn-Sindreu F, Mercad
M, Bueno R, Roig M. An evaluation of the
periapical status of teeth with necrotic pulps
using periapical radiography and cone-beam
computed tomography. Int Endod J
2014;47(4):387-96.
9. Bender IB, Seltzer S. Roentgenographic and
direct observation of experimental lesions
in bone. J Am Dent Assoc 1961;62:708.
10. Patel S, Dawood A, Whaites E, Pitt Ford T.
New dimensions in endodontic imaging: Part
1. Conventional and alternative radiographic systems. Int Endod J 2009;42:447-62.
11. Abella F, Patel S, Duran-Sindreu F, Mercad
M, Bueno R, Roig M. Evaluating the periapical status of teeth with irreversible pulpitis
by using cone-beam computed tomography
scanning and periapical radiographs. J Endod
2012;38(12):1588-91.

Oral Care repOrt

TECHNOLOGY
Fixed Orthodontic Appliances or Clear Aligner Treatment
Clear Aligner Treatment (CAT) was
introduced commercially approximately 15
years ago, and represents an alternative to traditional orthodontic tooth movement with a
fixed orthodontic appliance (FOA).1 Utilizing
a series of clear retainer-like appliances that
move the teeth in a sequential fashion, CAT
represents a major change in orthodontic care,
with more than 3 million patients having been
treated across the globe.2 CAT involves the
application of three-dimensional digital technology to dentistry, and represents another
aspect in the evolution of clinical practice.
Many types of malocclusion have now been
treated using CAT, including, but not limited to, maxillary and mandibular incisor crowding, tooth rotations, and class I, II, and III malocclusions.1,3-7 CAT offers some distinct advantages, as well as some limitations.8

Advantages of CAT
The advantages of CAT compared to FOA
include better esthetics during treatment, the
ability to more easily perform oral hygiene
since the aligners are removable, and an
absence of plaque traps (brackets and arch
wires). The result is improved oral health during orthodontic treatment.9-12

Oral Health-Related
Quality of Life (OHRQoL)
OHRQoL is a subjective assessment by
the patient of his/her perceived well-being
related to the oral cavity.13 In a study of 100
patients receiving CAT or FOA for a mean
duration of slightly over one year,9 6% of CAT
and 36% of FOA patients perceived a decline
in well-being. Statistically significant
differences were observed for willingness to
laugh (p = 0.012), impact on eating habits
(p = 0.066), and gingival irritation (p = 0.001).
Just 2% of patients receiving CAT said they
would be unwilling to have the same treatment
again vs. 22% of patients receiving FOA
(p = 0.004; see Figure 1).9
Would have
treatment again

78%
98%

Impact on
eating habits
Gingival
irritation

70%
50%
56%
14%

Reluctant
to laugh

6%

Decline in
well-being

6%

26%
36%

n FOA

n CAT

Figure 1. Subjective assessment of factors affecting OHRQoL.9

In a systematic review of 11 studies, the

first few weeks of wearing an FOA negatively
impacted OHRQoL, which then partially

rebounded. The most significant influence

on OHRQoL was pain.13 Ultimately, OHRQoL
was higher post- than pre-treatment. In one
FOA study, 91% of patients reported pain,
some citing it as a reason for wanting to end
treatment.14

98% of patients receiving CAT

said they would be willing to have
the same treatment again versus
78% of patients receiving FOA.
In a separate study, less intense and shorter duration of pain was experienced by patients
receiving CAT (n = 38) than FOA for edgewise treatment (n = 55), or a combination of
an FOA and then CAT (n = 52). For patients
receiving CAT who complained of pain, it was
usually due to tray deformation.15

Efficacy of FOA and CAT

The objective of orthodontic treatment
is to have esthetically pleasing and functional outcomes, usually with an ideal occlusion.
FOAs are effective in correcting malocclusions, and offer high success rates.16 However,
results vary depending on the malocclusion
and its severity, treatment provided, and
patient compliance.1,5,16 Open bites17 and molar
distalization, with movement of the upper
molars posteriorly to create space,18 present
treatment challenges. Relatively minor treatment differences may also influence outcomes;
for instance, FOA arch wire, sequencing, and
twisting of arch wire within the slots in the
brackets.5,19
Studies have compared actual and predicted tooth movement to measure orthodontic outcomes for CAT and FOA. For lower
anterior crowding, in one study a mean difference of 0.01 mm was observed for actual
and predicted tooth movement with CAT. The
only observed statistically significant difference was for overbite, with a mean difference
of 0.7 mm.20 Buccal expansion along with interproximal reduction (IPR) was determined
to be effective for mandibular crowding of
< 6 mm in a chart review of CAT (n = 61),
although more severe crowding resulted in
proclined and protruded lower incisors.3
Using superimposed digital images, no
statistically significant differences were found
for the same teeth for upper and lower arches in another study comparing actual vs. predicted tooth movements (n=37).21 However,
the accuracy of movements for different teeth
varied, e.g., derotation for canines was significantly less predictable than for lower central
incisors (Figure 2).21

54.2%

54.8%

59.3%

32.2%

Rotation
upper
canines

Rotation
upper
central
incisors

Lingual
Lingual
constriction constriction
lower
lower
laterals
canines

Figure 2. Mean accuracy of actual vs. predicted tooth

movements using CAT.21

There have been a number of small heterogeneous studies that assessed the efficacy
of CAT.1 A systematic review of 11 studies from
2000 to June 2014 has been published.1 CAT
was found to be as effective as FOA for the
control of vertical buccal occlusion and anterior intrusion, and to effectively level and align
arches.1 In addition, CAT was observed to be
predictable for upper molar distalization, with
an overall accuracy of 88% when 1.5 mm
movement was planned. However, results for
buccolingual tipping varied, the accuracy for
extrusion was 30%.1 CAT was not recommended for treatment of an open bite.1
Planned derotations < 15 and rotations with
a planned staging < 1.5/aligner, were significantly more accurate than the outcome for
larger derotations.5

