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Item ADDENDUM: Critical windows of fluoride neurotoxicity in Canadian Children(Elsevier, 2022) Farmus, Linda; Till, Christine; Green, Rivka; Hornung, Richard; Martinez Mier, E. Angeles; Ayotte, Pierre; Muckle, Gina; Lanphear, Bruce P.; Flora, David B.; Dental Public Health and Dental Informatics, School of DentistryItem Critical windows of fluoride neurotoxicity in Canadian children(Elsevier, 2021) Farmus, Linda; Till, Christine; Green, Rivka; Hornung, Richard; Martinez Mier, E. Angeles; Ayotte, Pierre; Muckle, Gina; Lanphear, Bruce P.; Flora, David B.; Dental Public Health and Dental Informatics, School of DentistryBackground: Fluoride has been associated with IQ deficits during early brain development, but the period in which children are most sensitive is unknown. Objective: We assessed effects of fluoride on IQ scores across prenatal and postnatal exposure windows. Methods: We used repeated exposures from 596 mother-child pairs in the Maternal-Infant Research on Environmental Chemicals pregnancy and birth cohort. Fluoride was measured in urine (mg/L) collected from women during pregnancy and in their children between 1.9 and 4.4 years; urinary fluoride was adjusted for specific gravity. We estimated infant fluoride exposure (mg/day) using water fluoride concentration and duration of formula-feeding over the first year of life. Intelligence was assessed at 3-4 years using the Wechsler Preschool and Primary Scale of Intelligence-III. We used generalized estimating equations to examine the associations between fluoride exposures and IQ, adjusting for covariates. We report results based on standardized exposures given their varying units of measurement. Results: The association between fluoride and performance IQ (PIQ) significantly differed across prenatal, infancy, and childhood exposure windows collapsing across child sex (p = .001). The strongest association between fluoride and PIQ was during the prenatal window, B = -2.36, 95% CI: -3.63, -1.08; the association was also significant during infancy, B = -2.11, 95% CI: -3.45, -0.76, but weaker in childhood, B = -1.51, 95% CI: -2.90, -0.12. Within sex, the association between fluoride and PIQ significantly differed across the three exposure windows (boys: p = .01; girls: p = .01); among boys, the strongest association was during the prenatal window, B = -3.01, 95% CI: -4.60, -1.42, whereas among girls, the strongest association was during infancy, B = -2.71, 95% CI: -4.59, -0.83. Full-scale IQ estimates were weaker than PIQ estimates for every window. Fluoride was not significantly associated with Verbal IQ across any exposure window. Conclusion: Associations between fluoride exposure and PIQ differed based on timing of exposure. The prenatal window may be critical for boys, whereas infancy may be a critical window for girls.Item Maternal fluoride exposure, fertility and birth outcomes: The MIREC cohort(Elsevier, 2022-04) Goodman , Carly; Hall , Meaghan; Green , Rivka; Hornung , Richard; Martinez-Mier , Esperanza Angeles; Lanphear , Bruce; Till, Christine; Dental Public Health and Dental Informatics, School of DentistryObjective Fluoride exposure >1.5 mg/L from water has been associated with adverse pregnancy and birth outcomes. Little is known, however, about the effect of fluoride at levels consistent with water fluoridation (i.e., 0.7 mg/L) on pregnancy and birth outcomes. We examined the relationship between maternal fluoride exposure, fertility, and birth outcomes in a Canadian pregnancy cohort living in areas where municipal drinking water fluoride concentrations ranged from 0.04 to 0.87 mg/L. Methods Using data from the Maternal-Infant Research on Environmental Chemicals (MIREC) study, we estimated fluoride exposure during pregnancy using three different metrics: (1) maternal urinary fluoride concentrations standardized for specific gravity (MUFSG) and averaged across all three trimesters (N = 1566), (2) water fluoride concentration (N = 1370), and (3) fluoride intake based on self-reported consumption of water, coffee, and tea, adjusted for body weight (N = 1192). Data on fertility, birth weight, gestational age, preterm birth, and small-for-gestational age (SGA) were assessed. We used multiple linear regression to examine associations between fluoride exposure, birth weight and gestational age, and logistic regression to examine