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How Internet-based CBT Reduces Dental Anxiety Among Children

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Researchers at Karolinska Institutet have developed an accessible therapy for children and adolescents suffering from dental phobia. The study, published in the Journal of Medical Internet Research, shows that guided Internet-based CBT is highly effective in reducing anxiety and increasing the ability to deal with dental treatment. One year later, half of the children were completely free of their phobia.

Dental anxiety often begins in childhood or adolescence and can develop into a phobia with avoidance, strong negative feelings, and thoughts aimed at dental care. Avoidance of dental care often leads to poor oral health, untreated caries or other dental problems.

Cognitive behavioural therapy (CBT) is an effective treatment for most forms of specific phobia. However, with regard to children and adolescents with dental phobia, there are organisational, financial and geographic obstacles to providing such therapy. Researchers in this study have therefore developed an internet-based CBT treatment that they have tested in an open, uncontrolled study of 18 patients between the ages of 8 and 15.

Treatment continued for 12 weeks

During the study, participants used an internet platform to obtain weekly online guidance from a psychologist via a chat system. Treatment continued for 12 weeks and included texts, animations and dental-related video clips. The treatment also included an exercise package with a dental mirror, probe, local anesthetic and cannula delivered to the home of the child/parent(s) with detailed instructions for the exercises. Through therapy and guidance from the psychologist, the home-based exercises were linked to real exposure and training visits to dental clinics around Sweden.

The results show a statistically and clinically significant increase in the children’s ability to manage dental treatment. The internet-based CBT also increased children’s and parents’ self-efficacy, leading to fewer negative thoughts and reduced anxiety aimed at dental treatment. At a one-year follow-up, 53 percent of the children were completely free of their dental phobia.

Surprisingly strong effects

“Even though we expected positive effects from the therapy, it was still surprising to see the scope of improvement and the strong effects of the therapy among the patients, given that they did not have a single physical meeting with the psychologist,” explains Shervin Shahnavaz at Karolinska Institutet’s Department of Dental Medicine who is the researcher behind the development of the therapy.

The researchers now hope to be able to repeat the results in an ongoing randomised controlled trial.

“Internet-based CBT for dental phobia in children and adolescents may be an efficient form of therapy with the potential to increase access to effective treatment,” says Dr. Shahnavaz.

The study is the result of a collaboration with Stockholm County Council’s unit for internet psychiatry. The research project was supported with grants from SOF; board of dental research at Karolinska Institutet and Stockholm County Council and the Mayflower Charity Foundation for children.

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New Smart Material Developed To Stop Bacteria From Causing Cavities Under Fillings

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When patients go to the dentist to fill a cavity, they’re trying to solve a problem — not create a new one. But many dental patients get some bad news: bacteria can dig under their tooth-coloured fillings and cause new cavities, called recurrent caries. This recurrent caries affects 100 million patients every year and costs an additional US$34 billion to treat.

Now, a research collaboration between the Department of Materials Science & Engineering (MSE), Faculty of Dentistry, and the Institute of Biomaterials and Biomedical Engineering (IBBME) at the University of Toronto has resulted in a novel way to minimize recurrent caries.

In a recent paper published in the journal Scientific Reports, professors Benjamin Hatton (MSE), Yoav Finer (Dentistry) and PhD student Cameron Stewart (IBBME) tackled the issue and proposed a novel solution: a filling material with tiny particles made by self-assembly of antimicrobial drugs, designed to stop bacteria in its tracks. These particles may solve one of the biggest problems with antibacterial filling materials: how do you store enough drug within the material to be effective for someone’s entire life?

“Adding particles packed with antimicrobial drugs to a filling creates a line of defense against cavity-causing bacteria,” says Hatton. “But traditionally there’s only been enough drug to last a few weeks. Through this research, we discovered a combination of drugs and silica glass that organize themselves on a molecule-by-molecule basis to maximize drug density, with enough supply to last years.”

