Department of Comprehensive Care and Allied Professions Works

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Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians
(BMC, 2010-05-13) Maupomé, Gerardo; Schrader, Stuart; Mannan, Saurabh; Garetto, Lawrence; Eggertsson, Hafsteinn; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Background It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians. Methods We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-analyzed, following the Gale and Marsden model for clinical decision-making. Limited tests used to contrast data were t, χ2, and Fisher's. Scott's π was used to determine inter-coder reliability. Results Fifteen dentists and 17 senior dental students participated in visits lasting 32.0 minutes (± 12.9) among experts, and 29.9 ± 7.1 among students; contact time with patient was 26.4 ± 13.9 minutes (experts), and 22.2 ± 7.5 (students). The time elapsed between the first and the last instances of the clinician looking in the mouth was similar between experts and students. Ninety eight types of pieces of information were used in combinations with 12 DTPs. The main differences found in DTP utilization had dentists conducting diagnostic interpretations of findings with sufficient certainty to be considered definitive twice as often as students. Students resorted more often to more general or clarifying enquiry in their search for information than dentists. Conclusions Differences in diagnostic strategies and concepts existed within clearly delimited types of cognitive processes; such processes were largely compatible with the analytic and (in particular) non-analytic approaches to clinical decision-making identified in the medical field. Because we were focused on a clinical presentation primarily made up of non-emergency treatment needs, use of other DTPs and concepts might occur when clinicians evaluate emergency treatment needs, complex rehabilitative cases, and/or medically compromised patients.
An In-Vitro Study to Determine Anti-Caries Efficacy of Fluoride Varnishes
(Office of the Vice Chancellor for Research, 2013-04-05) Al Dehailan, Laila; Mier, E. Angeles Martinez; Lippert, Frank
Fundamental research on fluoride varnishes (FV) and how different formulations affect adherence to teeth, fluoride release into saliva and uptake by teeth is virtually non-existent. The objective of this in vitro study was to investigate the anti-caries efficacy of five commercially available FV: Enamel Pro® Varnish Clear, Flor-Opal® Varnish White, MI Varnish™, PreviDent® and Vanish™. Ninety bovine enamel specimens (4x4mm) were prepared and assigned to five groups (n=18). Early caries lesions were created in the specimens and characterized using Vickers microhardness (VHN). FV was applied to each group of specimens. Immediately afterwards, 7.5ml of artificial saliva (AS) were pipetted over each group, collected and renewed every 15min for 6h. AS samples were analyzed for fluoride using a ion-specific electrode and meter. FV was removed using chloroform and part of the specimens protected to determine enamel fluoride uptake (EFU) using the acid etch technique. Each group was then subjected to pH cycling consisting of a 4h/day acid challenge and two, one-minute treatments with Crest Cavity Protection. Post-pH cycling microhardness was measured and compared to baseline values to determine the ability of the FV to enhance remineralization/prevent demineralization. One-way ANOVA was used for data analysis (p<0.05). Specimens treated with Enamel Pro® revealed an increase in VHN that was significantly higher than all other groups. There was no significant difference in ΔVHN for Flor-Opal® compared to MI Varnish™, PreviDent® and Vanish™. Specimens treated with MI Varnish™ showed significantly higher ΔVHN than Vanish™ only. No significant difference in EFU was found among groups. Total fluoride release over 6h was MI Varnish™(303μg/ml) > Enamel Pro® (217μg/ml) > Flor-Opal® (153μg/ml) > PreviDent® (84μg/ml) > Vanish(28μg/ml). In conclusion, anti-caries efficacy (measured through EFU, fluoride release and VHN) differs among FV products and this difference may be attributed to different composition, fluoride source and other active ingredients.
Effectiveness and Mechanisms of Action of Whitening Dentifrices on Enamel Extrinsic Stains
(Office of the Vice Chancellor for Research, 2013-04-05) Alshara, Salem; Lippert, Frank; Hara, Anderson T.
