Oral health and medical status in dentate low-income older persons

Candesartan exhibits low intrinsic permeation capacity and affects buccal tissue viability and integrity: An ex vivo study in porcine buccal mucosa

Candesartan is a nonpeptide angiotensin II receptor blocker that selectively binds to angiotensin II receptor subtype 1. It is administered orally in its ester form (candesartan cilexetil). However, its poor aqueous solubility results in its low bioavailability; therefore, other routes of administration must be explored. The buccal mucosa has been extensively studied as an alternative route for drug delivery as it improves the bioavailability of drugs administered via the peroral route. Porcine buccal mucosa has been widely used as an ex vivo model to study the permeability of various diffusants; however, studies on candesartan are limited. This study aimed to evaluate the ex vivo permeation profile of candesartan and its effects on the viability and integrity of porcine buccal mucosa. Initially, we evaluated the viability, integrity, and barrier function of the buccal tissue before performing permeability tests using freshly excised tissues or tissues after 12 h of resection. Here, three indicators were used: caffeine, β-estradiol, and FD-20 penetration; mucosal metabolic activity, as determined using MTT reduction assay; and haematoxylin and eosin staining. Our results indicated that the porcine buccal mucosa preserved its viability, integrity, and barrier function before the permeation assay, allowing the passage of molecules with a molecular mass of less than 20 kDa, such as caffeine, but not β-estradiol and FD-20. Furthermore, we analyzed the intrinsic capacity of candesartan to diffuse through the fresh porcine buccal mucosa under two pH conditions. The concentration of candesartan in the receptor chamber of Franz diffusion cell was quantified using ultra-high liquid chromatography. In the permeation assay, candesartan exhibited a low intrinsic permeation capacity that impacted the buccal tissue viability and integrity, suggesting that using the buccal mucosa as an alternative route of administration requires developing a pharmaceutical formulation that reduces the adverse effects on mucosa and increasing the buccal permeability of candesartan.

Sex hormone replacement therapy in periodontology-A systematic review

OBJECTIVE

To analyse whether sex hormone replacement therapy (HRT) improves periodontal parameters and dental implants osseointegration in humans.

MATERIALS AND METHODS

Electronic databases and hand searches were performed from June to August 2018 in SciELO, LILACS and PubMed/MEDLINE. Human observational and interventional studies that evaluated the following parameters were included: clinical attachment loss (CAL), probing pocket depth (PPD), bleeding on probing (BOP), radiographic bone loss (RBL) or osseointegration.

RESULTS

Initial search retrieved 1,282 non-duplicated articles. Fifteen studies were selected after inclusion criteria were applied. All studies were performed in postmenopausal women. Mean differences for PPD reduction ranged from 0.02 to 0.2 mm in HRT-positive patients; mean CAL gain -0.18 to 0.54 mm; mean RBL reduction -0.87 to 0.15 mm; and mean BOP reduction 9%-30.3%. Failure rate of dental implants increased -5.5% to 11.21% when HRT was used.

CONCLUSIONS

Very low but consistent evidence suggests a reduction in BOP and no impact on RBL in postmenopausal women receiving HRT. There are inconsistent reports that suggest that HRT in postmenopausal women: (a) improves or does not impact PPD reduction and CAL gain; and (b) does not impact or increase implant loss. In summary, there is no evidence to support HRT prescription for either men or women for periodontal/implant placement purposes.

Reduction in caries rate among patients with xerostomia using a power toothbrush

The purpose of this study was to evaluate whether the use of a Sonicare toothbrush could be beneficial in reducing coronal and/or root caries among patients with medication-induced xerostomia. Eighty subjects with drug-induced xerostomia using either a Sonicare toothbrush (SC) or a manual toothbrush (MTB) were included in the study. Control subjects using a MTB were frequency-matched to 40 subjects using a SC, based on age, gender, number of teeth at baseline, and salivary flow rates. Subjects were individually matched according to the type of xerostomic medication they were taking. Caries were assessed at baseline, and subjects were instructed to have carious teeth restored. Summary statistics were assessed and computed by treatment group for incipient and frank coronal and root caries after one year. Statistical comparisons of the number of frank and incipient coronal and root caries between treatment groups were conducted using paired t-tests. After one year of use, the numbers of incipient and frank root caries were significantly lower among subjects using SC compared to subjects using MTB. Subjects using SC also exhibited somewhat lower incipient and frank coronal caries than subjects using MTB, although their differences were not statistically significant. The authors concluded that the Sonicare toothbrush may be beneficial in reducing root caries among older adults with medication-induced xerostomia.

