Caries prevalence and associations with medications and medical comorbidities

High Anticholinergic Burden and Dental Caries: Findings from Northern Finland Birth Cohort 1966

INTRODUCTION

Anticholinergic drugs propose a threat for oral health by causing dry mouth. The aim of this cross-sectional study was to investigate whether a high anticholinergic burden was associated with the presence of initial caries lesions, manifested caries lesions, dental fillings, or tooth loss among 46-y-old people.

METHODS

The study population consisted of 1,906 participants from the Northern Finland Birth Cohort 1966 who underwent an oral health examination in 2012-2013. Socioeconomic and medical data were collected from questionnaires, medical records, and national registers. Nine previously published anticholinergic scales were combined and used to measure the high anticholinergic burden from the participants' medication data. Cariological status was determined according to the International Caries Detection and Assessment System, and the number of missing teeth (excluding third molars) was used as an indicator for tooth loss. The decayed, missing, and filled surfaces index was used to depict caries experience. Negative binominal regression models were used to estimate prevalence rate ratios (PRRs) and confidence intervals (CIs).

RESULTS

Fourteen percent of the participants (n = 276) used at least 1 anticholinergic drug and about 3% had a high anticholinergic burden (n = 61). After adjusting for confounding factors, participants with a high anticholinergic burden had a higher likelihood of having manifested carious lesions needing restorative treatment (PRR, 1.60; CI, 1.11-2.29) and more missing teeth (PRR, 1.59; CI, 1.13-2.24) when compared to participants without any or with a lower anticholinergic burden.

CONCLUSIONS

High anticholinergic burden was associated with a present caries experience and with tooth loss among the general middle-aged population.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study suggest that middle-aged patients with a high anticholinergic burden may have a heightened risk of dental caries. These patients may benefit from targeted caries preventive regimes.

The effect of antibiotic premedication on postoperative complications following dental extractions

OBJECTIVES

We aimed to evaluate the association between antibiotic prophylaxis and adverse outcomes following tooth extraction within the Veterans Affairs Healthcare System.

METHODS

We conducted a retrospective cohort study of patients undergoing dental extractions in 2015-2019. The primary exposure was antibiotic prophylaxis. The primary outcome was post-extraction complication within 7 days (e.g., alveolar osteitis and surgical site infection); the secondary outcome was subsequent medical care relating to a post-extraction oral complication within 7 days. Multivariable logistic regression models assessed the independent effect of antibiotic prophylaxis on each outcome.

RESULTS

Of 385,880 visits with a dental extraction, 122,810 (31.8%) received antibiotic prophylaxis. Overall, 3387 (0.9%) experienced a post-extraction complication and 350 (0.09%) received medical care relating to a post-extraction oral complication within 7 days. In multivariable regression, diabetes was a statistically significant (p = 0.01) effect modifier of the association between antibiotic prophylaxis and post-extraction complication. Among visits for patients without diabetes, antibiotic prophylaxis was significantly associated with an increased odds of post-extraction complication (odds ratio [OR] = 1.25, 95% confidence interval [CI]: 1.13-1.38), but among visits for patients with diabetes no significant effect was observed (OR = 1.03, 95% CI: 0.92-1.15). Antibiotic prophylaxis was not significantly associated with post-extraction medical care (OR = 1.04; 95% CI: 0.83-1.30).

CONCLUSIONS

In this large retrospective cohort, we observed no significant protective effect of antibiotic prophylaxis on post-extraction complications or subsequent medical care utilization in a setting with low complication rates. These data suggest that use of antibiotic prophylaxis in similar settings may need to be re-evaluated to minimize unnecessary antibiotic use.

The Association of Dental Caries or Dental Implant Placement Within One Year of Primary Total Hip Arthroplasty on Medical and Implant Complications

BACKGROUND

Total hip arthroplasty (THA) adverse events among patients who have dental diagnoses remain unclear. We sought to determine if dental caries or dental implant placements increased (1) 90-day medical complications, (2) 90-day readmissions, and (3) 2-year implant-related complications, including periprosthetic joint infections (PJIs) after THA.

METHODS

A nationwide database for primary THAs from 2010 to 2021 was queried to compare 3 patient cohorts. Patients who had a history of dental implants or caries within 12 months prior to THA (n = 1,179) or 12 months after THA (n = 1,218) were case-matched to patients who did not have dental history (n = 6,090) by age and comorbidities. Outcomes included 90-day complications, 90-day readmissions, and 2-year implant-related complications. Logistic regression models computed the odds ratios (ORs) of complications and readmissions. P values less than .006 were significant.

RESULTS

Patients who had dental caries or implant placement 12 months before or after THA experienced 1.6-fold greater odds of 90-day medical complications compared to case-matched patients. Readmissions within 90 days increased for patients who had a dental history before (11.7% versus 8.3%; OR: 1.49, P < .0001) and after (14.2% versus 8.3%; OR: 1.84, P < .0001) THA compared to case-matched patients. A dental caries diagnosis or dental implant placement within 12 months following THA increased 2-year implant complications compared to case-matched patients (15.2% versus 9.3%; OR: 1.69, P < .0001), including PJIs (5.3% versus 2.8%; OR: 1.98, P < .0001), dislocations (4.4% versus 2.7%; OR: 1.63, P = .002), and THA revisions (3.9% versus 2.5%; OR: 1.61, P = .005).