Results and Patient Satisfaction

Predicted and actual tooth movement
and occlusion were compared for 27 cases
for CAT using the American Board of
Orthodontics Objective Grading System
(OGS).22 It was concluded that tooth movement was not accurately predicted for CAT.
Nonetheless, the results were not dissimilar
to those found for FOA therapy. It was also
concluded that the OGS score for patients
treated with CAT would be clinically acceptable.22 Further, no matter how ideal the occlusion and alignment immediately following
treatment with FOA or CAT, settling/relapse
occurred post-retention.23,24

Auxiliary
Components/Attachments
Auxiliary components are now incorporated into CAT, with the goal of achieving better control of intended tooth movement, particularly for rotation and tipping.4 In one case,
severe lower incisor rotations were successfully corrected about 2/aligner, and the crossbite and crowding treated using attachments
with a series of 23 aligners over 12 months.4
In comparing actual vs. predicted tooth movement, an overall mean accuracy of 59% was
found in a split-mouth study (n = 30).5

Oral Care repOrt

6
The difficulty of treating extraction cases
with CAT was demonstrated in a 2006 case.25
A multicenter randomized controlled trial
compared the results of FOA (n = 80) and
CAT with attachments (n = 72) for Class I
crowding extraction cases.7 There were no
differences in the overall OGS scores for CAT
and FOA, although there were significant differences for two of the eight OGS categories
(buccolingual inclination and occlusal contacts; p = 0.002 and p = 0.000, respectively).
It was concluded that CAT and FOA were both
successful in treating Class I crowding extraction cases.7

In the future, additional and large-scale randomized clinical trials of CAT would provide
evidence supporting clinical decision making, treatment planning, and outcomes.
15.

References
1.

2.

3.

Recent Developments
Mini-screws or temporary anchorage
devices (TAD) may be used for supplemental anchorage with FOA, serving to prevent
unwanted tooth movement. For the treatment
of open bites, adjunctive use of TAD or traditional edgewise FOA treatment were both
found to be effective.17 An ideal occlusion was
obtained with both techniques. It was also
found that esthetics might be superior after
using TAD, with changes in facial morphology that resulted in lip competency.17 The
adjunctive use of TAD for CAT, together with
IPR and button attachments, is reported to
improve predictability for complex cases and
to help prevent tipping.26 TAD provided
anchorage and allowed for intended, but not
unintended, tooth movement.26
Photobiomodulation (PBM) using lightemitting diodes (LEDs) promotes bone
remodeling and can accelerate tooth movement. In a proof-of-principle case report, IPR
was performed, attachments were placed after
the patient had used the first and second aligners, and PBM was applied daily for five minutes to each arch. It was thereby possible to
change aligners every three days, and to complete treatment in six months rather than 92
weeks without any reported discomfort.27

4.

5.

6.

7.

8.

9.

Conclusions
CAT has increased the demand for orthodontic treatment, especially among adults,
by offering an esthetic solution during treatment. Other advantages include both
improved oral hygiene and OHRQoL. The
accuracy of tooth movements has, however,
been variable with CAT, depending on the
type of tooth movement and the severity of
the malocclusion. However, no one treatment
guarantees a perfect result, and settling/
relapse can occur post-retention; this may also
make minor differences in outcomes less relevant over time. Auxiliary CAT components
can provide additional control of tooth movement, and the adjunctive use of new technologies for FOA and CAT is promising.
Recently, a systematic review was conducted
examining the efficacy and outcomes of CAT.

10.

11.

12.

13.

14.

Rossini G, Parrini S, Castroflorio T, Deregibus

A, Debernardi CL. Efficacy of clear aligners
in controlling orthodontic tooth movement:
a systematic review. Angle Orthod
2015;85(5):881-9.
Align Technology, Inc. Invisalign. 2016.
Available from: www.aligntech.com/solutions/invisalign. Accessed 18 May 2016.
Duncan LO, Piedade L, Lekic M, Cunha RS,
Wiltshire WA. Changes in mandibular incisor position and arch form resulting from
Invisalign correction of the crowded dentition treated nonextraction. Angle Orthod
2015;86(4):577-83.
Frongia G, Castroflorio T. Correction of severe
tooth rotations using clear aligners: a case
report. Aust Orthod J 2012;28(2):245-9.
Simon M, Keilig L, Schwarze J, Jung BA,
Bourauel C. Treatment outcome and efficacy of an aligner techniqueregarding incisor torque, premolar derotation and molar
distalization. BMC Oral Health 2014;14:68.
Needham R, Waring DT, Malik OH. Invisalign
treatment of Class III malocclusion with lowerincisor extraction. J Clin Orthod 2015;49(7):
429-41.
Li W, Wang S, Zhang Y. The effectiveness of
the Invisalign appliance in extraction cases
using the ABO model grading system: a multicenter randomized controlled trial. Int J
Clin Exp Med 2015;8(5):8276-82.
Turpin DL. Clinical trials needed to answer
questions about Invisalign. Am J Orthod
Dentofacial Orthop 2005;127(2):157-8.
Azaripour A, Weusmann J, Mahmoodi B,
Peppas D, Gerhold-Ay A, Van Noorden CJ,
Willershausen B. Braces versus Invisalign:
gingival parameters and patients satisfaction
during treatment: a cross-sectional study. BMC
Oral Health 2015;15:69.
Hennessy J, Al-Awadhi EA. Clear aligners generations and orthodontic tooth movement.
J Orthod 2016;43(1):68-76.
Karkhanechi M, Chow D, Sipkin J, Sherman
D, Boylan RJ, Norman RG, Craig RG, Cisneros
GJ. Periodontal status of adult patients treated with fixed buccal appliances and removable aligners over one year of active orthodontic
therapy. Angle Orthod 2013;83(1):146-51.
Juliena KC, Buschang PH, Campbell PM.
Prevalence of white spot lesion formation during orthodontic treatment. Angle Orthod
2013;83(4):641-7.
Zhou ZY, Wang Y, Wang XY, Volire G, Hu
RD, et al. The impact of orthodontic treatment on the quality of life. a systematic review.
BMC Oral Health 2014;14:66.
Pringle AM, Petrie A, Cunningham SJ,