Chlorhexidine and Preservation of Sound Tooth Structure in Older Adults

The Trial to Enhance Elderly Teeth Health (TEETH) was designed to test the impact of regular rinsing with a 0.12% chlorhexidine (CHX) solution on tooth loss, and the causes of tooth loss (caries, periodontal disease and trauma) were also investigated. This paper reports on the effectiveness of a 0.12% CHX solution for controlling caries using a tooth surface (coronal and root) survival analysis. A total of 1,101 low income elders in Seattle (United States) and Vancouver (Canada), aged 60-75 years, were recruited for a double-blind clinical trial and assigned to either a CHX (n = 550) or a placebo (n = 551) mouth rinse. Subjects alternated between daily rinsing for 1 month, followed by weekly rinsing for 5 months. All sound coronal and root surfaces at baseline were followed annually for up to 5 years. At each follow-up examination, those tooth surfaces with caries, restored, or extracted were scored as 'carious'. The hazard ratio associated with CHX for a sound surface to become filled, decayed, or extracted was 0.87 for coronal surfaces (95% confidence interval: 0.71-1.14, p = 0.20) and 0.91 for root surfaces (95% confidence interval: 0.73-1.14, p = 0.41). These findings suggest that regular rinsing with CHX does not have a substantial effect on the preservation of sound tooth structure in older adults.

Prevalence of xerostomia in population-based samples: a systematic review

The consequences of xerostomia on oral health have been studied for decades; however, the actual prevalence of this disorder on the general population remains controversial. The purpose of this systematic review was to determine the prevalence of xerostomia in population-based samples. Electronic databases were screened for relevant articles and reference lists of pertinent articles were also hand-searched. Thirteen articles meeting the final inclusion criteria were identified. Based on the definition of xerostomia used in this review, only publications including a subjective diagnosis of the disorder were included. All of the self-reported diagnoses were achieved through a questionnaire either by mail, telephone, interview or self-administered by the patient. There was a variation across papers regarding number and content of the questions as well as guidelines for the diagnosis of xerostomia (i.e. answer yes to one or more than one question). The prevalence of xerostomia in the selected articles ranged from 0.9% to 64.8%. The majority of these studies were performed in Scandinavia. In 9 of the articles, the studied samples were 50 years and older. None of the studies evaluated the prevalence xerostomia among individuals younger than 18 years. Based on these observations, it can be concluded that there is a need for population-based studies on prevalence of xerostomia in regions other than Scandinavia. A standardized protocol to diagnose xerostomia needs to be developed. Patient-perceived treatment needs and impact on quality of life should be included to have a complete picture of public health implications of the disease.

Explaining sex differences in dental caries prevalence: Saliva, hormones, and “life-history” etiologies

When dental caries rates are reported by sex, females are typically found to exhibit higher prevalence rates than males. This finding is generally true for diverse cultures with different subsistence systems and for a wide range of chronological periods. Exceptions exist, but are not common. In this paper, we present new data for sex differences in dental caries rates among the Guanches (Tenerife, Canary Islands), summarize results of meta-analyses of dental caries prevalence, and emphasize new research that stresses the critical role of female hormones and life-history events in the etiology of dental caries. Among the Guanches, corrected tooth-count caries rates for females (8.8%, 158/1,790) are approximately twice the frequency of caries among males (4.5%, 68/1,498). Higher caries prevalence among females is often explained by one of three factors: 1) earlier eruption of teeth in girls, hence longer exposure of girls' teeth to the cariogenic oral environment, 2) easier access to food supplies by women and frequent snacking during food preparation, and 3) pregnancy. Anthropologists tend to favor explanations involving behavior, including sexual division of labor and women's domestic role in food production. By contrast, the causal pathways through which pregnancy contributes to poorer oral health and higher caries rates are deemphasized or discounted. This paper presents recent research on physiological changes associated with fluctuating hormone levels during individual life histories, and the impact these changes have on the oral health of women. The biochemical composition of saliva and overall saliva flow rate are modified in several important ways by hormonal fluctuations during events such as puberty, menstruation, and pregnancy, making the oral environment significantly more cariogenic for women than for men. These results suggest that hormonal fluctuations can have a dramatic effect on the oral health of women, and constitute an important causal factor in explaining sex differences in caries rates.