This discovery of using antimicrobials which self-assemble means the team can pack 50 times as much of the bacteria-fighting drugs into the particles.

“We know very well that bacteria specifically attack the margins between fillings and the remaining tooth to create cavities,” says Finer.

“Giving these materials an antimicrobial supply that will last for years could greatly reduce this problem.”

Looking ahead, the research team plans on testing these new drug-storing particles in dental fillings, monitoring their performance when attacked by bacteria and saliva in the complex environment in the mouth. With some fine-tuning, this new ‘smart’ material could create a stronger filling and fewer trips to the dentist.

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Who Has Stronger Teeth: Girls or Boys?

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Dentists and scientists often find it difficult to determine why some people’s teeth are affected by dental erosion and others not, despite similar drinking and eating habits. Many studies show more severe dental erosion in men than in women. Studies have been carried out on dental erosion in wine tasters and people suffering from eating disorders with vomiting. These people frequently expose their teeth to acid and therefore have a high risk of developing dental erosion. However, research shows that not all of these patients at risk have dental erosion. Researchers at the Faculty of Dentistry, University of Oslo, are now attempting to find an explanation for this.

Not just acid

How do we explain that some individuals may have no signs of dental erosion despite frequently exposing their teeth to acid, while certain individuals who seem to do everything right, still develop dental erosion? Ph.D. candidate Marte-Mari Uhlen has been taking a closer look at this in her doctoral work.

“As dentists and researchers, we are often facing cases of dental erosion that we have difficulties explaining, and we meet patients who don’t have dental erosion although their lifestyle indicates that they should. It is also a general assumption that boys tend to have more erosion and more severe erosive lesions than girls. We believe that this disparity is due to something more than just the acidic effect,” explains Uhlen.

Clinical study

Uhlen and her colleagues conducted a clinical study on 66 patients with eating disorders and vomiting. The study consisted of a clinical examination and a questionnaire-based survey in which the patients were interviewed about their illness. The questionnaire included questions about the duration of the eating disorder and frequency of vomiting as well as the participants’ general health, oral hygiene habits and eating and drinking habits.

“The results from the study showed that 70 percent of the patients had dental erosion and that those who had been ill the longest had more dental erosion and more severe lesions than the ones with a shorter duration of disease. This finding confirms our assumptions that dental erosion is a common problem in patients with eating disorders and vomiting. Nevertheless, we were surprised to find that a third of the patients had no sign of dental erosion at all, even patients who had vomited regularly for up to 32 years”, explains Uhlen.

The researchers also examined the oral environment and the tooth enamel. The oral environment includes the volume of saliva, the contents of the saliva as well as the dental pellicle, which is a protein film that covers the surface of the teeth. All these elements are important factors in protecting the teeth against acid attacks. Dental enamel consists mainly of minerals, and the formation and structure of enamel are controlled by genes.

Simulating vomiting episodes in the laboratory

In their next study, the scientists collected teeth from eight people and placed samples of enamel from these teeth on a plate in the mouth of six other volunteers.

The plates with the enamel samples were subjected to simulated vomiting episodes: The plates were removed from the mouth and washed in hydrochloric acid twice a day for a total of nine days.

“We hoped to see how the teeth would respond to being exposed to acid in a different mouth than the one they came from,” explains Uhlen. “In this way, we could examine the protecting effect of both the oral environment and of the enamel itself”

The results revealed that susceptibility to dental erosion seems to be influenced both by the quality of the dental enamel and the oral environment: While in some subjects the degree of protection by the oral environment appeared to be most important, in others, the strength or weakness of their dental enamel was more significant.

Association with enamel formation genes

Then, the attention was aimed at genetics. Could a strong or weak enamel be inheritable? The hypothesis was that the genes responsible for enamel formation may give us more information about why a person develops dental erosion or not. Results from previous studies suggest that variations in these enamel formation genes could influence the susceptibility to dental caries and dental erosion.