associations with fertility, preterm birth, and SGA, adjusted for relevant covariates. Results Median (IQR) MUFSG was 0.50 (0.33–0.76) mg/L, median water fluoride was 0.52 (0.17–0.64) mg/L, and median fluoride intake was 0.008 (0.003–0.013) mg/kg/day. MUFSG, water fluoride concentrations, and fluoride intake were not significantly associated with fertility, birth weight, gestational age, preterm birth, or SGA. Fetal sex did not modify any of the associations. Conclusion Fluoride exposure during pregnancy was not associated with fertility or birth outcomes in this Canadian cohort.Item Longevity of dental restorations in Sjogren's disease patients using electronic dental and health record data(Springer Nature, 2024-02-07) Gomez, Grace Gomez Felix; Wang, Mei; Siddiqui, Zasim A.; Gonzalez, Theresa; Capin, Oriana R.; Willis, Lisa; Boyd, LaKeisha; Eckert, George J.; Zero, Domenick T.; Thyvalikakath, Thankam Paul; Dental Public Health and Dental Informatics, School of DentistryBackground: Decreased salivary secretion is not only a risk factor for carious lesions in Sjögren's disease (SD) but also an indicator of deterioration of teeth with every restorative replacement. This study determined the longevity of direct dental restorations placed in patients with SD using matched electronic dental record (EDR) and electronic health record (EHR) data. Methods: We conducted a retrospective cohort study using EDR and EHR data of Indiana University School of Dentistry patients who have a SD diagnosis in their EHR. Treatment history of patients during 15 years with SD (cases) and their matched controls with at least one direct dental restoration were retrieved from the EDR. Descriptive statistics summarized the study population characteristics. Cox regression models with random effects analyzed differences between cases and controls for time to direct restoration failure. Further the model explored the effect of covariates such as age, sex, race, dental insurance, medical insurance, medical diagnosis, medication use, preventive dental visits per year, and the number of tooth surfaces on time to restoration failure. Results: At least one completed direct restoration was present for 102 cases and 42 controls resulting in a cohort of 144 patients' EDR and EHR data. The cases were distributed as 21 positives, 57 negatives, and 24 uncertain cases based on clinical findings. The average age was 56, about 93% were females, 54% were White, 74% had no dental insurance, 61% had public medical insurance, < 1 preventive dental visit per year, 94% used medications and 93% had a medical diagnosis that potentially causes dry mouth within the overall study cohort. About 529 direct dental restorations were present in cases with SD and 140 restorations in corresponding controls. Hazard ratios of 2.99 (1.48-6.03; p = 0.002) and 3.30 (1.49-7.31, p-value: 0.003) showed significantly decreased time to restoration failure among cases and positive for SD cases compared to controls, respectively. Except for the number of tooth surfaces, no other covariates had a significant influence on the survival time. Conclusion: Considering the rapid failure of dental restorations, appropriate post-treatment assessment, management, and evaluation should be implemented while planning restorative dental procedures among cases with SD. Since survival time is decreased with an increase in the number of surfaces, guidelines for restorative procedures should be formulated specifically for patients with SD.Item Findings and Future Directions from a Smoking Cessation Trial Utilizing a Clinical Decision Support Tool(Elsevier, 2022-09) Rindal, Donald Brad; Kottke, Thomas E.; Jurkovich, Mark W.; Asche, Stephen E.; Enstad , Chris J.; Truitt, Anjali R.; Ziegenfuss, Jeanette Y.; Romito, Laura M.; Thyvalikakath, Thankam P.; O'Donnell, Jean; Spallek, Heiko; Dental Public Health and Dental Informatics, School of DentistryBackground Tobacco smoking is the leading cause of disease, death, and disability in the United States. Dental practitioners are advised to provide evidence-based smoking cessation interventions to their patients, yet dental practitioners frequently fail to deliver brief smoking cessation advice. Objectives To test whether giving dental practitioners a clinical decisions support (CDS) system embedded in their electronic dental record would increase the rate at which patients who smoke (1) report receiving a brief intervention or referral to treatment during a recent dental visit, (2) taking action related to smoking cessation within 7 days of visit, and (3) stop smoking for 1 day or more or reduce the amount smoked by 50% within 6 months. Methods Two-group, parallel arm, cluster-randomized trial. From March through December 2019, 15 nonacademic primary care dental clinics were randomized via covariate adaptive randomization to either a usual care arm or the CDS arm. Adult smokers completed an initial telephone survey within 7 days of their visit and another survey after 6 months. Results Forty-three patients from 5 CDS and 13 patients from 2 usual care clinics completed the 7-day survey. While the proportion of patients who reported receipt of a brief intervention or referral to treatment was significantly greater in the CDS arm than the usual care arm (84.3% vs 58.6%; P = .005), the differences in percentage of patients who took any action related to smoking cessation within 7 days (44.4% vs 22.3%; P = .077), or stopped smoking for one day or more and/or reduced amount smoked by 50% within 6 months (63.1% vs 46.2%; P = .405) were large but not statistically significant. Conclusions Despite interruption by COVID-19, these results demonstrate a promising approach to assist dental practitioners in providing their patients with smoking cessation screening, brief intervention and referral to treatment.Item Demarcated Primary Second Molar Hypomineralization: Prevalence Data and Associated Sociodemographic Determinants from Indiana(American Academy of Pediatric Dentistry, 2021) Ahmed, Azza Tagelsir; Soto-Rojas, Armando; Dean, Jeffrey; Eckert, George J.; Martinez-Mier, Esperanza Angeles; Dental Public Health and Dental Informatics, School of DentistryPurpose: Demarcated primary second molar hypomineralization (DMH-Es) is a common developmental defect of enamel, with prevalence estimates between five percent and 20 percent. From the Americas, studies exploring the problem of DMH-Es and explicitly using the European Academy of Pediatric Dentistry diagnostic criteria were limited to some South American countries, but no similar studies were available from any of the North American countries including the United States. The purpose of this study was to investigate the prevalence and sociodemographic determinants of DMH-Es among schoolchildren in Indiana, USA. Methods: Four hundred twenty-three schoolchildren (average age equals 7.6 [±2.2 standard deviation] years) were examined by a calibrated pediatric dentist. Sociodemographic data were collected from patients' questionnaires and electronic dental records. Results: DMH-Es had a prevalence estimate of six percent versus 40 percent overall of any enamel defect (AED) of the primary second molars (PSMs) and/or the permanent first molars (PFMs). Race/ethnicity was significantly associated with a higher overall prevalence of AED of PSMs but not with the prevalence estimate of DMH-Es. Older age group (10 years or older), living in central Indiana, and water fluoridation were significantly associated with a higher overall prevalence of AEDs (P<0.01) but not with the prevalence of DMH-Es. Caries experience was significantly higher in children with demarcated molar hypomineralization (DMH) of PFMs and/or PSMs than in the group without. Conclusions: DMH-Es prevalence estimate was similar to the global figures. Certain demographic characteristics were significantly associated with the overall prevalence of the enamel defects of the examined teeth.Item Root Canal Treatment Survival Analysis in National Dental PBRN Practices(Sage, 2022-10) Thyvalikakath, T.; LaPradd, M.; Siddiqui, Z.; Duncan, W. D.; Eckert, G.; Medam, J. K.; Rindal, D. B.; Jurkovich, M.; Gilbert, G. H.; National Dental PBRN Collaborative Group; Dental Public Health and Dental Informatics, School of DentistryFew studies have examined the longevity of endodontically treated teeth in nonacademic clinical settings where most of the population receives its care. This study aimed to quantify the longevity of teeth treated endodontically in general dentistry practices and test the hypothesis that longevity significantly differed by the patient’s age, gender, dental insurance, geographic region, and placement of a crown and/or other restoration soon after root canal treatment (RCT). This retrospective study used deidentified data of