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The past few decades have witnessed an increased focus on the importance of oral health on the social, psychological and developmental well-being in children. Although effective and advanced dental prevention measures and treatment options are increasingly available, dental decay remains one of the most common chronic childhood diseases in the United States and around the world. Recently, the World Health Organization Assembly called attention to the significant burden oral disease has maintained in all countries around the world. Additionally, multiple studies have described disparities in oral health with a disproportionate amount of dental disease concentrated in children with special health care needs, those that live with poor families or that live in isolated or rural communities. In response to this issue there has been renewed focus on combating access to oral health care issues. One approach that has been suggested is the utilization of non-dental health professionals in assessing oral health, performing basic preventive steps and referral of high-caries risk children for further care. These non-dental professionals are often in a better position to evaluate children at an early age, are more likely to see poor children early and to provide care for them on a continuing basis when compared to dentists. However, several barriers have been mentioned in the literature that prevent or deter these non-dental health professionals from taking on a more active role in this access to care issue. Of which has been a reported lack in oral care education and training for medical care professionals. Additionally, collectively few studies have specifically identified the importance of different suggested influencing factors. In our present study, three main analyses were conducted. The first analysis assessed the oral-health knowledge, practices, and factors influencing the ability and willingness of Iowa pediatricians' to assess and refer high caries-risk children. In which, a 22-item survey was mailed to all licensed pediatricians in Iowa. Chi-square statistics and logistic regression models were used to analyze data. On questions regarding comfort levels when performing oral-health related practices on children under 3, physicians reported high levels of comfort with all specified issues. The majority of respondents routinely gave the name of a dentist to the caregiver when referring, where as only 4% made use of local care coordination services and only 9% actually made the dental appointment. Sixty-five percent referred all children 12 months or older to a dentist in accordance with AAPD and AAP guidelines. The ability to locate a dentist willing to accept Medicaid or uninsured children was noted as the major referral barrier. Bivariate and multivariate logistic regression analyses indicated that pediatricians who had higher frequency of seeing oral-health problems (p=0. 0.0488), greater mean total number of children seen per week (p=0.0431), and believed that children should have their 1st dental visit no later than 12 months of age (p=0.0196) were more likely to make frequent referrals to a dentist compared to their counterparts. The second analyses assessed Saudi medical interns' oral-health knowledge, and other factors influencing their ability and willingness to perform oral-health related practices for high caries-risk children. In which, a 15-item survey was emailed to all eligible graduating fifth year medical students at King Khalid University Hospital to address these areas of interest. Chi-square statistics and logistic regression models were used to analyze data. Similar to our first study physicians noted high levels of comfort with all specified oral health practices. However, students generally rated their medical training fair or poor in preparing them for oral-health assessments compared. Additionally, although 90% of respondents noted that the role of primary physicians in counseling/referring children with oral health was important; 60% did not agree with the AAPD and AAP guidelines that state that all children should be referred to a dentist by 12 months of age. Multivariate logistic regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. The choice of public-health oriented future clinical goals, the level of oral-health knowledge, how interns rated their oral health training in medical school, and the average number of children seen per week, all - to varying degrees - proved important predicator variables for the likelihood of performing them once in practice. In our third study focus was placed on assessing the effectiveness of an electronic educational intervention on improving primary care practitioners' knowledge, willingness, and comfort levels in identifying children who are at high risk for developing dental caries. Following the educational program, a 16-item survey was emailed to all participants to address the areas of interest. Bivariate correlation and linear regression were used to analyze data. Respondents gave a higher percentage of correct responses to the knowledge questions post-intervention compared to pre-intervention with an average increase of 63%. Additionally, nearly all respondents agreed with the statement that all children 12 months and older should be seen by a dentist in accordance the AAP & AAPD. Furthermore, physicians noted improved levels of comfort with all specified oral health practices. Most notable, following the educational intervention, 91% of respondents rated them-selves as comfortable in counseling, compared to only 25.6% that did so before the educational program. The only exception on comfort issues pertained to performing emergency treatments on young children with a majority of interns (92%) still considering themselves as neutral or uncomfortable in doing so. Multiple linear regression analyses revealed several statistically significant variables that predict the likelihood of performing various oral-health related practices. Increased oral health knowledge, higher self-perceived comfort levels and seeing oral-health problems more frequently all proved important predicator variables for the likelihood of performing oral-health related services. Collectively, these three analyses lead us to several main conclusions and future education recommendations. Educating medical practitioners and students about basic oral health recommendations and referral guidelines provides an excellent opportunity to alert medical professionals about the importance and timing of these dental referrals. Ultimately, earlier referrals by physicians can help improve dental utilization among high risk children, especially among lower income and rural families. Additionally, providing these medical professionals with experience opportunities in assessing the oral health of young children may improve both physician willingness and likelihood to perform various oral health practices for young children. Overall, increasing both knowledge and personal experience of training physicians' could lead to greater comfort levels in dealing with oral health issues affecting young children. Furthermore, establishing effective care coordinator services to assist in linking various health care professionals more directly; may also increase physician willingness to assess and refer high-caries-risk children by making the referral process easier for physician offices. This step helps in saving time and effort, two deterrents noted by physicians.