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

McKnight M. Prospective randomized clinical trial to compare pain levels associated with
2 orthodontic fixed bracket systems. Am J
Orthod Dentofacial Orthop 2009;136(2):160-7.
Fujiyama K, Honjo T, Suzuki M, Matsuoka S,
Deguchi T. Analysis of pain level in cases treated with Invisalign aligner: comparison with
fixed edgewise appliance therapy. Prog Orthod
2014;15:64.
Birkeland K, Furevik J, Be OE, Wisth PJ.
Evaluation of treatment and post-treatment
changes by the PAR Index. Eur J Orthod
1997;19(3):279-88.
Deguchi T, Kurosaka H, Oikawa H, Kuroda
S, Takahasi I, Yamashiro Y, Takano-Yamamoto
T. Comparison of orthodontic treatment outcomes in adults with skeletal open bite between
conventional edgewise treatment and implantanchored orthodontics. Am J Orthod Dentofacial
Orthop 2011;139(4 Suppl):60-8.
Jambi S, Thiruvenkatachari B, OBrien KD,
Walsh T. Orthodontic treatment for distalising upper first molars in children and adolescents. Cochrane Database Syst Rev
2013;(10):CD008375.
Flores-Mir C. Little evidence to guide initial
arch wire choice for fixed appliance therapy. Evid Based Dent 2014;15(4):112-3.
Krieger E, Seiferth J, Marinello I, Jung BA,
Wriedt S, Jacobs C, Wehrbein H. Invisalign
treatment in the anterior region: were the
predicted tooth movements achieved? J Orofac
Orthop 2012;73(5):365-76.
Kravitz ND, Kusnoto B, BeGole E, Obrez A,
Agrane B. How well does Invisalign work? A
prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am
J Orthod Dentofacial Orthop 2009;135:27-35.
Buschang PH, Ross M, Shaw SG, Crosby D,
Campbell PM. Predicted and actual end-oftreatment occlusion produced with aligner
therapy. Angle Orthod 2015;85:723-7.
Bondemark L, Holmb A-K, Hansenc K,
Axelssond S, Mohline B, Brattstrom V, Pauling
G, Pietila T. Long-term stability of orthodontic treatment and patient satisfaction. A systematic review. Angle Orthod 2007;77(1):
181-91.
Nett BC, Huang GJ. Long-term posttreatment
changes measured by the American Board
of Orthodontics objective grading system.
Am J Orthod Dentofacial Orthop 2005;127(4):
444-50.
Giancotti A, Greco M, Mampieri G. Extraction
treatment using Invisalign technique. Prog
Orthod 2006;7(1):32-43.
Lin JC, Tsai SJ, Liou EJ, Bowman SJ. Treatment
of challenging malocclusions with Invisalign
and miniscrew anchorage. J Clin Orthod
2014;48(1):23-36.
Ojima K, Dan C, Kumagai Y, Schupp W.
Invisalign treatment accelerated by photobiomodulation. The Cutting Edge 2016;L5:
309-17.

Oral Care repOrt

DENTISTRY AND HEALTH CARE

Obesity and Periodontitis
The relationship between systemic disease and oral disease has focused primarily on
cardiovascular disease (CVD), diabetes mellitus (DM), and pregnancy outcomes. One condition that is important in the development
of chronic diseases such as CVD and DM, and
has a role in complications of pregnancy, is
obesity. Recently published studies have examined the relationship of obesity and periodontitis in the general population, patients with
DM, and on birth outcomes in pregnant
women.1-5 A systematic review has also suggested that there is a bi-directional relationship
between obesity and tooth loss,6 a conclusion
based primarily on cross-sectional studies.
Worldwide, an estimated 38% of female
adults and 36.9% of male adults were overweight or obese in 2013.7 In total, 2.1 billion
children and adults were overweight or obese.7
In the United States, an estimated 33.9% of
women and 31.6% of men are obese.7 It is
important for oral healthcare providers
(OHCPs) to understand the health implications of obesity, and the relationship of oral
disease to excess weight gain. OHCPs may be
able to refer patients or assist them with weight
loss management programs, as caloric intake
and dietary choices are part of dental practice. This common risk factor approach can
help improve outcomes of care.8

