Periodontal

When we start visiting the dentist as children, the importance of brushing and flossing our teeth is something that is stressed from the outset. While many people dread flossing and do not devote ample time to it, flossing is a critical aspect of oral hygiene since it helps to remove food particles that lead to inflammation in the gums, a condition commonly known as gingivitis.

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Shot of dental implant in the mouth of a patient with advanced periodontitis GETTY
Gum disease or gingivitis which goes untreated may progress to a condition called periodontitis , in which inflammation and resulting infection in your gums spreads to the bone that supports your teeth.

Periodontitis is the most important cause of tooth loss in adults. It has also been linked to elevated risk for developing diabetes, osteoporosis, coronary artery disease, pneumonia and cancer. At the same time, periodontitis may also represent a risk factor for developing dementia, one of the leading causes for disability in older adults.

In fact, based on population and research data, the United Nations (U.N) estimates that 1 in 85 people will be diagnosed with Alzheimer’s dementia by 2050. At the same time, mitigating potential risk factors that lead to dementia and Alzheimer’s disease (coronary artery disease, stroke, diabetes, high blood pressure and elevated cholesterol) could also lower older adults’ chances of developing those conditions.

To accomplish this, researchers in South Korea studied the relationship between chronic periodontitis and dementia over a 10 year period.

Their findings were recently published in the Journal of the American Geriatrics Society.

Dental Care

Unique dental care needs
It’s a scenario with which Dr. Tracy Doyle is all too familiar.

To mark World Autism Awareness Day, the IWK Health Centre pediatric dentist and Dalhousie University instructor is offering some tips for parents and dentists on how provide effective oral health treatment for young patients with autism.

She says children with autism often avoid visiting the dentist and can miss out on a lot of preventative treatments. Oftentimes, she says, dentists may also be ill-prepared to work with patients with special needs.

“We see a lot of families who because of negative experiences with health care — because they’re really scared their child is going to react negatively — avoid coming to the dentist,” she said.

WATCH (Jan. 16, 2019): Nova Scotia government expands dental coverage for kids 14 and younger

She says children with autism often have unique concerns with their teeth. If they have sensory concerns, they may not like the feel of toothbrush bristles or the taste of toothpaste.

The children also tend to be very picky eaters.

“They tend to choose foods and drinks that aren’t very good for your teeth,” Doyle said. “They have very limited food intake so sometimes that’s all their parents can get them to eat.”

She adds that the experience of seeing a dentist can be “out of the ordinary” for most children and especially so for children with autism. From the bright lights to the loud noises and unfamiliar tools, it can be very overwhelming.

Tips for dentists and parents
That’s why she teaches her dental students to send out pre-appointment questionnaires and then tailor the experience for each child.

“If we know in advance what are some kids’ triggers then we can, maybe, [not] keep them in the busy waiting room, keep them in a dimly lit auditory [space] to keep things calm and less stimulating,” she said.

She also offers non-verbal patients flash cards with comments such as “stop” or “I need a drink of water” or “I’m nervous” so that young patients can communicate with their dentist.

She also advises parents and dentists to stick to a routine.

“We really advocate keeping things the same. For instance, if a child is coming to your office, you try to keep the same time of day, same dentist, same dental assistant if you can, same colour toothbrush, same toothpaste,” Doyle said.

The ultimate goal is to create a safe and welcoming space for patients and their parents so that they feel comfortable coming early on in the child’s life. Preventative treatment, she says, is easier than treating problems.

“Our goal is for all children to see a dentist by age one, and this is particularly important for children with special health-care needs who have additional barriers to maintaining good oral health,” she said.

Teaching the next generation of dentists
Doyle, who is also the director of pediatric dentistry undergraduate curriculum at Dalhousie University, has worked extensively with children with autism.

She was the clinical director of the Special Smiles program at the national Special Olympics in Antigonish, N.S., last year. That program offered free dental screening and tips for Special Olympics athletes.

READ MORE: Managing stress may improve oral health, says Nova Scotia Dental Association

She is also the faculty adviser for the annual Sharing Smiles Day at the university, which takes place this Saturday, April 6.

The event brings together dentistry students, faculty and participants with intellectual and physical challenges together in a fun setting so they can get comfortable with each other and learn more about oral health care.

“Hopefully having students interact with people with intellectual disabilities early in their career will foster positive relationships,” she said.

That’s why she incorporates special care dentistry into her curriculum for students and includes it in her continuing education classes.

Success story for Max
Meanwhile, Morrison’s son has found success after her family’s search for a dentist.

For the past decade, he’s been visiting a Halifax dentist who bonded with Max by letting him test out all the dental tools.

“Our dentist let Max handle all of the tools, and it really demystified the process for Max,” Morrison said.

“It took his anxiety down, and that was a huge step. That was huge for our family because I was really worried about his oral health.”

Therapy processes

In this Research & Commentary, Matthew Glans discusses two proposed bills in Florida that would allow dental therapists to practice as mid-level providers.

Like many states, Florida is suffering from a growing dentist shortage. There are currently 52.3 dentists per 100,000 Florida residents, compared to a national average of 60.8 according to the James Madison Institute. In fact, the U.S. Department of Health and Human Services (HHS) designated 240 Florida regions as Health Professional Shortage Areas (HPSAs) and more than 5.5 million Floridians live in these areas, according to the Kaiser Family Foundation.

At the state level, strict licensing requirements reduce dental access and increase costs. Supporters of strict licensing standards argue they assure quality care. However, critics claim the arduous and expensive licensing process is a barrier to entry that hinders new providers from entering the market; thereby impeding market competition that would reduce costs and increase patient access.