A socio-economic perspective on periodontal diseases: a systematic review

OBJECTIVE

The aim of this systematic review was to ascertain whether socio-economic conditions increase the risk of periodontal diseases.

METHODS

A MEDLINE search was conducted for the period 1965-April 2004. Only original articles were included; 47 studies remained for the final assessment. The studies were analysed regarding the outcome of the association between socio-economic variables and periodontal disease, depending on the study design (cross-sectional survey or longitudinal case-control) and whether smoking was included or not.

RESULTS

Twenty-nine out of 36 studies with a cross-sectional design were in favour of the association between socio-economic factors and periodontal diseases. In the studies with a longitudinal or case-control design, there were five in favour of the association, and also six against. When smoking was included in the analysis of cross-sectional studies, a significant association between socio-economic variables and periodontal disease was found in 11 studies and no significance in another five studies. The corresponding figures for case-control studies showed four studies being significant, but also four studies showing no significance.

CONCLUSION

Based on relevant study designs and including smoking in the analysis, the socio-economic variables associated with periodontal diseases appear to be of less importance than smoking.

Comparison between the Klemetti index and heel DXA BMD measurements in the diagnosis of reduced skeletal bone mineral density in the elderly

Osteopenia/osteoporosis affect many elderly people and might not be detected until symptoms of fractures occur. Early detection of osteopenia/osteoporosis is important and would allow preventive measures and treatment. Access to screening for osteopenia/osteoporosis is often limited, whereas panoramic radiography is commonly used in dentistry. The aim of this study was to determine the validity of the Klemetti index (KI), measured on panoramic radiographs, in the diagnosis of osteopenia/osteoporosis as defined by a bone mineral density (BMD) measurement below -1.5 standard deviations (SDs) of a community based sample. In total, 211 consecutive participants (102 men and 109 women) 60-96 years in the SNAC-Blekinge study (Swedish National Study on Ageing and Care) underwent bone densitometry [by dual-energy X-ray absorptiometry (DXA)] of both heels. A panoramic radiograph was taken of each participant, and mandibular cortex on a panoramic radiograph was classified as '0' or normal (even and sharp endosteal margin), '1', moderately eroded (evidence of lacunar resorption or endosteal cortical residues), or '2', severely eroded (unequivocal porosity). From logistic regression, the odds ratio of having a BMD measurement below -1.5 SD was 8.04 (95% CI 2.39 to 27.12, P<0.001) in the 'osteopenic' (KI category 2), compared with the 'normal' group (KI categories 0 and 1). Receiver operating characteristic (ROC) curve analysis was used to measure the validity of the KI indicating osteopenia (KI category 2) in predicting reduced BMD. This point provided a sensitivity of 50% and a specificity of 89%. Positive and negative predictive values were 21% and 97%, respectively. There were 87% correctly classified subjects. The area under the ROC curve was 0.64. The present study demonstrated that a negative finding (KI category <2) is highly predictive of the absence of osteopenia/osteoporosis as defined by the DXA measurements.

Comparison of utilization of dental care services among Chinese- and Russian-speaking immigrant elders

OBJECTIVE

The purpose of the study was to identify factors predictive of use of dental services among Chinese- and Russian-speaking immigrant elders.