It is important for oral healthcare

providers to understand the health
implications of obesity, and the
relationship of oral disease to
excess weight gain.
Measures of Obesity
Body mass index (BMI, which is calculated as weight divided by square of the height)
is used most frequently to measure obesity;9,10
other measures used include waist circumference (WC) and waist hip ratio (WHP; see
table).9
Neck circumference (NC) is now being
considered an alternative measure for obesity.11 In the Framingham Heart Study (n =
3,307), a mean BMI of 27.8 kg/m2 was equivalent to a mean NC of 34.2 cm for females
and 40.5 cm for males.12 In a second study,

Definitions Using BMI, WC, and WHP9

Female

Male

BMI: Obese

30 kg/m2

30 kg/m2

BMI: Overweight

25 kg/m2

25 kg/m2

BMI: Normal weight

18.5kg/m2

18.5kg/m2

WC: Obese

> 35 inches (88 cm)

> 40 inches (102 cm)

WHP: Obese

> 0.85

> 0.90

NC correlated more closely than WC with

metabolic parameters and hypertension; an
NC of 35 cm for females and 38 cm for
men was suggested as a clinically relevant obesity benchmark.11

Obesity and Clinical

Attachment Loss
A recent five-year prospective study (n =
582) is supportive of obesity as a risk factor
for progressive clinical attachment loss (CAL)
in females, but not in males.1 All participants
reported no history of DM, had 6 teeth and
a BMI 18.5kg/m2; CAL progression was
defined as proximal CAL 3 mm, in 4 teeth
over the five-year period. Among the subjects,
30% and 19% were overweight and obese,
respectively, and 38% experienced CAL progression.1 After adjusting for other factors (e.g.,
demographics, medical and dental history),
obesity increased the risk of CAL by 64% in
females (p=0.01). No significant increased
risk was observed for overweight females (p
= 0.34) or for overweight or obese males (p
= 0.70 and p = 0.56, respectively).1 This was
hypothesized to be the result of the inability
of BMI measurements to differentiate between
a lean body mass (muscle) and adipose tissue (see Figure 1).1
64%

21%

13%
6%

Overweight

Obese

n Females n Males
*p = 0.01

Figure 1. Increased risk of CAL based on BMI.1

An increased risk of CAL progression

has been observed in other studies. In one
prospective study (n = 3,590), statistically
significant increases in periodontitis risk of
30%, 70%, and 324% were observed, respectively, for obese males (p < 0.001), overweight
females (p < 0.01), and obese females (p <
0.05).2 A statistically significant association
was also observed for obesity and periodontitis (defined as pocket probing depths 4
mm and CAL 3 mm in 4 teeth) in a separate randomized study (n = 340).3 Subjects
defined as obese using the BMI, WC, and
high fat percentage (HFP) were 2.9, 2.1, and
1.8 times more likely, respectively, to have
periodontitis.3
In a systematic review of five studies (n =
42,198), obesity was also found to increase
the likelihood of developing periodontitis.4
Three studies used BMI to measure obesity,
and two used BMI, WC, and WHR. Compared
to normal weight subjects, overweight and
obese subjects were 1.13 and 1.33 times more
likely, respectively, to develop periodontitis.4

Compared to normal weight

subjects, overweight and obese
subjects were 1.13 and 1.33
times more likely, respectively, to
develop periodontitis.
Based on limited data, findings on a relationship between obesity and periodontal treatment outcomes are conflicting. One study
found an increased risk of poor treatment
outcomes in obese patients compared to
normal weight patients (p = 0.012).13 In contrast, conclusions from a systematic review
were that obesity does not negatively affect

Oral Care repOrt

8
the results of periodontal therapy.14 This question requires further investigation.

Obesity and Tooth Loss

Obese subjects were 1.49 times more likely to have tooth loss and 1.25 times more likely to be edentate based on a meta-analysis of
16 studies(p < 0.05).6 Conversely, subjects with
tooth loss and edentulism were 1.41 and 1.60
times more likely to be obese (p < 0.05). While
this might suggest a bi-directional relationship, these were cross-sectional studies, limiting interpretation of the data. In addition,
only 4 studies were included for tooth loss,
with criteria ranging from 1 tooth missing
to 6 teeth missing.6

Maternal Obesity and Adverse

Birth Outcome
Focusing on periodontitis and obesity/excess weight as potentially synergistic risk
factors for adverse pregnancy outcomes, one
study (n = 328) assessed the risk of pre-term
birth (PTB) in women with pre-eclampsia
(PE).5 PE accounts for up to 20% of all PTBs.15
Previous studies reported that periodontitis
may be associated with PTB and PE.16 In the
current study, PTB (< 37 weeks) was 5.56 times
more likely in women with PE if they had periodontitis (p < 0.027), and if they were also
obese/overweight that risk increased almost
three-fold (p < 0.001; see Figure 2).5

A study in the dental setting examining

risk factors for undiagnosed diabetes mellitus included the use of WC in the algorithm.17
One concern that has been raised with regard
to the application of this algorithm is the comfort OHCPs have in measuring WC. However,
a recent report suggests that NC may be a better indicator of metabolic health than WC
for severely obese individuals.11 This provides
OHCPs with a viable approach to assess weight
as a risk factor. In addition, OHCPs frequently see patients who believe they are healthy
and may have undiagnosed DM, which may
first manifest with intraoral signs and symptoms. This provides an opportunity for early
intervention.

1.

5.56*
2.08

3.

*p < 0.027

Periodontitis and
obese/overweight

**p < 0.001

Figure 2. Increased risk level for PE-associated PTB based on

maternal weight.5

4.

