Department of Dental Public Health and Dental Informatics

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Advancing cognitive engineering methods to support user interface design for electronic health records
(Elsevier, 2014-04) Thyvalikakath, Thankam P.; Dziabiak, Michael P.; Johnson, Raymond; Torres-Urquidy, Miguel Humberto; Acharya, Amit; Yabes, Jonathan; Schleyer, Titus K.; Department of Cariology, Operative Dentistry and Dental Public Health, IU School of Dentistry
Background Despite many decades of research on the effective development of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow, especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practitioners in the United States. A critical reason for slow adoption is the poor usability of clinical systems, which makes it difficult for providers to navigate through the information and obtain an integrated view of patient data. Objective In this study, we documented the cognitive processes and information management strategies used by dentists during a typical patient examination. The results will inform the design of a novel electronic dental record interface. Methods We conducted a cognitive task analysis (CTA) study to observe ten general dentists (five general dentists and five general dental faculty members, each with more than two years of clinical experience) examining three simulated patient cases using a think-aloud protocol. Results Dentists first reviewed the patient’s demographics, chief complaint, medical history and dental history to determine the general status of the patient. Subsequently, they proceeded to examine the patient’s intraoral status using radiographs, intraoral images, hard tissue and periodontal tissue information. The results also identified dentists’ patterns of navigation through patient’s information and additional information needs during a typical clinician-patient encounter. Conclusion This study reinforced the significance of applying cognitive engineering methods to inform the design of a clinical system. Second, applying CTA to a scenario closely simulating an actual patient encounter helped with capturing participants’ knowledge states and decision-making when diagnosing and treating a patient. The resultant knowledge of dentists’ patterns of information retrieval and review will significantly contribute to designing flexible and task-appropriate information presentation in electronic dental records.
Relative fluoride response of caries lesions created in fluorotic and sound teeth studied under remineralizing conditions
(Elsevier, 2015-01) Alhawij, Hala; Lippert, Frank; Martinez-Mier, Esperanza Angeles; Department of Cariology, Operative Dentistry and Dental Public Health, IU School of Dentistry
Objectives The present in vitro pH cycling study investigated potential differences between caries lesions created in fluorosed and sound enamel with regards to their responsiveness to fluoride under remineralizing conditions. Methods 360 human first molars (sound and fluorosed) were divided into four groups based on their Thylstrup–Fejerskov score (TF0-3). Each group was further divided into two treatment groups (n = 45): deionized water or 383 ppm fluoride. Artificial enamel caries lesions were created and pH cycled for 20 d using an established net remineralization model. Quantitative light-induced fluorescence was used throughout the study to investigate lesion severity and changes thereof. Data were analyzed using two-way ANOVA. Results There were no differences in lesion severity between all groups after lesion creation (plesion = 0.1934). The TF score vs. treatment interaction was significant at all other time points (p10 d = 0.0280; p20 d ≤ 0.0001; psecdemin = 0.0411). Relative differences in responsiveness to fluoride vs. deionized water increased with increasing TF scores. In comparison to lesions created in sound enamel, lesions created in enamel with moderate fluorosis (TF 2/3) were more prone to remineralization in the presence than in the absence of fluoride. Furthermore, lesions created in enamel with moderate fluorosis exhibited more remineralization in the presence of fluoride than lesions created in sound teeth, whereas the opposite was true for deionized water. Conclusion Bearing in mind the limitations of laboratory research, the extent of enamel fluorosis severity may directly impact subsequent lesion re- and progression as well as the lesion's responsiveness to fluoride. Clinical relevance Caries lesions in fluorotic teeth are more vulnerable to progression but respond more strongly to fluoride than those in non-impacted teeth.
Photo Inactivation of Streptococcus mutans Biofilm by Violet-Blue light
(Springer, 2016-09) Gomez, Grace F.; Huang, Ruijie; MacPherson, Meoghan; Zandona, Andrea G. Ferreira; Gregory, Richard L.; Department of Biomedical and Applied Sciences, IU School of Dentistry
Among various preventive approaches, non-invasive phototherapy/photodynamic therapy is one of the methods used to control oral biofilm. Studies indicate that light at specific wavelengths has a potent antibacterial effect. The objective of this study was to determine the effectiveness of violet-blue light at 380–440 nm to inhibit biofilm formation of Streptococcusmutans or kill S. mutans. S. mutans UA159 biofilm cells were grown for 12–16 h in 96-well flat-bottom microtiter plates using tryptic soy broth (TSB) or TSB with 1 % sucrose (TSBS). Biofilm was irradiated with violet-blue light for 5 min. After exposure, plates were re-incubated at 37 °C for either 2 or 6 h to allow the bacteria to recover. A crystal violet biofilm assay was used to determine relative densities of the biofilm cells grown in TSB, but not in TSBS, exposed to violet-blue light. The results indicated a statistically significant (P < 0.05) decrease compared to the non-treated groups after the 2 or 6 h recovery period. Growth rates of planktonic and biofilm cells indicated a significant reduction in the growth rate of the violet-blue light-treated groups grown in TSB and TSBS. Biofilm viability assays confirmed a statistically significant difference between violet-blue light-treated and non-treated groups in TSB and TSBS. Visible violet-blue light of the electromagnetic spectrum has the ability to inhibit S.mutans growth and reduce the formation of S.mutans biofilm. This in vitro study demonstrated that violet-blue light has the capacity to inhibit S. mutans biofilm formation. Potential clinical applications of light therapy in the future remain bright in preventing the development and progression of dental caries.
