The management of an endodontically abscessed tooth: patient health state utility, decision-tree and economic analysis

<p>Abstract</p> <p>Background</p> <p>A frequent encounter in clinical practice is the middle-aged adult patient complaining of a toothache caused by the spread of a carious infection into the tooth's endodontic complex. Decisions about the range of treatment options (conventional crown with a post and core technique (CC), a single tooth implant (STI), a conventional dental bridge (CDB), and a partial removable denture (RPD)) have to balance the prognosis, utility and cost. Little is know about the utility patients attach to the different treatment options for an endontically abscessed mandibular molar and maxillary incisor. We measured patients' dental-health-state utilities and ranking preferences of the treatment options for these dental problems.</p> <p>Methods</p> <p>Forty school teachers ranked their preferences for conventional crown with a post and core technique, a single tooth implant, a conventional dental bridge, and a partial removable denture using a standard gamble and willingness to pay. Data previously reported on treatment prognosis and direct "out-of-pocket" costs were used in a decision-tree and economic analysis</p> <p>Results</p> <p>The Standard Gamble utilities for the restoration of a mandibular 1st molar with either the conventional crown (CC), single-tooth-implant (STI), conventional dental bridge (CDB) or removable-partial-denture (RPD) were 74.47 [± 6.91], 78.60 [± 5.19], 76.22 [± 5.78], 64.80 [± 8.1] respectively (p < 0.05). Their respective Willingness-to-Pay ($CDN) were 1,782.05 [± 361.42], 1,871.79 [± 349.44], 1,605.13 [± 348.10], 1,351.28 [± 368.62] (p < 0.05).</p> <p>The standard gamble utilities for the restoration of a maxillary central incisor with a CC, STI, CDB and RPD were 88.50 [± 6.12], 90.68 [± 3.41], 89.78 [± 3.81] and 91.10 [± 3.57] respectively (p > 0.05). Their respective willingness-to-pay ($CDN) were: 1,782.05 [± 361.42], 1,871.79 [± 349.44], 1,605.13 [± 348.10] and 1,351.28 [± 368.62]. A statistical difference was found between the utility of treating a maxillary central incisor and mandibular 1st-molar (p < 0.05).</p> <p>The expected-utility-value for a 5-year prosthetic survival was highest for the CDB and the STI treatment of an abscessed mandibular molar (74.75 and 71.47 respectively) and maxillary incisor (86.24 and 84.91 respectively). This held up to a sensitivity analysis when the success of root canal therapy and the risk of damage to the adjacent tooth were varied. The RPD for both the molar and incisor was the favored treatment based on a cost-utility (3.85 and 2.74 CND$per year of tooth saved respectively) and cost-benefit analysis (0.92 to 0.60 CND$ of cost per $ of benefit, respectively) for a prosthetic clinical survival of 5-years.</p> <p>Conclusion</p> <p>The position of the abscessed tooth and the amount of insurance coverage influences the utility and rank assigned by patients to the different treatment options. STI and CDB have optimal EUVs for a 5-year survival outcome, and RPD has significantly lower cost providing the better cost:benefit ratio.</p

Human Breast Milk and Antiretrovirals Dramatically Reduce Oral HIV-1 Transmission in BLT Humanized Mice

Currently, over 15% of new HIV infections occur in children. Breastfeeding is a major contributor to HIV infections in infants. This represents a major paradox in the field because in vitro, breast milk has been shown to have a strong inhibitory effect on HIV infectivity. However, this inhibitory effect has never been demonstrated in vivo. Here, we address this important paradox using the first humanized mouse model of oral HIV transmission. We established that reconstitution of the oral cavity and upper gastrointestinal (GI) tract of humanized bone marrow/liver/thymus (BLT) mice with human leukocytes, including the human cell types important for mucosal HIV transmission (i.e. dendritic cells, macrophages and CD4+ T cells), renders them susceptible to oral transmission of cell-free and cell-associated HIV. Oral transmission of HIV resulted in systemic infection of lymphoid and non-lymphoid tissues that is characterized by the presence of HIV RNA in plasma and a gradual decline of CD4+ T cells in peripheral blood. Consistent with infection of the oral cavity, we observed virus shedding into saliva. We then evaluated the role of human breast milk on oral HIV transmission. Our in vivo results demonstrate that breast milk has a strong inhibitory effect on oral transmission of both cell-free and cell-associated HIV. Finally, we evaluated the effect of antiretrovirals on oral transmission of HIV. Our results show that systemic antiretrovirals administered prior to exposure can efficiently prevent oral HIV transmission in BLT mice

Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians

<p>Abstract</p> <p>Background</p> <p>It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians.</p> <p>Methods</p> <p>We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-analyzed, following the Gale and Marsden model for clinical decision-making. Limited tests used to contrast data were t, χ², and Fisher's. Scott's π was used to determine inter-coder reliability.</p> <p>Results</p> <p>Fifteen dentists and 17 senior dental students participated in visits lasting 32.0 minutes (± 12.9) among experts, and 29.9 ± 7.1 among students; contact time with patient was 26.4 ± 13.9 minutes (experts), and 22.2 ± 7.5 (students). The time elapsed between the first and the last instances of the clinician looking in the mouth was similar between experts and students. Ninety eight types of pieces of information were used in combinations with 12 DTPs. The main differences found in DTP utilization had dentists conducting diagnostic interpretations of findings with sufficient certainty to be considered definitive twice as often as students. Students resorted more often to more general or clarifying enquiry in their search for information than dentists.</p> <p>Conclusions</p> <p>Differences in diagnostic strategies and concepts existed within clearly delimited types of cognitive processes; such processes were largely compatible with the analytic and (in particular) non-analytic approaches to clinical decision-making identified in the medical field. Because we were focused on a clinical presentation primarily made up of non-emergency treatment needs, use of other DTPs and concepts might occur when clinicians evaluate emergency treatment needs, complex rehabilitative cases, and/or medically compromised patients.</p