Fortunately, for states with a lack of dental services, there is a simple solution that would expand dental care access and lower costs: dental therapists (DT). Indeed, states across the country are increasing the number of licensed DTs to help relieve dental shortages.

The path to becoming a DT requires significant training. However, it is far less costly and time consuming than what is necessary to become a dentist. DTs are allowed to provide a limited range of services. Therefore, they can typically complete their education requirements for about $36,000.

In an effort to relieve the dental service shortage in the Sunshine State, two bills have been filed that would allow dental therapists to practice as mid-level providers.

Senate Bill 684 and House Bill 649 require DTs receive training in line with national standards of safety and quality developed by the Commission on Dental Accreditation (CODA), the American Dental Association’s accrediting body. The bills would also require DTs to graduate with a degree from a CODA accredited program. Across the Sunshine State, several colleges are equipped to offer dental therapy training programs, according to the News-Press.

As is the case with all bills, scope and details matter. In general, DT laws should require general supervision only, which means DTs would not need direct supervision from a dentist when providing dental services. This is important because limiting DTs to direct supervision would not substantially increase dental access. The Florida bills call for general supervision and allow supervising dentists to determine which procedures DTs could provide under their supervision. The Florida bills also allow DTs to provide remote care, which would help fill shortages in rural areas.

In 2009, Minnesota became the first state to authorize increased licenses for DTs. Based on the available evidence, Minnesota’s reforms have been positive. After just one year of expanding licenses for DTs, patient visits increased by 27 percent.

Moreover, children and adults served by DTs receive more frequent preventive care, which leads to a reduced need for invasive procedures over the long term, according to a report in the Journal of Public Health Dentistry.

In short, states ought to ease licensing standards on DTs and allow them to practice without a dentist physically present. These much-needed reforms would help patients receive preventive and restorative treatment in a timely and affordable manner.

The following articles examine dental health care and dental therapist licensing in greater detail.

Dental Therapists: Sinking Our Teeth into Innovative Workforce Reform
https://www.jamesmadison.org/wp-content/uploads/2018/05/PolicyBrief-DentalTherapy-v07-web.pdf
In this Policy Brief from the James Madison Institute, Jennifer Minjarez and Sal Nuzzo examine the positive role that dental therapists can have on access to care and dental utilization rates. “Florida policymakers should reform licensure regulations to grant dental providers the freedom to innovate. Florida’s population is rapidly growing and Floridians’ demand for dental care will continue to evolve. The best way to ensure Floridians have access to dental care is to let the market determine the number and types of Florida’s dental care providers. Allowing dental therapists the ability to practice would be a significant step in this direction,” wrote Minjarez and Nuzzo.

Dental Utilization for Communities Served by Dental Therapists in Alaska’s Yukon Kuskokwim Delta: Findings from an Observational Quantitative Study
https://www.heartland.org/publications-resources/publications/dental-utilization-for-communities-served-by-dental-therapists-in-alaskas-yukon-kuskokwim-delta-findings-from-an-observational-quantitative-study
This study from the University of Washington examines whether dental utilization rates in Alaska Native communities were associated with the number of dental therapist treatment days and quantifies differences in dental utilization rates between communities without dental therapist treatment days and those communities with the highest number of dental therapist treatment days.

The Case for Licensing Dental Therapists in North Dakota
https://www.heartland.org/_template-assets/documents/publications/Policy%20Brief%20Dental%20Therapy%20North%20Dakota.pdf
In this Policy Brief, Michael Hamilton, Bette Grande, and John Davidson ask North Dakota lawmakers: “Does licensing dental therapists in North Dakota pose a risk to public health great enough to justify depriving (1) dentists of their right to employ and supervise dental therapists and (2) patients of their right to access providers of their choice?” They argue the answer is clearly “no.” Far from jeopardizing the public health, licensing dental therapists would likely expand patient access to high-quality oral care services and reduce oral care costs in North Dakota.

Early Impacts of Dental Therapists in Minnesota
https://mn.gov/boards/assets/2014DentalTherapistReport_tcm21-45970.pdf
The Minnesota Department of Health and Minnesota Board of Dentistry examine in this report how authorizing dental therapy in Minnesota resulted in increased access for previously uncared-for patients.

A Review of the Global Literature on Dental Therapists
https://www.heartland.org/publications-resources/publications/a-review-of-the-global-literature-on-dental-therapists
This report from the W.K. Kellogg Foundation provides a 460-page review of the benefits of dental therapy as demonstrated in more than 50 countries.

Dental Care Health Professional Shortage Areas (HPSAs)
Dental Care Health Professional Shortage Areas (HPSAs)
The Kaiser Family Foundation analyzes the dental care health professional shortage areas in each state in order to show which states have the largest discrepancies in dental-care access.

Pew Charitable Trust: Dental Campaign
http://www.pewtrusts.org/en/projects/dental-campaign
Pew Charitable Trust has been providing research and analysis to encourage state lawmakers to allow dental therapists in their states to ensure patients have greater access to preventive and restorative treatment services. “Pew’s dental campaign works to close gaps in dental-care access by increasing the number of available providers and expanding the reach of preventive services through the use of dental sealant programs in high-need schools. Research shows that such programs are a valuable, cost-effective way to treat the children most at risk of tooth decay.”

5 Dental Therapy FAQs
http://www.pewtrusts.org/en/research-and-analysis/q-and-a/2016/04/5-dental-therapy-faqs
While states continue to grapple with what dental therapists are, how much education dental therapists receive, and where therapy is practiced, Pew Charitable Trusts has put together a helpful FAQ page to answer the most important and difficult questions related to dental therapy.