Relationship between enamel fluorosis severity and fluoride content
(Elsevier, 2016-03) Martinez-Mier, Esperanza A.; Shone, Devin B.; Ando, Masatoshi; Lippert, Frank; Soto-Rojas, Armando E.; Department of Pediatric Dentistry, IU School of Dentistry
OBJECTIVES: Enamel fluorosis is a hypomineralization caused by chronic exposure to high levels of fluoride during tooth development. Previous research on the relationship between enamel fluoride content and fluorosis severity has been equivocal. The current study aimed at comparing visually and histologically assessed fluorosis severity with enamel fluoride content. METHODS: Extracted teeth (n=112) were visually examined using the Thylstrup and Fejerskov Index for fluorosis. Eruption status of each tooth was noted. Teeth were cut into 100 μm slices to assess histological changes with polarized light microscopy. Teeth were categorized as sound, mild, moderate, or severe fluorosis, visually and histologically. They were cut into squares (2 × 2 mm) for the determination of fluoride content (microbiopsy) at depths of 30, 60 and 90 μm from the external surface. RESULTS: Erupted teeth with severe fluorosis had significantly greater mean fluoride content at 30, 60 and 90 μm than sound teeth. Unerupted teeth with mild, moderate and severe fluorosis had significantly greater mean fluoride content than sound teeth at 30 μm; unerupted teeth with mild and severe fluorosis had significantly greater mean fluoride content than sound teeth at 60 μm, while only unerupted teeth severe fluorosis had significantly greater mean fluoride content than sound teeth at 90 μm. CONCLUSIONS: Both erupted and unerupted severely fluorosed teeth presented higher mean enamel fluoride content than sound teeth. CLINICAL SIGNIFICANCE: Data on fluoride content in enamel will further our understanding of its biological characteristics which play a role in the management of hard tissue diseases and conditions.
Teeth With Mild and Moderate Enamel Fluorosis Demonstrate Increased Caries Susceptibility In Vitro
(Elsevier, 2017) Martinez-Mier, E. Angeles; Lippert, Frank; Department of Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Subjects In this laboratory study, 49 human unerupted third molars extracted for clinical reasons and classified as scores 0-4 using the Thylstrup and Fejerskov (TF) index (n = 9 for TF0, n = 10 for TF1, n = 10 for TF2, n = 10 for TF3, and n = 10 for TF4) were included. TF1-TF4 teeth were collected in Colombia, and TF0 teeth were obtained from the University of Copenhagen. Ethical approval was obtained. Key Risk/Study Factor Teeth in the study were subjected to pH cycling to induce caries lesions. Main Outcome Measure The primary outcome measure was resistance to a cariogenic challenge determined using cross-sectional microhardness. A series of indentations, starting at 10 μm below the anatomic surface down to 200 μm, were placed in the teeth using a Knoop indenter. These measurements were performed before and after pH cycling, yielding baseline and demineralization areas, both calculated “by numerical integration of the hardness vs depth values using the trapezoidal rule.” The demineralization data were then normalized for differences at baseline and a “percentage reduction” was calculated, with higher numbers being indicative of greater susceptibility to caries lesion formation. Main Results Teeth with scores of TF3 and TF4 exhibited greater susceptibility to caries lesion formation than all other teeth, with no differences being observed between unaffected teeth (TF0) and teeth with scores of TF1 and TF2. Teeth with scores of TF3 and TF4 also displayed a lower mean baseline area than those with TF1 and TF2, although not compared to TF0 teeth, indicative of greater hypomineralization. Conclusions The authors concluded that the results of their study suggest that teeth with moderate fluorosis had an increased caries susceptibility when compared to teeth with very mild or no fluorosis. They hypothesized that these differences in caries susceptibility are mainly due to dissimilarities in porosity of the enamel—in fluorotic teeth, a greater subsurface mineral area is exposed to demineralization, and deeper acid diffusion through enamel is facilitated.