Whitening dentifrices utilize different approaches for stain removal and/or prevention, including the use of abrasive, oxidizing and chemical cleaning agents. The objectives of this in vitro study were: 1. to compare the whitening effect of commercial whitening and non-whitening dentifrices; 2. to verify the mechanism of action of whitening dentifrices by contrasting two experimental models: chemical (toothpaste exposure only) and chemo-mechanical (toothpaste exposure with tooth brushing abrasion). Two hundred fifty six bovine enamel specimens (10x10mm) were prepared and partially stained. They were assigned to 8 groups: 6 whitening dentifrices, 1 non-whitening reference dentifrice and deionized water (control); and further divided in 2 subgroups (n=16) according to the experimental models: chemical or chemo-mechanical. Specimens were daily exposed to dentifrice slurries 2x/day for 1min and brushed or not, according to each model. In between dentifrice treatments, specimens were exposed to the staining solution for 5h. This protocol was repeated for 5 consecutive days and enamel color changes (Delta E) were measured by spectrophotometry, after each day. The abrasivity of the toothpastes was determined using standard test (ISO 11609). Significantly higher Delta E values (whitening effect) were observed for all groups (p<0.05), except control, when tested in the chemo-mechanical model. In this model, the whitening ability of the toothpastes was mainly determined by their abrasive levels. For the chemical model, no significant differences were observed among groups (p>0.05). Whitening dentifrices can be effective preventing/removing enamel surface staining, when associated to tooth brushing abrasion. This seemed to be modulated mainly by the abrasive level of the tested toothpastes, with no action attributed to the chemical agents.
Comparison Between Radiotracer and Surface Profile Methods for the Determination of Dentifrice
(Office of the Vice Chancellor for Research, 2013-04-05) Sabrah, Alaa; Lippert, Frank; Kelly, Adam B.; Hara, Anderson T.
Introduction: ISO11609 states that a surface profile (Sp) method can be used to determine dentifrice abrasivity in relation to dentin (RDA) as an alternative to the traditional radiotracer method (Rt). A comparison between both methods was performed in this study. Methods: Specimens from human root dentin were prepared for each method and randomly assigned to 8 dentifrice/abrasive groups (n=8), which represented a wide abrasivity range. Aqueous dentifrice slurries or abrasive suspensions in a solution containing 0.5% carboxymethylcellulose and 10% glycerin were used to brush specimens in a custom-made V-8 cross-brushing machine. Two independent studies (Sp, Rt) were carried out. For Rt, the specimen preparation, study design, analysis and calculation of the abrasive level (RDA) followed the ISO11609/Annex A guidelines. Similarly for Sp, the ISO11609/Annex B recommendations were followed, except by the number of brushing strokes, which was pre-determined to be 2000 strokes (instead of 10000) in a preliminary test. Data were analyzed using ANOVA and Tukey tests, with significance level set at 5%. The correlation between methods was also investigated. Results: Overall, higher variation and RDA values were observed for the Sp method compared to Rt. While good correlation was found between methods (R2=0.841), group ranking was dissimilar and better statistical differentiation among groups was observed in Rt. Conclusions: The Rt method showed to be a more standardized and robust method compared to Sp for the determination of RDA values of dentifrices/abrasives. Sp needs to be further developed before being considered as an equivalent test method for RDA. The determination of the abrasive levels of toothpastes using standard testing methods is important to guide oral care professionals and patients on the prevention of toothbrushing abrasive wear.
