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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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Regrowing Dental Tissue With Stem Cells From Baby Teeth

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Sometimes kids trip and fall, and their teeth take the hit. Nearly half of children suffer some injury to a tooth during childhood. When that trauma affects an immature permanent tooth, it can hinder blood supply and root development, resulting in what is essentially a “dead” tooth.

Until now, the standard of care has entailed a procedure called apexification that encourages further root development, but it does not replace the lost tissue from the injury and, even in a best-case scenario, causes root development to proceed abnormally.

New results of a clinical trial, jointly led by Songtao Shi of the University of Pennsylvania and Yan Jin, Kun Xuan, and Bei Li of the Fourth Military Medicine University in Xi’an, China, suggest that there is a more promising path for children with these types of injuries: Using stem cells extracted from the patient’s baby teeth. The work was published in the journal Science Translational Medicine.

“This treatment gives patients sensation back in their teeth. If you give them a warm or cold stimulation, they can feel it; they have living teeth again,” says Shi, professor and chair in the Department of Anatomy and Cell Biology in Penn’s School of Dental Medicine.

“So far we have follow-up data for two, two and a half, even three years and have shown it’s a safe and effective therapy.”

Shi has been working for a decade to test the possibilities of dental stem cells after discovering them in his daughter’s baby tooth. He and colleagues have learned more about how these dental stem cells, officially called human deciduous pulp stem cells (hDPSC), work and how they could be safely employed to regrow dental tissue, known as pulp.

The Phase I trial, conducted in China, which has a research track for clinical trials, enrolled 40 children who had each injured one of their permanent incisors and still had baby teeth. Thirty were assigned to hDPSC treatment and 10 to the control treatment, apexification.

Those that received hDPSC treatment had tissue extracted from a healthy baby tooth. The stem cells from this pulp were allowed to reproduce in a laboratory culture, and the resulting cells were implanted into the injured tooth.

Upon follow-up, the researchers found that patients who received hDPSCs had more signs than the control group of healthy root development and thicker dentin, the hard part of a tooth beneath the enamel. Blood flow increased as well.

At the time the patients were initially seen, all had little sensation in the tissue of their injured teeth. A year following the procedure, only those who received hDPSCs had regained some sensation. Examining a variety of immune-system components, the team found no evidence of safety concerns.

As further support of the treatment’s efficacy, the researchers had the opportunity to directly examine the tissue of a treated tooth when the patient reinjured it and had to have it extracted. They found that the implanted stem cells regenerated different components of dental pulp, including the cells that produce dentin, connective tissue, and blood vessels.

“For me the results are very exciting,” Shi says.

“To see something we discovered take a step forward to potentially become a routine therapy in the clinic is gratifying.”

It is, however, just a first step. While using a patient’s own stem cells reduces the chances of immune rejection, it’s not possible in adult patients who have lost all of their baby teeth. Shi and colleagues are beginning to test the use of allogenic stem cells, or cells donated from another person, to regenerate dental tissue in adults. They are also hoping to secure FDA approval to conduct clinical trials using hDPSCs in the United States.

Eventually, they see even broader applications of hDPSCs for treating systemic disease, such as lupus, which Shi has worked on before.

“We’re really eager to see what we can do in the dental field,” Shi says, “and then building on that to open up channels for systemic disease therapy.”

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Antibiotics Destroy ‘Good Bacteria’ And Worsen Oral Infection

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New research shows that the body’s own microbes are effective in maintaining immune cells and killing certain oral infections.

A team of Case Western Reserve University researchers found that antibiotics actually kill the “good” bacteria keeping infection and inflammation at bay.

Scientists have long known that overuse of antibiotics can do more harm than good. For example, overuse can cause antibiotic resistance. But research into this phenomenon in oral health was uncharted territory.

Pushpa Pandiyan, an assistant professor of biological sciences in the School of Dental Medicine, led a team of researchers to examine “resident” bacteria, their fatty acids and their effect on certain types of white blood cells that combat infections in the mouth.

Specifically, researchers looked at the “short-term maintenance” of Tregs and Th-17 cells in fighting fungal infections, such as Candida, in a laboratory setting.

They found that those natural defenses were very effective in reducing infection and unwanted inflammation — and antibiotics can prevent such natural defenses. Their work was recently published in Frontiers in Microbiology.

“We set out to find out what happens when you don’t have bacteria to fight a fungal infection,” Pandiyan said.

“What we found was that antibiotics can kill short-chain fatty acids produced by body’s own good bacteria.”

“We have good bacteria doing good work every day, why kill them?” Pandiyan added.

“As is the case with many infections, if you leave them alone, they will leave on their own.”

“Of course, antibiotics are still needed for life threatening infections. No question about that. Our bodies have many natural defenses that we shouldn’t meddle with,” she said.

However, needless overuse of antibiotics is not helpful, she said.

“Also, we know there is a definite link between oral health and overall health,” she added.

Pandiyan said the study could have broader implications on protective effects of “resident microbiota” in other types of infections.

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New Findings On Chronic Pain Syndrome In The Mouth

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The picture is becoming clearer regarding the chronic oral pain condition known as Burning Mouth Syndrome, or BMS, which mainly affects women who are middle-aged and older. In a dissertation at Sahlgrenska Academy, additional steps are being taken toward better diagnosis and treatment.

“Our hope is that the new findings will contribute to the development of objective diagnostic criteria and effective individualized treatment both that are currently lacking,” says Shikha Acharya, who has a PhD in oral microbiology and immunology at the Institute of Odontology.

Burning Mouth Syndrome (BMS) is a chronic pain syndrome in the oral cavity that affects approximately 4% of the Swedish population. This chronic condition mainly affects middle-aged and elderly women.

The pain is experienced as burning or stinging. The tongue is most often afflicted, but the palate, lips and gums also may be affected. Other common symptoms include dry mouth and altered taste sensation, such as a bitter or metallic taste in the mouth.

BMS is a challenge for health care providers, particularly in dental care, and a debilitating condition for many of the patients. When they estimate their problem on a visual analogue scale (VAS) where 0 is “not at all difficult” and 100 is “unbearable,” the average response is 66, the dissertation indicates. The findings came from 56 women with BMS.

In her work Shikha Acharya also connected clinical findings and self-reported reported findings from questionnaires from patients with BMS about their symptoms and background (other diseases, use of medications, etc.) along with saliva-related factors. The results have been compared with a gender- and age-matched control group.

It turns out that 45 percent of the BMS patients reported to have altered taste sensations. A total of 73 percent experienced pain that was burning or stinging or a combination of the two, but stinging and numbness also occurred.

In addition to BMS, they have a higher incidence of other types of diseases, use more medications, are more prone to grinding their teeth and report more allergies than the control group. However, more advanced analyses show that BMS was strongly associated to self-reported skin diseases and subjective oral dryness.

The fact that the BMS patients, compared with people in the control group, report that they suffer considerably more from skin diseases and skin problems is a new discovery. Similarly, that the mucin proteins in BMS patients’ saliva are altered and contain lower amounts of carbohydrate structures that affect the oral cavity’s immune system.

Analysis of inflammatory constituents in saliva shows complex relationship between BMS and background inflammation, with some of the BMS patients having higher levels of inflammation than the control group while others had lower.

The dissertation work is part of a larger project aimed at finding a model for BMS that can facilitate diagnosis and treatment in the future. The new pieces of the puzzle are helping to characterize the disease and the persistent mouth pain associated with it.

“It’s important because the afflicted patients often feel that their surroundings and health care professionals doubt their ailment,” says Shikha.

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