METHODS

The data for this analysis were collected from the 1997 survey "Assessing public health and health care needs of Russian-speaking elderly immigrants." A similar survey was replicated among Chinese-speaking elderly immigrants in 2000. Community-based samples of 300 Russian elders and 177 Chinese elders were recruited for the study.

RESULTS

Chinese elders used dental care services at lower rates than Russian elders. Education, length of stay in the U.S., social support, and smoking behavior were significant predictors for the use of dental services among Chinese. However, among Russian elders, age, income, and denture use predicted utilization of dental services.

CONCLUSIONS

Although Chinese- and Russian-speaking elders have similar immigrant experiences and share the same geographic location and urban setting, the two groups have different patterns of dental service use. These differences may be due to differences in socio-demographic characteristics, values, attitudes and knowledge of oral health and dental care, and unique cultural backgrounds.

Biomarkers of bone turnover can be assayed from human saliva

The purpose of this study was to determine if biomarkers of bone turnover [deoxypyridinium (D-PYR) or osteocalcin (OC)] could be detected in human saliva. These biomarkers have been measured in ovariectomized sheep saliva, but not in human saliva. Saliva was collected from 37 women. The bone mineral density of the calcaneus was assessed by quantitative ultrasound and expressed as a T score. Salivary D-PYR and OC concentrations were determined by enzyme-linked immunosorbent assay. Data were analyzed by a Spearman's rho correlation test and factorial analysis of variance was followed by a post hoc Tukey's test. There were significant correlations between age, body mass index, D-PYR, or OC concentration and calcaneus T scores (p<.05), suggesting that saliva could be used as a fluid for assay of human biomarkers of bone turnover. Our data suggest a beneficial use of saliva in situations where a large number of patients are to be screened for metabolic bone diseases.

Response to direct and indirect recruitment for a randomised dental clinical trial in a multicultural population of elders

OBJECTIVES

Recruitment for randomised clinical trials and community-based studies has received little attention in the dental literature. The goal of this study was to report on our experiences with direct and indirect recruitment methods for a trial to prevent tooth loss in elders.

METHODS

A direct approach, consisting of an introductory lecture with the help of a local contact person in each of the nine community centres, resulted in 208 recruits mostly from minority non-English speaking communities (52%), whereas the other 192 recruits who responded to newspaper announcements (48%) were, in large part, from the English-speaking community.

RESULTS

The response suggests that a more direct and culturally specific approach is more productive when recruiting elders from ethnic minority groups, whereas elders from the dominant culture can be recruited indirectly and for about half the financial cost through newspaper announcements.

CONCLUSION

We conclude, therefore, that both direct and indirect methods are needed to recruit a multiethnic sample of subjects for a trial.

Assessment of periodontal conditions and systemic disease in older subjects. I. Focus on osteoporosis

BACKGROUND

Osteoporosis (OPOR) is a common chronic disease, especially in older women. Patients are often unaware of the condition until they experience bone fractures. Studies have suggested that OPOR and periodontitis are associated diseases and exaggerated by cytokine activity. Panoramic radiography (PMX) allows studies of mandibular cortical index (MCI), which is potentially diagnostic for OPOR.

AIMS

i). To study the prevalence of self-reported history of OPOR in an older, ethnically diverse population, ii). to assess the agreement between PMX/MCI findings and self-reported OPOR, and iii). to assess the likelihood of having both a self-reported history of OPOR and a diagnosis of periodontitis.

MATERIALS AND METHODS

PMX and medical history were obtained from 1084 subjects aged 60-75 (mean age 67.6, SD +/- 4.7). Of the films, 90.3% were useful for analysis. PMXs were studied using MCI. The PMXs were used to grade subjects as not having periodontitis or with one of three grades of periodontitis severity.

RESULTS

A positive MCI was found in 38.9% of the subjects, in contrast to 8.2% self-reported OPOR. The intraclass correlation between MCI and self-reported OPOR was 0.20 (P < 0.01). The likelihood of an association between OPOR and MCI was 2.6 (95%CI: 1.6, 4.1, P < 0.001). Subjects with self-reported OPOR and a positive MCI had worse periodontal conditions (P < 0.01). The Mantel-Haentzel odds ratio for OPOR and periodontitis was 1.8 (95%CI: 1.2, 2.5, P < 0.001).