Implications for Dental Care

The importance of patient obesity when
providing oral healthcare services can be seen
in many ways. Obesity has been observed to
impact CAL and oral health, and may increase
the risk of PE-associated PTB. Further, obesity is associated with DM, while DM has a bidirectional relationship with periodontitis.

9.

10.
11.

12.

References

2.

Periodontitis

8.

Conclusions
Strong evidence provides support for the
importance of obesity as a risk factor for systemic disease. OHCPs are in a unique position to consider obesity as a common risk factor for oral and systemic disease, and to advise,
counsel, and/or refer patients for lifestyle modifications.8 In doing so, OHCPs have an opportunity to intervene, collaborate with medical
professionals, and to help improve oral and
general health outcomes for patients. O
C

15.94**

Obese/
overweight

7.

5.

6.

Gaio EJ, Haas AN, Rosing CK, Oppermann

RV, Albandar JM, Susin C. Effect of obesity
on periodontal attachment loss progression:
a 5-year population-based prospective study.
J Clin Periodontol 2016;43(7):557-65.
Morita I, Okamoto Y, Yoshii S, Nakagaki H,
Mizuno K, Sheiham A, Sabbah W. Five-year
incidence of periodontal disease is related
to body mass index. J Dent Res 2011;90(2):
199-202.
Khader YS, Bawadi HA, Haroun TF, Alomari
M, Tayyem RF. The association between periodontal disease and obesity among adults in
Jordan. J Clin Periodontol 2009;36(1):18-24.
Nascimento GG, Leite FR, Do LG, Peres KG,
Correa MB, Demarco FF, Peres MA. Is weight
gain associated with the incidence of periodontitis? A systematic review and meta-analysis. J Clin Periodontol 2015;42(6):495-505.
Lee HJ, Ha JE, Bae KH. Synergistic effect of
maternal obesity and periodontitis on preterm
birth in women with preeclampsia: a prospective study. J Clin Periodontol 43(8):646-51.
Nascimento GG, Leite FR, Conceicao DA,
Ferrua CP, Singh A, Demarco FF. Is there a

13.

14.

15.

16.

17.

relationship between obesity and tooth loss

and edentulism? A systematic review and metaanalysis. Obes Rev 2016;17(7):587-98.
The GBD 2013 Obesity Collaboration, Ng M,
Fleming T, et al. Global, regional and national prevalence of overweight and obesity in
children and adults 1980-2013: A systematic
analysis. Lancet 2014;384(9945):766-81.
Cullinan M. The role of the dentist in the management of systemic conditions. Ann R
Australas Coll Dent Surg 2012;21:85-7.
World Health Organization. Waist
Circumference and Waist-Hip Ratio Report
of a WHO Expert Consultation. Geneva, 811 December, 2008. Available at:
http://www.who.int/nutrition/publications/obesity/WHO_report_waistcircumference_and_waisthip_ratio/en/.
Kopelman PG. Obesity as a medical problem.
Nature 2000;404(6778):635-43.
Assyov Y, Gateva A, Tsakova A, Kamenov Z. A
comparison of the clinical usefulness of neck
circumference and waist circumference in
individuals with severe obesity. Endocr Res
2016;6:1-9.
Preis SR, Massaro JM, Hoffmann U,
DAgostino RB Sr, Levy D, Robins SJ, Meigs
JB, Vasan RS, ODonnell CJ, Fox CS. Neck
circumference as a novel measure of cardiometabolic risk: the Framingham Heart
study. J Clin Endocrinol Metab 2010;95(8):
3701-10.
Suvan J, Petrie A, Moles DR, Nibali L, Patel
K, Darbar U, Donos N, Tonetti M, DAiuto
F. Body mass index as a predictive factor of
periodontal therapy outcomes. J Dent Res
2014;93(1):49-54.
Nascimento GG, Leite FR, Correa MB, Peres
MA, Demarco FF. Does periodontal treatment
have an effect on clinical and immunological parameters of periodontal disease in obese
subjects? A systematic review and meta-analysis. Clin Oral Investig 2016;20(4):639-47.
Jeyabalan A. Epidemiology of preeclampsia:
impact of obesity. Nutr Rev 2013;71(Suppl
1):S18-25.
Kumar A, Basra M, Begum N, Rani V, Prasad
S, Lamba AK, Verma M, Agarwal S, Sharma
S. Association of maternal periodontal health
with adverse pregnancy outcome. J Obstet
Gynaecol Res 2013;39(1):40-5.
Li S, Williams PL, Douglass CW. Development
of a clinical guideline to predict undiagnosed
diabetes in dental patients. J Am Dent Assoc
2011;142(1):28-37.

Oral Care repOrt

PREVENTIVE DENTISTRY
Dental Management of Patients with Autism
Autism represents a spectrum of neurodevelopmental disorders. It is characterized by altered social interaction, affecting
communication and interaction with others,
and repetitive behavior.1,2 The 1994 clinical
diagnostic criteria for autism in the Diagnostic
and Statistical Manual of Mental Disorders, 4th
Edition included five subtypes of autism.1,2
However, since 2013 autism has been defined
as one disorder.1 The prevalence of autism
has been the subject of debate, and has been
reported globally to range from 0.1% to 2%.1,3
In the United States, it appears that the diagnosis is now made more often, but it is unclear
if the prevalence has actually increased or may
be at least partly attributable to more thorough assessments. More males are affected
than females, with a 4.5:1 ratio.1