Fluoride Release from Fluoride Varnishes under Acidic Conditions
(2014-09) Lippert, Frank; Department of Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Objective: The aim was to investigate the in vitro fluoride release from fluoride varnishes under acidic conditions. Study design: Poly(methyl methacrylate) blocks (Perspex, n=3 per group) were painted with 80±5 mg fluoride varnish (n=10) and placed into artificial saliva for 30min. Then, blocks were placed into either 1% citric acid (pH 2.27) or 0.3% citric acid (pH 3.75) solutions (n=3 per solution and varnish) for 30min with the solutions being replaced every 5min. Saliva and acid solutions were analyzed for fluoride content. Data were analyzed using three-way ANOVA (varnish, solution, time). Results: The three-way interaction was significant (p>0.0001). Fluoride release and release patterns varied considerably between varnishes. Fluoride release in saliva varied by a factor of more than 10 between varnishes. Some varnishes (CavityShield, Nupro, ProFluorid, Vanish) showed higher fluoride release in saliva than during the first 5min of acid exposure, whereas other varnishes (Acclean, Enamel-Pro, MI Varnish, Vella) showed the opposite behavior. There was little difference between acidic solutions. Conclusions: Fluoride release from fluoride varnishes varies considerably and also depends on the dissolution medium. Bearing in mind the limitations of laboratory research, the consumption of acidic drinks after fluoride varnish application should be avoided to optimize the benefit/risk ratio.
Network science and oral health research
(Wiley Blackwell (Blackwell Publishing), 2015) Maupome, Gerardo; McCranie, Ann; Department of Cariology, Operative Dentistry and Dental Public Health, IU School of Dentistry
The present overview of research methods describes a scientific enquiry paradigm that is well established in other disciplines, including health research, but that is fairly new to oral health research. Social networks analysis (SNA) or network science research is a set of relational methods purporting to identify and characterize the connections between members of a system or network, as well as the structure of the network. Persons and communities making up the members of networks have commonly been the focus of SNA studies but corporations or living organisms might just as well be organized in networks. SNA is grounded in both graphic imagery and computational models. SNA is based on the assumptions that features and structure of networks are amenable to characterization, that such information sheds light on the ways members of the network relate to each other (sharing information, diseases, norms, and so on), and that through these connections between members the overall network structure and characteristics are shaped. The overview resorts to examples specific to oral health themes and proposes a few general avenues for population-based research.
Lay public’s use of a support group for general dental problems
(2016) Walker, K. K.; Jackson, Richard D.; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
Objective: To categorize and tabulate layperson inquiries made to an Internet dental health support site to identify oral conditions and associated behaviors of concern. Methods: A retrospective tabulation of wall postings was made from an established dental health support website hosted by WebMD over a 2-year period (April 2013-April 2015). A mixed method approach of content and thematic analysis was used. Content analysis identified content of oral health concerns, while thematic analysis using grounded theory identified themes and beliefs concerning associated behaviors. Results: The presence of non-descript growths on the tongue and swelling and/or discoloration of the lips elicited the most inquires. These were often self-diagnosed as oral candidiasis, a STD or a carcinoma, provoking high levels of self-concern. Unprotected sexual activity, excessive ingestion of soft and hard beverages, smoking and overexposure to the sun were the most frequently self-reported behaviors associated with their concerns. Many questions focused upon “normal” healing, including the amount of edema and discomfort that could occur following oral surgery or other dental procedures. Information concerning alternative treatments was often solicited, and many alluded that they had not been provided sufficient information to make informed decisions prior to dental treatment. Conclusion: Laypersons have many oral health concerns particularly in relationship to the development of undiagnosed pathologies in conjunction with a history of volitional behaviors. The dental community should monitor these sites to provide advice and links to information about common oral health concerns and their possible association with detrimental behaviors. Key words: oral health, self-help groups, knowledge, health education, online, internet
Segmentation of Mexican-Heritage Immigrants: Acculturation Typology and Language Preference in Health Information Seeking
(Springer, 2016) Shin, YoungJu; Maupome, Gerardo; Department of Cariology, Operative Dentistry and Dental Public Health, IU School of Dentistry
With the fast growing number of Mexican immigrants in the United States, more attention is needed to understand the relationship between acculturation and language preference in health information seeking. Latent class analysis provides one useful approach to understanding the diversity in sample of Mexican immigrants (N = 238). Based on 13 linguistic, psychological and behavioral indicators for acculturation, four discrete subgroups were characterized: (1) Less acculturated, (2) Moderately acculturated, (3) Highly acculturated, (4) Selectively bicultural. A Chi-square test revealed that three sub-groups were significantly different in language preference when seeking health information. Less acculturated and moderately acculturated groups sought health information in Spanish, whereas the highly acculturated group preferred English for health information. Selectively bicultural group preferred bilingual health information. Implications for health campaign strategies using audience segmentation are discussed.