The researchers then collected a tooth and a saliva sample from 90 people. Samples of enamel from these teeth were then mounted on a plate and exposed to acid. The amount of enamel loss was then measured using an advanced microscope.

The scientists extracted DNA from the saliva samples to investigate whether enamel formation genes might play a role in the susceptibility to dental erosion. Seven genes were selected.

“We selected these particular genes because they are important in different phases in the formation of the enamel”, says Uhlen.

Genetic variation affects susceptibility

Comparing the amount of enamel loss and the variation in the selected genes, the scientists discovered that some gene variations involved in the formation of the enamel seem to influence the susceptibility to dental erosion. The results from the genetic analyses also indicated that enamel from female donors is more protected against dental erosion than enamel from male donors. This supported the results from the eating disorder study, namely that the enamel in girls are genetically more protected against dental erosion than the enamel in boys.

“Our findings indicate that the susceptibility to dental erosion varies from individual to individual. Factors related to both the oral environment and the quality of the enamel seem to influence the susceptibility. In addition, the susceptibility to dental erosion appears to be affected by genetic variation”, Uhlen explains.

Furthermore, the findings confirm an assumption long held by clinicians and researchers that men are more prone to dental erosion than women.

Clinical significance

The results from these studies indicate that what is generally considered a normal intake of acidic food and beverages may cause dental erosion in subjects at risk. It is important that clinicians and researchers recognize this difference in susceptibility and inform their patients.

“Recognition of the fact that some people are more vulnerable or susceptible to dental erosion as well as an awareness of males possibly being particularly susceptible, dental professionals can distribute their resources better and devote more time to the patients who need it the most,” concludes Uhlen.

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Removing Dental Plaque with Micro-bubbles

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Whether through an accident or a disease, teeth loss can cause many inconveniences. Dental implants such as crowns, however, have allowed people to overcome most of these and live a better quality of life.

But just like normal teeth, these dental implants require proper care and oral hygiene to prevent further complications, such as the inflammation of the tissues surrounding the implants. While the buildup of dental plaque sticks mainly to the crown, it also adheres to the exposed parts of the screw that holds the dental fixture in place, and these are much harder to clean because they contain microgrooves that make them fit better into the upper or lower jaw bones.

Hitoshi Soyama from Tohoku University and his team from Showa University in Japan conducted a study to look for better ways for dentists to remove this plaque and prevent complications. The team wanted to study the efficiency of a cavitating jet, where a high-speed fluid is injected by a nozzle through the water to create very tiny bubbles of vapour. When these bubbles collapse, they produce strong shockwaves that are able to remove contaminants.

The researchers used a certain type of nozzle to create the cavitation bubbles which removed the plaque when they collapsed.

The team compared the cleaning effect of a cavitating jet to that of a water jet, which has been used for a long time to remove plaque from dental implants to keep them clean. They grew a biofilm over three days within the mouths of four volunteers, then proceeded to clean that with the two different methods, measuring the amount of plaque remaining at several time intervals.

While there was little difference between the amounts of dental plaque removed by both methods after one minute of cleaning, that changed after longer exposure. After three minutes, the cavitating jet had removed about a third more plaque than the water jet did, leaving little plaque stuck to the implant at the end of the experiment. The cavitating jet was also able to remove the plaque not only from the root section of the screws but also from the harder-to-reach crest section, though to a lesser extent.

“Conventional methods cannot clean plaques on the surface of dental implants very well, so this new method could give dentists a new tool to better manage these fixtures which are becoming more common,” says Soyama.

Previous research has shown that water flow exerts shear stress to remove the biofilm. In addition to this shear effect, the cavitating jet also produces a considerable force when the bubbles collapse that is able to remove particles from the biofilm and carry them away. The researchers suggest that the two processes probably work in synergy to make the cavitating jet superior to the water jet when cleaning the plaque off the irregular surface of dental implants.

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