Caring for Dental Patients

with Autism
Dental care for persons with autism can
be challenging due to a lack of effective communication and, for patients, the unfamiliar
setting and unfamiliar tasks and activities.2
Patients with autism may exhibit unusual and
uncooperative behavior, such as head banging, tantrums, hyperactivity, and agitation.
Signs of self-injurious behavior may be evident; these include biting, grinding, cheek
biting, head banging, and pinching. Self-injurious behavior is reported to occur in up to
70% of children with autism.4

Dental care for persons with

autism can be challenging due to
a lack of effective communication,
the unfamiliar setting, and
unfamiliar tasks and activities.
Due to altered sensory processing,
patients with autism do not interpret sensations in the same manner as patients without
autism, which may also lead to exaggerated
responses to sounds, smells, lights, or touch,
all of which can occur during treatment.5-7 In
one study, more than half of children and adolescents with autism were uncooperative with
dental care, compared with 25.4% of the unaffected group, and just 9.2% exhibited positive behavior (p < 0.0001).8 As a result of the
challenges in providing comprehensive care
to individuals with autism, there is the possibility of long-term neglect of oral health.2
Behavioral management techniques
should be emphasized when providing dental care to persons with autism.3 Prevention is
key, especially when caring for children, but
even simple preventive procedures may not
be easily accomplished. Techniques that teach
skills and improve communication help to
overcome difficulties in treating patients with
autism. Tell-show-do and positive reinforcement may be effective depending on the
patients level of impairment. Brief clear commands are required.6 Another approach,
which does not rely heavily on interpersonal

communication, has been referred to as dental stories.5

autism will see the same dental team members on each visit, as this makes the patient
more comfortable.12

Behavioral Approaches
Suggested behavioral approaches include
applied behavior analysis (ABA).9 This technique requires participation of the dental
provider, and also parents and teachers.9
Patients with autism fail to develop joint attention, and therefore may be unable to share
information and have no curiosity about their
surroundings.9 ABA involves analyzing behavior, then implementing actions that will modify this behavior. Observing, gathering information using questionnaires or interviews with
patients/parent/caregivers, and understanding what the patient achieves with a given
behavior (for example, whether it means the
patient avoids treatment) are important in
determining what is required to modify such
functional behavior.9
A pre-visit session with parents/caregivers
is recommended to determine how they can
help with home preparation prior to the
patients visit to the dental office.10 Parents/caregivers can help prepare the patient at home
by getting him/her familiar with dental instruments such as mirrors, showing pictures of the
dental office and chair, and coaching them
on activities and phrases that will be used (e.g.,
open your mouth or close your mouth).10
In this manner, it is possible to teach the behavior that will be needed for a successful dental
visit.10 Dental treatment and the patients cooperation are a team effort.9
Desensitization is a process by which
the patient is gradually introduced to the
dental setting with progressively longer visits that may start with just a few seconds and
then build up. Distracting the patient with
a video or music, or having the patient hold
on to objects, may also be helpful during
appointments.11 Ideally, the patient with

Figure 1. Picture vocabulary chart for dental visits.

Ideally, the patient with autism

will see the same dental team
members on each visit, as this
makes the patient more
comfortable.
Dental Stories
Dental stories are social stories that use
basic language and images to describe the dental operatory environment to patients with
autism and what will happen during the visit.
Dental stories are read/viewed repeatedly
before the first dental appointment. Both print
and video versions have been utilized to prepare a child with autism for a dental visit.4
Dental stories are also available as comic books,
drawings, and photographs. The choice of
medium depends on language comprehension and preference in the home (p = 0.038
and p = 0.002, respectively).13 Standard dental stories are also available that can be adapted for an individual office.11 More information on dental stories and books about visiting the dentist such as Show Me Your Smile!
A Visit to the Dentist, and Dora the Explorer can
be found on the Autism Speaks website.11

Communicating with
Pictures and Icons
Patients with autism who have difficulty
with language may communicate using pictures, photos, a tablet with images, a simple
word processor, or a formal communication
tool with simple words/images/icons.11
Examples include a picture vocabulary chart
(Figure 1) and the Neo from AlphaSmart
(Figure 2).

Oral Care repOrt

10
For some patients, behavioral issues make
treatment without additional approaches
impossible. In certain cases, protective stabilization may be considered appropriate, however this is controversial.11 Nitrous oxide may
be helpful, provided the patient can inhale
through the nose during treatment. If conscious sedation is being considered, the
patients physician should be consulted and
a physical exam performed. General anesthesia may also be a necessary option, subject to health considerations.11

Figure 2. The Neo from AlphaSmart.

Medication Use
In one study of patients with autism
(n = 187), 47% took medications associated
with their condition, most commonly antipsychotics which reduce irritability, self-injurious behavior, distress, and other disorders.
Of the patients taking medications, almost
half were taking more than one. Forty-one
percent, 20%,16%, and 11% of patients were
receiving antipsychotics, central nervous system stimulants and other drugs, anticonvulsants, and antidepressants, respectively (Figure
3).8 Some of the signs and symptoms associated with these medications include dry
mouth, difficulty swallowing, gingivitis, stomatitis, gingival enlargement, sialadenitis, and
tongue discoloration.8 Nonetheless, children
and adolescents with autism have been found
to experience no more, or less, caries than
unaffected children. In one study, 68% of
patients with autism experienced caries vs.
86% of unaffected subjects (n = 269 and 332,
respectively; p < 0.0001).8

Antidepressants
Anticonvulsants
CNS Stimulants,
Other Drugs

11%
16%
20%

Anti-Psychotics

41%

It is important that a positive

relationship is developed with the
patient and that care is managed
in coordination with parents/
caregivers.
Another real challenge is the lack of exposure to patients with autism and other developmental disorders during dental and dental hygiene school training. The necessity of
including these experiences in the curriculum was underscored by the Commission on
Dental Accreditation, which stated in 2006
that all schools considered for accreditation
must offer such didactic and clinical education to students.16

4.