CONCLUSIONS

Dental diagnoses within 12 months of THA are associated with increased medical complications. Dental diagnoses occurring 12 months after THA are associated with greater implant-related complications, including PJIs. Delaying invasive dental procedures for 12 months after THA may be advisable.

Risk factors for oral infection and dry socket post-tooth extraction in medically complex patients in the absence of antibiotic prophylaxis: A case-control study

INTRODUCTION

Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket).

METHODS

Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction.

RESULTS

Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88).

CONCLUSION

Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted.

Comparison of guideline concordant antibiotic prophylaxis in Veterans Affairs and non-Veterans Affairs dental settings among those with cardiac conditions or prosthetic joints

BACKGROUND

No research has been conducted to assess whether antibiotic prophylaxis prescribing differs by dental setting. Therefore, the goal of this study was to compare the prescribing of antibiotic prophylaxis in Veterans Affairs (VA) and non-Veterans Affairs settings.

METHODS

This was a retrospective study of veteran and non-veteran dental patients with cardiac conditions or prosthetic joints between 2015-2017. Multivariable log binomial regression analysis was conducted to compare concordant prescribing by setting with a sub-analysis for errors of dosing based on antibiotic duration (i.e., days prescribed).

RESULTS

A total of 61,124 dental visits that received a prophylactic antibiotic were included. Most were male (61.0%), and 55 years of age or older (76.2%). Nearly a third (32.7%) received guideline concordant prophylaxis. VA dental settings had a lower prevalence of guideline concordant prescribing compared to non-VA settings in unadjusted results (unadjusted prevalence ratio [uPR] = 0.92, 95% CI: 0.90-0.95). After adjustment, prevalence of guideline concordant prescribing was higher in those with prosthetic joints in the VA setting (adjusted prevalence ratio [aPR] = 1.73, 95% CI: 1.59-1.88), with no difference identified in those without a prosthetic joint (aPR = 0.99, 95% CI: 0.96-1.01). Concordance of dosing was higher in VA compared to non-VA settings (aPR = 1.11, 95% CI: 1.07-1.15).

CONCLUSIONS

VA has a higher prevalence of guideline concordant prescribing among those with prosthetic joints and when assessing dosing errors. Though the presence of an integrated electronic health record (EHR) may be contributing to these differences, other system or prescriber-related factors may be responsible. Future studies should focus on to what extent the integrated EHR may be responsible for increased guideline concordant prescribing in the VA setting.

Topical Fluoride Effectiveness in High Caries Risk Adults

This retrospective analysis of longitudinal data was developed to determine which types, combinations, and intensities of topical fluorides more effectively prevent new caries-related restorations and extractions in high caries risk adults. We included data from October 1, 2008, through June 30, 2018, from electronic dental and medical records and pharmacy database from the US Department of Veterans Affairs. Veterans who were eligible for continuing and comprehensive care, met the criteria of high caries risk (received 2 or more caries-related restorations within a 365-d period), and had 3 y of follow-up were included. Multivariable logistic regression models estimated the odds of caries-related treatment during the 1-y observation period, controlling for age, gender, race and ethnicity, illness burden (Selim comorbidity index), use of prescription medications, attendance at dental prophylaxis appointments, number of caries-related restorations during the index year, and time between first and last caries-related restoration during the index year. The study sample included 68,757 veterans, who were primarily male (91.5%), were White (73.6%), had a mean age of 59.2 ± 13.5 y, and had significant medical comorbidity as measured by the Selim index (3.7 ± 2.4 physical and 1.3 ± 1.2 mental diagnoses). They had 10.8 ± 6.3 prescription VA drug classes, took 0.6 ± 0.8 strong anticholinergic medications, and had 3.9 ± 2.6 teeth restored due to caries during the index year. Adjusted multivariable logistic regression models showed veterans who received a varnish or gel/rinse fluoride intervention versus no fluoride had an approximately 29% decreased odds of receiving caries-related treatment during the observation period (gel/rinse adjusted odds ratio [AOR] = 0.72; 95% confidence interval [CI], 0.67-0.76; varnish AOR = 0.71; 95% CI, 0.67-0.75). The receipt of a varnish and gel/rinse did not demonstrate statistically better odds than each intervention alone (AOR = 0.69; 95% CI, 0.64-0.75). A dose-response effect was observed. Two-plus applications of varnish versus none (AOR = 0.73; 95% CI, 0.69-0.77) and 2-plus applications of gel/rinse versus none (AOR = 0.71; 95% CI, 0.67-0.75) were more effective than 1 application of either modality versus none.

Anticholinergic medication and dental caries status in middle-aged xerostomia patients-a retrospective study

Background/purpose

Xerostomia is the most frequent side effect of anticholinergic (AC) medications, which block the cholinergic neurotransmission of saliva secretion. As the most significant increase in AC medications’ usage reported in middle-aged adults, we aimed to explore whether the level of exposure to AC medication show association with the severity of caries status of middle-aged individuals who complained about medication-induced xerostomia.