CONCLUSIONS

The prevalence of positive MCI was high and consistent with epidemiological studies, but only partly consistent with a self-reported history of osteoporosis with a higher prevalence of positive MCI in Chinese women. Horizontal alveolar bone loss is associated with both positive self-reported OPOR and MCI.

Salivary variables in relation to tobacco smoking and female sex steroid hormone-use in 30 to 59-year-old women

Several systemic conditions may have an influence on oral health. Hormone replacement therapy (HRT) has a positive effect on alveolar bone of menopausal women and smoking a negative effect. However, little is known about their effect on saliva. The purpose of this study was to examine the effect of hormone-use and tobacco smoking on the composition of saliva, in particular on the inorganic constituents. Salivary samples were collected from a representative study group comprising 1,013 women (30-59 years) participating in a pre-screen referral program for osteoporosis. The participants were divided into 2 subgroups according to age. The younger group (< or = 45 years) comprised 413 women and the older group (> or = 50 years) 600 women. Salivary calcium, magnesium, sodium, potassium, inorganic phosphate, total protein, and flow rate of paraffin-stimulated saliva were measured. In the older age group, female sex steroid users (hormone users) had lower salivary protein concentrations than non-users. Smoking was associated with high salivary calcium, magnesium, and potassium levels in the group of older participants. Neither tobacco smoking nor female sex steroid hormones had any significant effect on the salivary composition in the younger age group. In conclusion, smoking was reflected more clearly than female sex steroid hormone-use in the inorganic composition of saliva in the older age group. The salivary composition was not affected by hormone-use or by smoking among the younger age group.

Environmental illness: evaluation of salivary flow, symptoms, diseases, medications, and psychological factors

Patients with symptoms allegedly caused by abnormal sensitivity to dental fillings and/or to electromagnetic fields and other environmental factors frequently report oral complaints. Forty-four consecutive patients with these symptoms were studied. The aim was to investigate whether unstimulated salivary flow rate was associated with Candida, symptoms, disease, medication, age, sex, anxiety, depression, and stress. Furthermore, the aim was to compare the level of anxiety, depression, and stress in these patients with an age- and sex-matched control group. Fifty percent had no or low flow rate from the minor salivary glands. Candida pseudohyphae were found in 50% of the patients. Hypothyroidism and/or intake of thyroid hormones, headache, fatigue, and age were negatively associated with unstimulated salivary flow rate, and dizziness was positively associated. Unstimulated salivary flow rate was positively associated with stimulated salivary flow rate and flow rate from the minor salivary glands. Burning mouth and subjective oral dryness were reported by 48%, and 46%, respectively. The patients were more anxious, stressed, and especially more depressed than the control group. Unstimulated salivary flow rate was negatively associated with state anxiety. Measurement of salivary flow rate is important in patients with environmental illness and can be used in combination with other measurements as a diagnostic tool.

Geriatric dentistry in the next millennium: opportunities for leadership in oral health

"The twentieth century will be remembered chiefly, not as an age of political conflicts and technical inventions, but as an age in which human society dared to think of the health of the whole human race as a practical objective." Arnold Toynbee, British historian. Individuals throughout the world often view the passage of a new year as a time for re-evaluation of personal and/or professionals goals. The new millennium offers the dental profession a chance to view the future and observe the challenges and opportunities facing it. Professor Toynbee's observation is particularly poignant when one considers the improvements in oral health made in the last 100 years. Caries, once considered a ubiquitous oral disease, has been prevented in some children in developed countries. Research on periodontal disease continues to identify risk factors and the pathobiological mechanisms underlying the disease. Concurrently the population of the world is aging presenting new opportunities for improving oral health. In this paper the data on aging, chronic diseases and oral health is largely from the US but reflects to varying degrees other industrial countries. By integrating these demographic, epidemiologic and biologic data, one can paint a portrait of the future dental patient and their oral health needs. From this portrait, dental professionals can identify leadership opportunities to improve the oral health of an aging world population.