5.

6.

7.

8.

9.

10.

Conclusions
Knowledge concerning autism and an
understanding of its behavioral principles are
essential when treating these patients. Using
ABA procedures can help with the effective
management of problem behaviors when providing dental care. In addition, the involvement of parents/caregivers is an important
part of a successful approach to providing dental care to patients with autism. O
C

References
1.

Figure 2. Percentage of patients with autism using medications.8

Other Considerations
and Implications
It is essential that patients with autism
have a dental home and that they receive regular preventive care to maintain oral health.14
However, barriers to care include the childs
attitude toward dental procedures and limited resources.15 It is, therefore, important that
a positive relationship is developed with the
patient and that care is managed together with
parents/caregivers.

3.

2.

Christensen DL, Baio J, Braun KV, Bilder D,

Charles J, Constantino JN, Daniels J, Durkin
MS, Fitzgerald RT, Kurzius-Spencer M, Lee
L-C, Pettygrove S, Robinson C, Schulz E, Wells
C, Wingate MS, Zahorodny W, Yeargin-Allsopp
M. Prevalence and Characteristics of Autism
Spectrum Disorder Among Children Aged
8 Years Autism and Developmental
Disabilities Monitoring Network, 11 Sites,
United States, 2012. MMWR Surveill Summ
2016;65(No. SS-3)(No. SS-3):123.
Gandhi RP, Klein U. Autism spectrum disorders: an update on oral health management.
J Evid Based Dent Pract 2014;14(Suppl):
115-26.

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16.

Centers for Disease Control and Prevention.

Autism spectrum disorder. Available
at: http://www.cdc.gov/ncbddd/autism/
data.html.
Murshid EZ. Oral health status, dental needs
habits and behavioral attitude towards dental treatment of a group of autistic children
in Riyadh, Saudi Arabia. Saudi Dent J
2005;17:132-9.
National Institute of Dental and Craniofacial
Research. Practical oral care for people with
autism. Available at: http://www.nidcr.nih.gov/
OralHealth/Topics/DevelopmentalDisabilities
/PracticalOralCarePeopleAutism_mobile.htm.
Gupta M. Oral health status and dental management considerations in autism. Int J
Contemp Dent Med Rev 2014; Article ID
011114:1-6.
Stein LI, Polido JC, Mailloux Z, Coleman GG,
Cermak SA. Oral care and sensory sensitivities in children with autism spectrum disorders. Spec Care Dentist 2011;31:102-10.
Loo CY, Graham RM, Hughes CV. The caries
experience and behavior of dental patients
with autism spectrum disorder. J Am Dent Assoc
2008;139(11):1518-24.
Hernandez P, Ikkanda Z. Applied behavior
analysis: behavior management of children
with autism spectrum disorders in dental environments. J Am Dent Assoc 2011;142(3):
281-7.
Delli K, Reichart PA, Bornstein MM, Livas C.
Management of children with autism spectrum disorder in the dental setting: Concerns,
behavioural approaches and recommendations. Med Oral Patol Oral Cir Bucal
2013;18(6):e862-8.
Autism Speaks. Treating children with autism
spectrum disorders. A tool kit for dental professionals. Available at: https://www.autismspeaks.org/docs/sciencedocs/atn/dentaltoolkit.pdf
Marshall J, Sheller B, Manci L, Williams BJ.
Parental attitudes regarding behavior guidance of dental patients with autism. Pediatr
Dent 2008;30(5):400-07.
Marion IW, Nelson TM, Sheller B, McKinney
CM, Scott JM. Dental stories for children with
autism. Spec Care Dentist 2016;36(4):181-6.
Charles JM. Dental care in children with developmental disabilities: attention deficit disorder, intellectual disabilities, and autism. J Dent
Child (Chic) 2010;77(2):84-91.
Lai B, Milano M, Roberts MW, Hooper SR.
Unmet dental needs and barriers to dental
care among children with autism spectrum
disorders. J Autism Dev Disord 2012;42:
1294-303.
Commission on Dental Accreditation 2006.

Oral Care repOrt

11

HEALTHCARE TRENDS
Methamphetamine Abuse and the
Role for the Dental Profession
A

Editor-in-Chief
Ira B. Lamster, DDS, MMSc
Professor of Health Policy &
Management,
Mailman School of Public Health
Dean Emeritus,
Columbia University College of
Dental Medicine

International Editorial Board

P. Mark Bartold, BDS, BScDent
(Hons), PhD, DDSc, FRACDS
(Perio); Australia
John J. Clarkson, BDS, PhD; Ireland
Kevin Roach, BSc, DDS, FACD;
Canada
Prof. Cassiano K. Rsing; Brazil
Mariano Sanz, DDS, MD; Spain
Ann Spolarich, RDH, PhD; USA
Xing Wang, MD, PhD; China
Rebecca S. Wilder, RDH, MS; USA
David T.W. Wong, DMD, DMSc; USA
2016 Colgate-Palmolive Company.
All rights reserved.
The Oral Care Report
(ISSN 1520-0167) is supported by
the Colgate-Palmolive Company for
oral care professionals.
Editorial Quality Control by
Teri S. Siegel.
Layout and graphic design by
Horizons Advertising and Graphic
Design, Morrisville, PA (USA).
Published by Professional Audience
Communications, Inc.,
Charlotte, NC (USA).
E-mail comments and queries to the
Editor, Oral Care Report...
ColgateOralCareReport@gmail.com