Clinician-Patient Small Talk: Comparing Fourth-Year Dental Students and Practicing Dentists in a Standardized Patient Encounter
(2016) Maupome, Gerardo; Holcomb, Christopher; Schrader, Stuart; Cariology, Operative Dentistry and Dental Public Health, School of Dentistry
The aim of this study was to establish whether frequency of non-diagnostic, non-management exchanges between clinicians and patient (called “socioemotional communication,” SC) during a consultation differed between fourth-year dental students and dentists, controlling for clinically driven exchanges of information. Fifteen dentists and 17 fourth-year dental students were recorded in 2006 while undergoing a consultation with a live standardized patient and were subsequently interviewed by investigators in a separate room with the recording present for analysis. Their shared interpretations of cognitive strategies were recorded and compared for differences in the presence of SC. The results showed that most of the students and dentists engaged in SC throughout the consultation with a few exceptions. There were no significant differences between student and dentist cohorts for overall SC presence (p=0.62), time to first instance of SC from overall start of the consultation (p=0.73), and time to first instance of SC after first intraoral examination had taken place (p=0.76). Nonsignificant differences were also recorded for overall frequency at which SC occurred from overall start of the consultation (p=0.89) and after the first intraoral examination had taken place (p=0.12). The patterns showed SC interaction occurring throughout the consultation, not concentrated at the beginning or end. SC did not appear to differ between practitioners and students in terms of prevalence, frequency, or timing. Future research should examine the detailed association between SC and diagnostic thinking processes to further delineate the relationship and characterize possible pedagogical applications.
Tooth-Loss Experience and Associated Variables among Adult Mexicans 60 Years and Older
(2016-06) Islas-Granillo, Horacio; Borges-Yañez, Aida; Medina-Solis, Carlo Eduardo; Lucas-Rincón, Salvador Eduardo; Navarrete-Hernández, José de Jesus; Villalobos-Rodelo, Juan José; Casanova-Rosado, Juan Fernando; Maupome, Gerardo; Department of Cariology, Operative Dentistry and Dental Public Health, IU School of Dentistry
Objective: This study was conducted to determine the experience of tooth loss, as well as its associated variables, in a sample of adult Mexicans, aged 60 years and older. Materials and Methods: This cross-sectional study was part of a larger project to measure diverse oral health indicators in a convenience sample: it included 139 adult Mexican seniors (69.1% of whom were women), ages 60 years and older, either living in long-term care facilities or living independently and participating in adult day care services. Each participant underwent an oral examination to determine the number of missing teeth. Questionnaires were administered to collect sociodemographic, socioeconomic, and behavioral data. Statistical analyses were performed using nonparametric tests and negative binomial regression. Results: The mean age was 79.06 (±9.78 years). The mean number of missing teeth was 20.02 (±8.61; median, 24); 99.3% of the participants had at least 1 missing tooth, and only 14 had 20 teeth or more. Using a negative binomial regression multivariate model, we found that for each year’s increase in age, the mean number of teeth lost increased by 1% (p<0.05). In individuals who brushed their teeth fewer than two times a day, who had received radiotherapy, or who were currently smokers, the average tooth loss increased 49.2%, 22.6%, and 19.0%, respectively (p<0.01). Conclusion: Tooth-loss experience in these Mexican seniors was very high (20.02±8.61). Older age (within the range of this group of seniors), tooth-brushing patterns, the receipt of radiation therapy, and (current) tobacco use were associated with higher experience of tooth loss.

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