patients who underwent RCT of permanent teeth through October 2015 in 99 general dentistry practices in the National Dental Practice-Based Research Network (Network). The data set included 46,702 patients and 71,283 RCT permanent teeth. The Kaplan–Meier (product limit) estimator was performed to estimate survival rate after the first RCT performed on a specific tooth. The Cox proportional hazards model was done to account for patient- and tooth-specific covariates. The overall median survival time was 11.1 y; 26% of RCT teeth survived beyond 20 y. Tooth type, presence of dental insurance any time during dental care, placement of crown and/or receiving a filling soon after RCT, and Network region were significant predictors of survival time (P < 0.0001). Gender and age were not statistically significant predictors in univariable analysis, but in multivariable analyses, gender was significant after accounting for other variables. This study of Network practices geographically distributed across the United States observed shorter longevity of endodontically treated permanent teeth than in previous community-based studies. Also, having a crown placed following an RCT was associated with 5.3 y longer median survival time. Teeth that received a filling soon after the RCT before the crown was placed had a median survival time of 20.1 y compared to RCT teeth with only a crown (11.4 y), only a filling (11.2 y), or no filling and no crown (6.5 y).Item Dentists’ Information Needs and Opinions on Accessing Patient Information via Health Information Exchange: Survey Study(JMIR, 2024-01-11) Li, Shuning; Gomez, Grace Felix; Xu, Huiping; Rajapuri, Anushri Singh; Dixon, Brian E.; Thyvalikakath, Thankam; Biostatistics and Health Data Science, Richard M. Fairbanks School of Public HealthBackground: The integration of medical and dental records is gaining significance over the past 2 decades. However, few studies have evaluated the opinions of practicing dentists on patient medical histories. Questions remain on dentists' information needs; their perception of the reliability of patient-reported medical history; satisfaction with the available information and the methods to gather this information; and their attitudes to other options, such as a health information exchange (HIE) network, to collect patient medical history. Objective: This study aims to determine Indiana dentists' information needs regarding patients' medical information and their opinions about accessing it via an HIE. Methods: We administered a web-based survey to Indiana Dental Association members to assess their current medical information-retrieval approaches, the information critical for dental care, and their willingness to access or share information via an HIE. We used descriptive statistics to summarize survey results and multivariable regression to examine the associations between survey respondents' characteristics and responses. Results: Of the 161 respondents (161/2148, 7.5% response rate), 99.5% (n=160) respondents considered patients' medical histories essential to confirm no contraindications, including allergies or the need for antibiotic prophylaxis during dental care and other adverse drug events. The critical information required were medical conditions or diagnosis, current medications, and allergies, which were gathered from patient reports. Furthermore, 88.2% (n=142) of respondents considered patient-reported histories reliable; however, they experienced challenges obtaining information from patients and physicians. Additionally, 70.2% (n=113) of respondents, especially those who currently access an HIE or electronic health record, were willing to use an HIE to access or share their patient's information, and 91.3% (n=147) shared varying interests in such a service. However, usability, data accuracy, data safety, and cost are the driving factors in adopting an HIE. Conclusions: Patients' medical histories are essential for dentists to optimize dental care, especially for those with chronic conditions. In addition, most dentists are interested in using an HIE to access patient medical histories. The findings from this study can provide an alternative option for improving communications between dental and medical professionals and help the health information technology system or tool developers identify critical requirements for more user-friendly designs.Item Fluorotic