recent essay in the ADA News discussed the effects of recreational use of methamphetamine
(meth) on the oral cavity.1 This is a condition that was identified 15 years ago, seen in individuals who
abuse methamphetamine.2,3 Methamphetamine is a stimulant, very addictive, and induces wakefulness
and excessive physical activity. The adverse side effects include elevated blood pressure, cardiac arrhythmias, hallucinations, and bizarre and often violent behavior.
A severe form of oral disease characterized by extensive dental caries, worn teeth, and periodontal disease was first described by two emergency department physicians in 2000.3 Since that
time, there have been a number of published case reports or case series, often appearing in local dental journals,4-6 suggesting a clustering of cases in certain areas of the United States. However meth
mouth, as this has come to be known, is an international problem, reported in Europe,7 Taiwan,8 and
South Africa.9 The oral findings in persons with meth mouth are believed to be due to xerostomia,
excessive tooth clenching, a lack of concern about oral hygiene, and increased consumption of sugarsweetened beverages.
Early reports were limited by the number of cases that were reported, not allowing conclusions
regarding prevalence or distribution by age, sex, or drug use. Shetty and colleagues,3 however, have published the findings of a study of methamphetamine users in the Los Angeles, California, area.
This study used a stratified sampling approach to assess the oral status of a large sample of methamphetamine users. A total of 571 individuals were examined and divided into light, moderate, and heavy
users. The majority were male, and either Hispanic or African-American. Nearly 70% were currently
using cigarettes. The oral findings revealed extensive severe oral disease. Being older and a moderate or
heavy user were associated with more extensive caries, periodontal disease, and tooth loss. Women were
affected to a greater degree than men. Molars were the teeth that demonstrated the greatest extent and
severity of oral disease, and maxillary anterior teeth demonstrated greater caries experience than mandibular anterior teeth. Of all users, 96% had evidence of caries and nearly 60% had untreated caries.
Periodontitis was also common in these individuals, with nearly 60% of moderate/heavy methamphetamine users demonstrating moderate periodontitis and nearly one-third demonstrating severe
periodontitis. Further, a majority of the methamphetamine users reported embarrassment as a result of
their oral condition.
The onset of this relatively new oral syndrome highlights the pressing need for oral healthcare
providers (OHCPs) to take a broader view of their role in patient care. First, patients presenting with the
conditions seen in these reports require more than dental care alone. If seeing a patient with oral findings suggestive of methamphetamine abuse, OHCPs must treat the whole patient, while considering the
need for medical/psychiatric consultation, appropriate management of pain that does not add to the
addictive problems often faced by these patients, and avoidance of drugs used during dental treatment
that may be affected by methamphetamine use (i.e., the cardiac effects of vasoconstrictors such as epinephrine in local anesthetics). This epidemic further emphasizes the importance of interprofessional
practice, and the need for multiple healthcare providers to participate in patient care.

Dental offices can be points of surveillance for newly emerging diseases and
disorders, and also provide opportunities for OHCPs to have a positive impact
on the overall health of persons in their care.
Second, the appearance of meth mouth also stresses that OHCPs must be vigilant for the next new
oral disorder or manifestation of a systemic condition. In recent years bisphosphonate-related osteonecrosis of the jaws (BRONJ), as well as peri-implant mucositis and perimplantitis, have been identified. Thirty
years ago it was a variety of newly identified oral manifestations of HIV infection, including hairy leukoplakia and HIV-associated periodontitis.
Dental offices can be points of surveillance for newly emerging diseases and disorders, and also provide opportunities for OHCPs to have a positive impact on the overall health of persons in their care. O
C

References
1.

2.

Earn 3 CE credits
for this issue
of the
Oral Care Report
online at
www.colgateprofessional.com.

3.
4.
5.
6.
7.
8.
9.

American Dental Association. ADA News. MyView: Meth: the loss of Americas smile. Available from:
http://www.ada.org/en/publications/ada-news/viewpoint/my-view/2016/may/meth-the-loss-of-americas-smile.
Accessed 16 May 2016.
Richards JR, Brofeldt BT. Patterns of tooth wear associated with methamphetamine use. J Periodontol 2000;71(8):
1371-4.
Shetty V, Harrell L, Murphy DA, Vitero S, Gutierrez A, Belin TR, Dye BA, Spolsky VW. Dental disease patterns
in methamphetamine users: Findings in a large urban sample. J Am Dent Assoc 2015;146(12):875-85.
Jones K. Meth mouth: one dentists personal experience. J Mich Dent Assoc 2011;93(2):60-1.
Settle SL. Meth mouth for the general practitioner. J Okla Dent Assoc 2010;101(8):31-42.
Brown RE, Morisky DE, Silverstein SJ. Meth mouth severity in response to drug-use patterns and dental access
in methamphetamine users. J Calif Dent Assoc 2013;41(6):421-8.
De-Carolis C, Boyd GA, Mancinelli L, Pagano S, Eramo S. Methamphetamine abuse and meth mouth in
Europe. Med Oral Patol Oral Cir Bucal 2015;20(2):e205-10.
Wang P, Chen X, Zheng L, Guo L, Li X, Shen S. Comprehensive dental treatment for meth mouth: a case
report and literature review. J Formos Med Assoc 2014;113(11):867-71.
Naidoo S, Smit D. Methamphetamine abuse: a review of the literature and case report in a young male. SADJ
2011;66(3):124-7.