Materials and methods

Our retrospective study included 414 individuals (between 45 and 64 years) with self-reported xerostomia. We determined caries status by the Decayed, Missing, or Filled Teeth (DMFT) index and quantified the level of AC drug exposure by the AC Drug Scale (ADS), verified through electronic medication records. Statistical analyses were performed using chi-square and ANOVA tests. Covariates were age, gender, smoking, edentulism, comorbidities, polypharmacy, number, and the type of AC medications.

Results

In total, 54% of patients were taking five or more AC drugs. The mean number of anticholinergics was 5.41 (±3.44), most frequently antidepressants and antipsychotics, among all medications 10.63 (±5.79). Higher ADS scores were associated (p = 0.006) with a higher number of missing teeth. Multiple linear regression model showed that the number of AC medications, age, and smoking status are associated with DMFT (mean of 18.7 ± 8.96) scores.

Conclusion

Caries status of middle-aged xerostomia patients was found to be reflective of the level of AC exposure from medications. Our finding emphasizes the importance of assessing AC medication burden in affected dental patients to improve clinical prevention strategies and guide interdisciplinary treatment plans.

Anticholinergic medication: Related dry mouth and effects on the salivary glands

OBJECTIVE

Salivary glands are among the most sensitive target organs of medications with anticholinergic (AC) properties, interrupting the neural stimulation of saliva secretion and reducing saliva flow. Hyposalivation results in dry mouth, leading to dental caries, intraoral infection, orofacial pain, problems with speaking and swallowing, and diminished oral health--related quality of life. Current understanding of the pharmacokinetics of AC medications and their effect on muscarinic receptors in the salivary glands were reviewed to assist clinicians in predicting salivary damage in patients with AC medication-induced dry mouth.

STUDY DESIGN

We summarized the literature related to the mechanisms and properties of AC medications, anticholinergic adverse effects, and their effect on salivary function and management strategies to prevent oral health damage.

RESULTS

Although a large number of studies reported on the frequencies of medication-induced dry mouth, we found very limited data on predicting individual susceptibility to AC medication--caused hyposalivation and no prospective clinical studies addressing this issue.

CONCLUSION

Dry mouth is most frequently caused by medications with AC properties, which interrupt the neural stimulation of saliva secretion. Interdisciplinary care should guide pharmacotherapeutics and dental interventions should aim in preventing AC salivary adverse effects and reducing the oral health burden from AC medication-induced dry mouth.

Validation of a Subjective Caries Risk Assessment Tool

OBJECTIVE

The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record.

METHODS

This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification.

RESULTS

The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination.

CONCLUSIONS

The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period.

CLINICAL SIGNIFICANCE

The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans' Affairs (VA) dentistry

OBJECTIVE

United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription.

DESIGN

Cross-sectional analysis.

METHODS

We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription.

RESULTS

Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days' supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%-49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics.

CONCLUSIONS

Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.

Caries Risk Prediction Models in a Medical Health Care Setting

Despite development of new technologies for caries control, tooth decay in primary teeth remains a major global health problem. Caries risk assessment (CRA) models for toddlers and preschoolers are rare. Among them, almost all models use dental factors (e.g., past caries experience) to predict future caries risk, with limited clinical/community applicability owing to relatively uncommon dental visits compared to frequent medical visits during the first year of life. The objective of this study was to construct and evaluate risk prediction models using information easily accessible to medical practitioners to forecast caries at 2 and 3 y of age. Data were obtained from the Growing Up in Singapore Towards Healthy Outcomes (GUSTO) mother-offspring cohort. Caries was diagnosed using modified International Caries Detection and Assessment System criteria. Risk prediction models were constructed using multivariable logistic regression coupled with receiver operating characteristic analyses. Imputation was performed using multiple imputation by chained equations to assess effect of missing data. Caries rates at ages 2 y (n = 535) and 3 y (n = 721) were 17.8% and 42.9%, respectively. Risk prediction models predicting overall caries risk at 2 and 3 y demonstrated area under the curve (AUC) (95% confidence interval) of 0.81 (0.75-0.87) and 0.79 (0.74-0.84), respectively, while those predicting moderate to extensive lesions showed 0.91 (0.85-0.97) and 0.79 (0.73-0.85), respectively. Postimputation results showed reduced AUC of 0.75 (0.74-0.81) and 0.71 (0.67-0.75) at years 2 and 3, respectively, for overall caries risk, while AUC was 0.84 (0.76-0.92) and 0.75 (0.70-0.80), respectively, for moderate to extensive caries. Addition of anterior caries significantly increased AUC in all year 3 models with or without imputation (all P < 0.05). Significant predictors/protectors were identified, including ethnicity, prenatal tobacco smoke exposure, history of allergies before 12 mo, history of chronic maternal illness, maternal brushing frequency, childbearing age, and so on. Integrating oral-general health care using medical CRA models may be promising in screening caries-susceptible infants/toddlers, especially when medical professionals are trained to "lift the lip" to identify anterior caries lesions.