Utility of point-of-care vs reference laboratory testing for the evaluation of glucose levels

AIMS

To assess the level of agreement between point-of-care and laboratory reference glucose values in defining glycaemic status.

METHODS

We analysed 1292 overweight/obese, non-institutionalized participants, aged 40-65 years, in the San Juan Overweight Adults Longitudinal Study. Fasting venous blood glucose was determined using a point-of-care Bayer Contour Blood Glucose Meter and by Vitros System 250 instrument (laboratory). American Diabetes Association thresholds were used to classify participants into normoglycaemia (< 5.6 mmol/l), prediabetes (5.6 to 6.9 mmol/l), or diabetes groups (≥ 7 mmol/l).

RESULTS

Bland-Altman plot analysis showed a slope of 0.04 (P=0.002) for the regression between the mean difference and the average of the two methods. The slopes were significantly different from zero among people with normoglycaemia (β=-0.57, P<0.001), and prediabetes (β=-0.75, P<0.001) but not among people with diabetes (β=-0.02, P=0.68). When the prediabetes and diabetes groups were merged into one group, the slope was 0.01, and the glucose values remained similar using the two methods (P=0.76).

CONCLUSION

Point-of-care blood glucose measurement may be useful to screen people with diabetes, and to assess glucose among individuals with diabetes where blood can be drawn, but laboratory tests are unavailable or untimely.

Prediction of Periodontal Disease From Multiple Self-Reported Items in a German Practice-Based Sample

BACKGROUND

Ascertainment of periodontal disease using self-reported measures would be useful for large epidemiologic studies. This study evaluates whether a combination of self-reported items with established risk factors in a predictive model can assess periodontal disease accurately.

METHODS

Responses of 246 subjects to a detailed questionnaire were compared to their periodontal disease history as assessed from radiographs. Multiple regression modeling was used to construct predictive models using self-reported items and established risk factors.

RESULTS

Depending on the definition of gold-standard periodontal disease, two or three self-reported items were selected for the predictive models, in addition to age, gender, and smoking. Self-reported tooth mobility was associated strongly with periodontal disease independent of other risk factors and was selected in all models. For dichotomous definitions of periodontal disease, discrimination of predictive logistic regression models was good with areas under the receiver operating characteristic curve >0.80. Assessment of periodontal disease history based on extreme quantiles of model-predicted values yielded high sensitivity and specificity.

CONCLUSION

The combination of several self-reported items may be useful for ascertainment of periodontal disease in epidemiologic studies.

Perinatal factors, growth and development, and osteosarcoma risk

Osteosarcoma incidence patterns suggest an aetiologic role for perinatal factors, and growth and development. Osteosarcoma patients (n=158) and controls with benign orthopaedic conditions (n=141) under age 40 were recruited from US orthopaedic surgery departments. Exposures were ascertained by interview, birth, and growth records. Age- and sex-adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated. Current height and age- and sex-specific height percentiles were not associated with osteosarcoma risk. Male cases, however, appeared to have an earlier adolescent growth period, and earlier attainment of final height (OR=7.1; 95% CI=1.6–50 for <19 vs 19+ years), whereas earlier puberty appeared protective with ORs of 0.41 (95% CI 0.18–0.89) and 0.68 (95% CI 0.31–1.5) for developing facial and pubic hair, respectively. High birth weight was associated with an elevated osteosarcoma risk (OR=3.9; CI=1.7–10 for 4000 g vs 3000–3500 g), although there was no trend in risk with increasing weight. These data provide some evidence that osteosarcoma is related to size at birth and in early adolescence, while earlier puberty in male subjects may be protective.

Validation of self-reported periodontal disease: a systematic review

Self-report is an efficient and accepted means of assessing many population characteristics, risk factors, and diseases, but has rarely been used for periodontal disease (chronic periodontitis). The availability of valid self-reported measures of periodontal disease would facilitate epidemiologic studies on a much larger scale, allow for integration of new studies of periodontal disease within large ongoing studies, and facilitate lower-cost population surveillance of periodontitis. Several studies have been conducted to validate self-reported measures for periodontal disease, but results have been inconsistent. In this report, we conducted a systematic review of the validation studies. We reviewed the 16 studies that assessed the validity of self-reported periodontal and gingivitis measures against clinical gold standards. Seven of the studies included self-reported measures specific to gingivitis, four included measures only for periodontitis, and five included both gingivitis and periodontal measures. Three of the studies used a self-assessment method where they provided the patient with a detailed manual for performing a self-exam. The remaining 13 studies asked participants to self-report symptoms, presence of periodontal disease itself, or their recollection of a dental health professional diagnosing them or providing treatment for periodontal disease. The review indicates that some measures showed promise, but results varied across populations and self-reported measures. One example of a good measure is, "Has any dentist/hygienist told you that you have deep pockets?", which had a sensitivity of 55%, a specificity of 90%, positive predictive value of 77%, and negative predictive value of 75% against clinical pocket depth. Higher validity could be potentially obtained by the use of combinations of several self-reported questions and other predictors of periodontal disease.