Avoidable use of the Emergency Departments (EDs) constitutes a significant public health problem, which has health, economic and ethical implications. The factors that affect avoidable use of the EDs are complex and poorly understood. The goal of this dissertation was to examine the role of medical home in avoidable pediatric ED visits, assess the impact of Medicaid policy on ED visits for dental problems and assess the factors affecting follow-up dental care after a dental ED visit. Iowa Household Health Survey data was used for the first study, which included a sample of families with at least one child residing in Iowa. It was found that 68% of parents who took their child to an ED in the previous year thought the ED visit could have been avoided if primary care was available to them. Having a medical home was not found to be associated with pediatric ED visits; however, food insecurity was significantly associated. Parents of children with public insurance, those who were not referred by a healthcare provider and those who reported difficulty in getting routine care appointments were more likely to report an avoidable ED visit by their child. The second study examined a policy change in California where Medicaid eliminated its comprehensive adult dental coverage on July 1, 2009. State Emergency Department Database were obtained from Agency for Healthcare Research and Quality for California for 2006 through 2011. Interrupted time series, a quasi-experimental approach of was used to examine the impact of the policy change on rate of dental ED visits by Medicaid enrolled adults. Segmented linear regression revealed that policy change led to an immediate significant increase in the rate of dental ED visits. The policy had a differential impact on various subgroups based on age, race-ethnicity and residential location. The annual costs associated with dental ED visits made by Medicaid adults also increase 68%. Survival analytic approach was used in the final study to examine the patterns of dental care following a dental ED visit by Medicaid enrolled adults in Iowa. Medicaid claims and enrollment data were used to identify adults with an index dental ED visit in 2011, and then each subject was followed for up to 6 months. About 52% of all adults who satisfied the study inclusion criteria, had a follow up dental visit within 6 months of the index dental ED visit. Cox regression model revealed that adults who had visited a dentist in the year prior to the ED visit had greater hazards of having an early dental follow up after the ED visit. Having repeated dental ED visits was found to have a dose-response relationship to follow-up time to dentist visit, with those having 1 repeat ED visit having 53% hazards and those with 2 or more repeat ED visits having 34% hazards of having a follow-up dentist visit, compared to those with no repeat ED visits. Collectively, the results from this dissertation provide important insights in understanding the complex problem of avoidable ED visits. Factors such as food insecurity and medical home need to be further investigated in their association with avoidable ED visits. State Medicaid policy plays an important role and limiting Medicaid adult dental coverage may lead to an increased reliance of the affected population on EDs for dental care. However, EDs do not provide any definitive dental care, and our results indicate that almost half of the adults with dental ED visit do not have a follow-up dentist visit in the next 6 months.