In vitro Validation of Quantitative Light-Induced Fluorescence for the Diagnosis of Enamel Fluorosis in Permanent Teeth
(Karger, 2017-11) Cuevas-Espinosa, D. M.; Martinez-Mier, E. Angeles; Ando, Masatoshi; Castiblanco, G. A.; Cortes, F.; Rincon-Bermudez, C. M.; Martignon, Stefania; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
This study aimed to validate quantitative light-induced fluorescence (QLF) as a diagnostic tool for mild and moderate enamel fluorosis in permanent teeth, comparing it to visual diagnosis and histological assessment completed using polarized light microscopy (PLM). The buccal surfaces of 139 teeth were visually classified using the Thylstrup and Fejerskov Index (TFI) into sound (TFI 0; n = 17), mild (TFI 1-2; n = 69), and moderate (TFI 3-4; n = 43) fluorosis. Fluorosis was then assessed with QLF (variables ΔF, A, and ΔQ at 5-, 15-, and 30-radiance thresholds) using as reference areas the entire surface and a region of interest (ROI), identified as the most representative region of a fluorosis lesion. PLM images of longitudinal thin sections including the ROI were assessed for histological changes. Correlations among TFI, PLM, and QLF were determined. A receiver-operating characteristic curve was conducted to determine QLF's diagnostic accuracy when compared to the TFI and PLM assessments. This was used to assess the probability that the images were correctly ranked according to severity as determined by PLM and TFI. A positive correlation was found between QLF and PLM, and between QLF and TFI. QLF showed the highest sensitivity and specificity for the diagnosis of mild fluorosis. There was also a strong agreement between TFI and PLM. The selection of a ROI resulted in a stronger correlation with TFI and PLM than when the entire surface was used. The study results indicate that defining an ROI for QLF assessments is a valid method for the diagnosis of mild and moderate enamel fluorosis.
Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration
(BMC, 2018-05-21) Thyvalikakath, Thankam; Song, Mei; Schleyer, Titus; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Currently, many risk assessment tools are available for clinicians to assess a patient’s periodontal disease risk. Numerous studies demonstrate the potential of these tools to promote preventive management and reduce morbidity due to periodontal disease. Despite these promising results, solo and small group dental practices, where most people receive care, have not adopted risk assessment tools widely, primarily due to lack of studies in these settings. The objective of this study was to explore the knowledge, attitudes, and beliefs of dental providers in these settings toward risk-based care through focus groups.
Effect of Violet-Blue Light on Streptococcus mutans-Induced Enamel Demineralization
(MDPI, 2018-03-21) Felix Gomez, Grace Gomez; Lippert, Frank; Ando, Masatoshi; Zandona, Andrea Ferreira; Eckert, George J.; Gregory, Richard L.; Biomedical and Applied Sciences, School of Dentistry
Background: This in vitro study determined the effectiveness of violet-blue light (405 nm) on inhibiting Streptococcus mutans-induced enamel demineralization. Materials and Methods: S. mutans UA159 biofilm was grown on human enamel specimens for 13 h in 5% CO2 at 37 °C with/without 1% sucrose. Wet biofilm was treated twice daily with violet-blue light for five minutes over five days. A six-hour reincubation was included daily between treatments excluding the final day. Biofilms were harvested and colony forming units (CFU) were quantitated. Lesion depth (L) and mineral loss (∆Z) were quantified using transverse microradiography (TMR). Quantitative light-induced fluorescence Biluminator (QLF-D) was used to determine mean fluorescence loss. Data were analyzed using one-way analysis of variance (ANOVA) to compare differences in means. Results: The results demonstrated a significant reduction in CFUs between treated and non-treated groups grown with/without 1% sucrose. ∆Z was significantly reduced for specimens exposed to biofilms grown without sucrose with violet-blue light. There was only a trend on reduction of ∆Z with sucrose and with L on both groups. There were no differences in fluorescence-derived parameters between the groups. Conclusions: Within the limitations of the study, the results indicate that violet-blue light can serve as an adjunct prophylactic treatment for reducing S. mutans biofilm formation and enamel mineral loss.
Identifying Patients' Smoking Status from Electronic Dental Records Data
(IOS Press, 2017) Patel, Jay; Siddiqui, Zasim; Krishnan, Anand; Thyvalikakath, Thankam; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Smoking is a significant risk factor for initiation and progression of oral diseases. A patient's current smoking status and tobacco dependency can aid clinical decision making and treatment planning. The free-text nature of this data limits accessibility causing obstacles during the time of care and research utility. No studies exist on extracting patient's smoking status automatically from the Electronic Dental Record. This study reports the development and evaluation of an NLP system for this purpose.
Characterizing Restorative Dental Treatments of Sjögren's Syndrome Patients Using Electronic Dental Records Data
(IOS Press, 2017) Siddiqui, Zasim; Wang, Yue; Makkad, Payal; Thyvalikakath, Thankam; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Scant knowledge exists on the type of restorative treatments Sjögren's syndrome patients (SSP) receive in spite of their high dental disease burden due to hyposalivation. Increased adoption of electronic dental records (EDR) could help in leveraging information from these records to assess dental treatment outcomes in SSP. In this study, we evaluated the feasibility of using EDR to characterize the dental treatments SSP received and assess the longevity of implants in these patients. We identified 180 SSP in ten years of patients' data at the Indiana University School of Dentistry clinics. A total of 104 (57.77%) patients received restorative or endodontic treatments. Eleven patients received 23 implants with a survival rate of 87% at 40 months follow-up. We conclude that EDR data could be used for characterizing the treatments received by SSP and for assessing treatment outcomes.

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