Strength of evidence linking oral conditions and systemic disease

Associations between dental diseases and systemic outcomes are potentially important because of the high occurrence of dental diseases. If this extremely common source of chronic infection (dental disease) leads to an increased morbidity and mortality rate, the public health impact of oral disease on millions of Americans would be substantial. Recent studies demonstrate an association between dental and systemic diseases, including systemic infections, cardiovascular disease, pregnancy outcomes, respiratory diseases, and increased all-cause mortality rate. Because there are several common risk factors for oral and systemic diseases, and limitations in published studies, a careful interpretation is needed. Confounding (shared risk factors for both systemic and dental disease) may explain part of the reported associations. It is also plausible that there may be a causal link. It is likely that if there is a causal link, several pathways and mediators coexist, linking oral and systemic disease. Bacteremia, bacterial endotoxins, cytokines, and other inflammatory mediators could conceivably be playing a direct or indirect role. Missing teeth are a surrogate marker for previous dental infection, and may also lead to altered dietary intake. Hence, diet may be an additional mediator for several of these outcomes. We caution clinicians not to recommend extracting infected teeth, based on the periodontal-systemic disease associations, if the teeth do not warrant extraction otherwise, because loss of teeth and edentulousness are associated with increased risk of systemic diseases. When assessed against causal-defined criteria, the evidence suggests possible causal associations between chronic periodontal disease and tooth loss with cardiovascular disease, bacterial endocarditis, pregnancy outcomes, and all-cause overall mortality. Further studies are needed to show consistency, to corroborate that the associations are independent of common risk factors for both systemic and dental disease, including healthy lifestyle factors, and to evaluate different biological pathways.

Seasonal variation of acute necrotising ulcerative gingivitis in South Africans

OBJECTIVES

To examine seasonal variations in the presentation of acute necrotising ulcerative gingivitis (ANUG) in a previously unstudied population in Cape Town, South Africa.

DESIGN

A descriptive study of all presenting cases of ANUG at a health center over 6 years; patients were examined at one point in time.

SETTING

A clinic-based cross-sectional study was carried out among patients presenting routinely to the oral medicine clinic at the University of the Western Cape. Patients at this clinic were mostly colored and black people, and were of low socioeconomic status.

SUBJECTS AND METHODS

All patients presenting to the periodontal clinic were examined during the period from 15 March 1992 to 15 March 1998 and interviews were conducted. A comprehensive clinical intra-oral and peri-oral examination was carried out using a dental mirror and blunt probe by three trained calibrated dental examiners. The minimum criteria for inclusion as an ANUG patient were painful, bleeding gums with irreversible destruction of the interdental papillae (cratering) and marginal gingiva. Patients with multiple small ulcerations not restricted to the gingiva, but including other oral sites such as the tongue and buccal mucosa were diagnosed as herpetic stomatitis. Other distinguishing characteristics of ANUG included presence of a pseudomembrane, odor, a strange taste in the mouth, and hypersalivation. Swabs and biopsies taken to verify the diagnosis when necessary. If there was any doubt as to the diagnosis of the lesion it was not included among the ANUG cases.

MAIN OUTCOME MEASURE

Presence of ANUG.

RESULTS

Among the 19944 patients presenting for periodontal treatment, 684 were found to have ANUG. The ANUG patients consisted of 58% males; 73% of the ANUG patients were between the ages of 5 to 12 years. The majority of ANUG patients presented during the summer (55.4%), 27.7% in autumn and 8.4% during both winter and spring. Significant differences were evident between the numbers seen during the different seasons.

CONCLUSIONS

This study demonstrated a significant seasonal variation in the occurence of ANUG in Cape Town, South Africa.

Smoking and alcohol in the etiology of oral cancer: gender-specific risk profiles in the south of Greece

Oral and pharyngeal cancer (OC) mortality is very low in Greece, especially among men, compared to other European countries. We conducted a case-control study of OC in Athens, and obtained information on tobacco, alcohol use and other potential risk factors and confounding variables for 110 incident cases and 115 hospital-based controls. We used multivariate logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Tobacco smoking (pack years, P(trend)=0.01) and alcohol use (drinks/week, P(trend)=0.07) were independent risk factors, with a multiplicative effect for combined exposures (OR, 8.3; 95% CI, 2.4-29.1, for >28 alcohol drinks/week and >50 pack years of cigarette smoking). The type of alcoholic beverage also seemed important: drinking ouzo and tsipouro (liquors of high ethanol concentration) was associated with greater increased OC risk than drinking comparable amounts of wine, beer or dark spirits. While alcohol drinking is more common for male cases versus controls, few men reported regularly consuming large quantities of ethanol associated with highest risk of OC in other studies. This may partially explain the low rates of male OC mortality in Greece. Among the 38% of our cases who were women, however, neither smoking nor alcohol drinking frequencies were significantly elevated compared to controls, and so the etiology of OC risk in females requires further investigation.