Objective: The goal of the present study was to investigate the effect of chairside surface treatments on biaxial flexural strength and subsurface damage of monolithic zirconia ceramics. Methods: Specimens (15x15x1.2 mm3) were prepared by sectioning from commercially available zirconia blanks (BruxZirTM) and sintering according to manufacturer's recommendations. Fully dense specimens were randomly divided into five groups (n=30) and treated as follows; 1) as-sintered (AS) 2) air abraded with 50 μm alumina fine particles (AAF), 3) air abraded with 250 μm coarse alumina particles (AAC), 4) ground (G), and 5) ground and polished (GP) to mimic chairside and dental laboratory treatments. Microstructural changes were thoroughly characterized by optical and scanning electron microscopy, surface profilometry and atomic force microscopy. Crystalline phases and their depth profile were investigated by x-ray diffraction (XRD) and grazing incidence x-ray diffraction (GIXRD). Results were analyzed by Kruskal-Wallis test and Tukey's adjustment for multiple comparisons. A 0.05 level of significance was used. Reliability was evaluated by Weibull analysis. Results: All treatment groups exhibited a significant difference in mean surface roughness (Rq) compared to the as-sintered group (p<0.05). The AAC group showed the highest surface roughness at 1.08 ± 0.17 μm, followed by the G, AAF and AS groups. The GP group exhibited the lowest surface roughness. The group air abraded with fine particles showed the highest mean biaxial flexural strength (1662.62 ± 202.58 MPa), but was not different from the ground and polished group (1567.19 ± 209.76 MPa). The groups air abraded with coarse particles or ground with diamond bur exhibited comparable mean biaxial flexural strength at 1371.37 ±147.62 MPa and 1356.98 ±196.77 MPa, respectively. The as-sintered group had the lowest mean biaxial flexural strength at 1202.29 ±141.92 MPa. The depth of compressive stress layer, measured by GIXRD was approximately 50 μm in the AAF group, followed by the AAC group with ~35 μm, ~10 μm for the ground group and ~5 μm for the ground and polished group. Deep subsurface cracks were observed in the AAC group (~80 μm in depth) and G group (~25 μm in depth), whereas shallower flaws were present in the AAF and GP groups at 10 and 3 μm, respectively. Weibull analysis represented a greater reliability in zirconia specimens treated with air abrasion groups. Conclusions: Surface treatments induced the t-m transformation in 3Y-TZP and associated development of compressive stresses to a depth that varied with the severity of the treatment performed. GIXRD revealed that AAF led to the thickest compressive stress layer, followed by AAC, G and GP. SEM revealed that subsurface damage was most severe with AAC, followed by G, AAF and GP. We propose that the flexural strength results can be explained by the difference between the depth of the compressive stress layer induced by the transformation and the depth of the subsurface flaws.

Thesis problem: Cone beam computed tomography (CBCT) can provide images with identical information and considerable dose reduction compared with reasonably low costs compared to multislice computed tomography (MSCT) especially where multiple follow up imaging studies are needed. The purpose of this study was to evaluate the diagnostic usefulness of CBCT, using i-CAT®'s software, for detection of the anatomical landmarks of the external, middle and inner ear to answer this question whether MSCT Can be replaced by dental CBCT for evaluation of the temporal bone. Material and methods: Cone beam computed tomography (CBCT) images of 63 subjects made with the same machine, with unknown clinical histories and no evidence of pathosis on CBCT images, were evaluated by two oral and maxillofacial radiologists retrospectively. Seven anatomical points (scutum, oval window, incudomalleolar joint, the tympanic/horizontal and mastoid/vertical segments of the facial nerve, anterior and posterior crura of stapes) of the right and left temporal bone (total of 120 temporal bones) were evaluated. The results were provided as percentage of the points identified by each radiologist. The intra and inter observer agreement were calculated using kappa statistic. Results: The scutum, the tympanic/horizontal segment of the facial nerve canal and the oval window of the right and left temporal bone of 63 cases (total 126 temporal bones) were visualized by the first observer as well-defined structures in 100%, 96.03% and 100% of the cases, respectively. The tympanic/horizontal segment of the facial nerve canal was visualized