Enamel Susceptibility to Dental Erosion and Fluoride Treatment(Ribeirão Preto Dental Foundation, 2023) Silva, Cristiane Araújo Maia; de Sousa, Frederico Barbosa; Martinez-Mier, Esperanza Angele; Vieira, Basílio Rodrigues; do Nascimento, Johnatan Meireles; Hara, Anderson Takeo; Dental Public Health and Dental Informatics, School of DentistryThe purpose of this in vitro study was to test the hypothesis that fluoride treatment can prevent dental erosion on fluorotic enamel of different severities. It followed a 3×2 factorial design, considering a) fluorosis severity: sound (TF0, Thylstrup-Fejerskov Index), mild (TF1-2), moderate (TF3-4); and b) fluoride treatment: 0 (negative control) and 1150ppmF. Human molars with the three fluorosis severities (n=16, each) were selected and randomly assigned to the two fluoride treatments (n=8). Enamel blocks (4×4mm) were prepared from each tooth and subjected to a dental erosion cycling model, for 10 days. The daily cycling protocol consisted of erosive challenges (1% citric acid, pH 2.4), interspersed by periods of immersion in artificial saliva, and three 2-minute treatments with either 0 or 1150ppm F. The enamel volume loss (mm3) was calculated by subtracting values obtained by microtomography before and after cycling. Two-Way ANOVA showed no significant interaction between fluorosis severity and fluoride treatment (p=0.691), and no significant effect for either fluorosis severity (TF0 mean±standard-deviation: 13.5(10-2±0.42(10-2, TF1-2: 1.50(10-2±0.52(10-2, TF3-4: 1.24(10-2±0.52(10-2, p=0.416) or treatment (0ppmF: 1.49(10-2±0.53(10-2; 1150ppmF: 1.21(10-2±0.42(10-2; p=0.093), when evaluated independently. Considering the limitations of this in vitro study, the presence and severity of fluorosis in enamel do not appear to affect its susceptibility to dental erosion. Fluoride treatment was not effective in preventing the development of dental erosion in both sound and fluorotic enamel substrates under our experimental conditions.Item Domain-specific effects of prenatal fluoride exposure on child IQ at 4, 5, and 6–12 years in the ELEMENT cohort(Elsevier, 2022) Goodman, Carly V.; Bashash, Morteza; Green, Rivka; Song, Peter; Peterson, Karen E.; Schnaas, Lourdes; Mercado-García, Adriana; Martínez-Medina, Sandra; Hernández-Avila, Mauricio; Martinez-Mier, Angeles; Téllez-Rojo, Martha M.; Hu, Howard; Till, Christine; Dental Public Health and Dental Informatics, School of DentistryObjective: Prenatal exposure to fluoride has been associated with adverse neurodevelopmental outcomes. However, the neuropsychological profile of fluoride's developmental neurotoxicity at low levels and the stability of this relationship across childhood has not been characterized. We investigated the longitudinal and domain specific effect of prenatal fluoride exposure on IQ among children ages 4, 5, and 6-12 years in the Early Life Exposures in Mexico to Environmental Toxicants (ELEMENT) cohort. Methods: We measured the average of maternal urinary fluoride at each trimester of pregnancy adjusted for creatinine (MUFCRE). Children were administered the McCarthy Scales of Children's Abilities at ages 4 (N = 386) and 5 (N = 308), and the Wechsler Abbreviated Scale of Intelligence at age 6-12 (N = 278). We used generalized estimating equation (GEE) models to estimate the population averaged effect of MUFCRE concentration on longitudinal General Cognitive Index (GCI)/Full-Scale IQ (FSIQ), Verbal IQ (VIQ), and Performance IQ (PIQ) scores (N = 348). We tested for possible interactions between MUFCRE and child sex as well as for MUFCRE and time point on children's IQ. All models controlled for relevant available covariates. Results: The mean/median MUFCRE concentration was 0.90/0.83 mg/L (SD = 0.39; IQR, 0.64-1.11 mg/L). A 0.5 mg/L increase in MUFCRE predicted an average 2.12-point decrease in GCI/FSIQ (95% CI: -3.49, -0.75) and 2.63-point decrease in PIQ (95% CI: -3.87, -1.40). MUFCRE was marginally associated with VIQ across time (B = -1.29, 95% CI: -2.60, 0.01). No interactions between MUFCRE and child sex or MUFCRE and time were observed. Conclusion: The negative association between prenatal fluoride exposure and longitudinal IQ was driven by decrements in non-verbal intelligence (i.e. PIQ), suggesting that visual-spatial and perceptual reasoning abilities may be more impacted by prenatal fluoride exposure as compared to verbal abilities.