as a poorly-defined structure in 2.38 % and could not be identified in 1.59% of the cases. The anterior and posterior crura of stapes, the mastoid/vertical segments of the facial nerve canal and the incudomalleolar joint were visualized as well-defined structures in 24.60%, 53.17%, 99.21% and 57.94% of the cases, as poorly defined structures in 32.54%, 41.27%, 0.79% and 39.68% of the cases respectively. The anterior and posterior crura of stapes, the mastoid/vertical segments of the facial nerve canal and the incudomalleolar joint could not be identified in 42.86%, 5.56%, 0% and 2.38% of the cases respectively. The intra- and inter-observer agreement ranged from strong for tympanic/horizontal and mastoid/vertical segments of the facial nerve canal to poor for the anterior and posterior crura of stapes and also the incudomalleolar joint. Conclusion: The i-CAT CBCT machine is a promising replacement for MSCT in evaluation of the temporal bone where there is no need for evaluation of the anterior and posterior crura of stapes and the incudomalleolar joint which are the smallest anatomical structures in the temporal bone. Other CBCT machines with higher contrast to noise ratio should be evaluated for detection of those anatomical structures since CBCT can reduce the patient dose substantially where multiple follow up CT studied are needed. Key words: Computed tomography; cone beam CT; multislice helical CT; middle ear; inner ear; temporal bone.

Oral health may serve as an indicator of overall systemic health, with each disease or condition manifesting differently in the oral cavity. Sickle cell disease (SCD) is a genetic disorder in which sickled red blood cells cause blood vessel occlusion and potentially bleeding in specific sites (e.g., gastrointestinal and intracranial bleeding). With SCD being one of the most common hereditary diseases in the world, it is essential to understand the disease and improve awareness to better treat this population. While studies have been done to evaluate the oral health of persons with SCD, few have explored the occurrence of gingival bleeding and their experience with dental care. Due to this gap in the literature, the present study investigates the potential relationship between SCD, gingival bleeding, and certain other oral manifestations. Adults with and without SCD responded to an online questionnaire regarding oral health and dental care. The data was collected and analyzed during the 2022 spring semester. The data collected from Qualtrics was downloaded into JASP for statistical analysis. While there was a greater prevalence of gingival bleeding and caries in those with SCD, analysis of the sample showed no significant association between the oral manifestations and SCD. A deeper subgroup analysis suggested that those with SCD and no employment may be at higher risk for dental caries, orofacial pain, and gingival bleeding. Further investigation is necessary to determine the direct effect of the disease. The findings may justify further studies to include clinical evaluations by oral health care providers and larger quantity of participants. A better understanding of the relationship between SCD and oral health may lead to oral hygiene improvement strategies geared explicitly toward persons with SCD.

AN INVESTIGATION OF SURFACE CHARACTERISTICS OF ENAMEL TREATED WITH INFILTRATIVE RESIN: A SCANNING ELECTRON MICROSCOPY STUDY Danielle E. Easterly, Doctorate of Dental Surgery. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Dentistry at Virginia Commonwealth University. Virginia Commonwealth University. 2017. Director: Dr. Eser Tüfekçi D.D.S., M.S., Ph.D., M.S.H.A. Objective: To evaluate the microstructural changes of a resin infiltrant (ICON®, DMG America LLC, Englewood, NJ) after six months of simulated toothbrushing. Materials and Methods: Ten extracted third molars (n=10) were collected. Artificial white spot lesions were created and resin applied. Environmental SEM images at 250X and 500X were taken after application of Icon® (T1), and after six months of simulated toothbrushing (T2). Micrographs were evaluated for changes in surface characteristics. Results: SEM showed some changes in the surface characteristics of the resin after simulated toothbrushing. However, changes in presence of enamel rods, microcracks, or fractures were not statistically significant (p>0.05). The effects of polymerization shrinkage were noted on most samples in the form of clefts and fissures. Conclusions: Icon® resin seems to withstand challenge by toothbrush abrasion over a six-month period, with some evidence of microstructural wear.

Candida albicans is an opportunistic pathogen that is present in the normal flora in a majority of individuals. One key factor in C. albicans virulence is the ability to change its morphology from yeast to an elongated or hyphal form. The regulation of this morphogenesis relies in part upon quorum sensing (QS) molecules. C. albicans often exists as part of a mixed culture alongside other microbes and is influenced by their presence as well as the presence of QS molecules that they produce. In this study, a library of diploid homozygous transcriptional regulator knockout (TRKO) mutants were screened to identify strains capable of forming hyphae in the presence of Pseudomonas aeruginosa, Staphylococcus aureus, and Escherichia coli. We identified three strains that showed increased hyphae development compared to wild type C. albicans. The strains identified had deletions of the transcriptional regulating genes Orf19.3928, Orf19.2842 (GZF3), and Orf19.3865 (RFX1). These strains were tested for alterations of filamentation in liquid media, and biofilm formation. All three strains showed increased rates of biofilm formation compared to the wild type. Orf19.3928 showed altered response to farnesol, a marked in biofilm formation and no inhibition of filamentation when farnesol was present in liquid media. The GZF3 deletion strain showed enhanced filamentation with all three bacterial species while the RFX1 deletion strain showed increased filamentation only with E. coli and S. aureus. In spent media, GZF3 showed slight increases in filamentation in E. coli and S. aureus while RFX1 had moderate increases in filamentation in E. coli and S. aureus and slight increases with P. aeruginosa.

Objectives: The primary objective was to assess the impact of two denture fabrication techniques, conventional and CAD/CAM, on oral health-related quality of life (OHRQoL) and patient satisfaction in complete denture wearers. The secondary objective was to compare the level of microorganisms present on complete dentures from the two fabrication techniques. Methods: Twenty-eight completely edentulous subjects (16 men and 21 women, age range from 49 to 87 years old.), who had been edentulous for at least 6 months, were wearing ill-fitting complete dentures, or unsatisfied with their existing complete dentures were recruited. Subjects were randomized to conventional and computer-aided design/ computer-aided manufacturing (CAD/CAM) treatment groups. Subjects in both groups were given the OHIP-EDENT (Oral Health Impact Profile for Edentulous Patients) and patient satisfaction questionnaires to record the data at baseline and at 1 month post-delivery of the new prostheses. Plaque samples were collected from intaglio surfaces of maxillary complete dentures at 1 month post-delivery to culture for any colonization of bacteria and/or yeasts. Results: There was a significant reduction in OHIP-EDENT scores within both treatment groups at the 1 month follow-up (p < 0.05). There was also a significant reduction in almost all OHIP-EDENT domains scores at 1 month. Gender was significantly associated with OHIP-EDENT score at baseline (p = 0.0419) and at 1 month (p = 0.0152). Female subjects tend to have higher OHIP-EDENT scores than male subjects. There was no significant difference in patient satisfaction between treatment groups both at baseline and at the 1 month visit for almost all aspects of satisfaction (p> 0.05). Appearance of maxillary denture was the only significant difference in patient satisfaction across treatment groups (p = 0.0213). The comparisons of microbial counts showed no significant difference between treatment groups. Conclusions: There were no significant difference on oral health-related quality of life (OHRQoL) and patient satisfaction between two treatment groups at baseline and 1 month. There was no significant difference in microbial counts between two treatment groups.

Instrumental to forensic investigations is the ability to identify unknown human remains providing key evidence to criminal cases, resolution to missing persons, and assistance in mass or natural disasters. Identification of remains in an effort to determine age is an area of forensics that has received considerable attention. Traditional methods in age determination such as morphology are often biased, antiquated, and frequently result in a large margin of error. Conversely, the emergence of new forensic techniques provide promise to reduce the margin of error in determining age. One such technique has focused on relating the extent of amino acid racemization in teeth to age. Past research has focused primarily on the analysis of aspartic acid due to its high racemization rate. Our research indicates that glutamic acid also shows promise as related to age determination. Results will be presented illustrating optimization of gas chromatography using a chiral column for separation of amino acids found in dentin and their enantiomeric ratio quantification. Age correlation data will be presented on collected teeth ranging from mid-teens to early seventies.