Oral health problems and significant weight loss among community-dwelling older adults

BACKGROUND

Studies of hospitalized and institutionalized older adults suggest a relationship between poor oral health and subsequent weight loss. Given the association between weight loss and subsequent mortality and morbidity, we evaluated how oral health problems contributed to significant weight loss over a 1-year period among a representative sample of community-dwelling older adults.

METHODS

The study population consisted of 563 adults aged 70 years and older living at home in rural and urban areas in six New England states. Baseline data included information regarding health status, functional status, physical activity, disease diagnoses, lifestyle behaviors, and cognitive and affective status. Dentists performed oral health assessments. One year later, participants were called and asked questions regarding their health and dietary practices and their current weight.

RESULTS

Over the 1-year period of follow-up, approximately one third of the sample had lost 4% or more of their previous total body weight; 6% of men and 11% of women lost 10% or more of their previous body weight. Of the subjects, 37% were edentulous; most of these individuals wore full dentures. With gender, income, advanced age, and baseline weight controlled for, edentulousness remained an independent risk factor for significant weight loss (odds ratio 1.63 for 4% weight loss and 2.03 for 10% weight loss). Individuals with increasing numbers of posterior teeth and functional units were at slightly lower risk for weight loss; however, these associations did not reach statistical significance.

CONCLUSIONS

Dentate status is an important risk factor for clinically significant weight loss among community-dwelling older adults.

Meta-analysis of surgical versus non-surgical methods of treatment for periodontal disease

A meta-analysis was performed on 5 randomized controlled trials comparing surgical with non-surgical treatment for periodontal disease. The specific procedures considered were the modified Widman flap compared with scaling and root planning or curettage with anesthesia. We chose the most consistently reported outcomes, pocket depth and attachment level, for analysis. At 1 year of follow-up, surgical treatment reduced pocket depth more than non-surgical for all initial levels of disease, but by 5 years, only the deepest initial pockets (> 7 mm) showed significant improvement over non-surgically treated teeth (0.51 mm reduction, p < 0.01). Attachment level showed significantly better early results for non-surgical treatment for less diseased teeth, but by 5 years, all significant differences had disappeared. We computed quality scores following a method described by Chalmers. The mean quality score for study data analysis and presentation was 0.37 +/- 0.009 and for the study protocol, the mean quality score was 0.19 +/- 0.002. We find that this meta-analysis supports findings relating response to therapy with initial level of disease severity. We also find that the choice of outcome measure influences the choice of therapy, with surgical therapy providing greater benefit for probing depth and non-surgical therapy providing greater benefit for attachment level. These results must be viewed, however, in light of the low quality scores of the evaluated studies and the potential for bias due to lack of binding, the small mean treatment differences, and the observer measurement variability.

The association of mutans streptococci and non-mutans streptococci capable of acidogenesis at a low pH with dental caries on enamel and root surfaces

Coronal dental plaque from each of 12 caries-positive subjects (Group I) was pooled from "white spot" tooth surface areas and, separately, from sound surface areas; sound surface areas in each of 18 caries-free subjects (Group II) were sampled similarly. Two samples, one consisting of material from a root-surface lesion and another of plaque from a sound root-surface area, were obtained from each of another 10 subjects (Group III). The samples from Groups I and II were evaluated for: (1) pH-lowering potential in vitro with dispersed plaque suspensions, excess glucose supply, and a 60-minute test; (2) the levels of mutans streptococci (MS) and lactobacilli; and (3) the distribution of the predominant non-mutans streptococci (non-MS) according to their final pH in glucose broth; only microbial analysis was done for the Group III samples. The levels of the MS were generally positively associated with caries. A weaker positive association was found for the levels of those non-MS capable of acidogenesis at low pH (final pH < 4.4). The latter generally far outnumbered the MS in all types of samples. The levels of lactobacilli were nearly always very low. The pH-lowering potential (final pH and pH drop rate) was higher for plaque from "white spot" areas than for plaque from sound surface areas (Group I). The samples from caries-free subjects (Group II), however, exhibited a pH-lowering potential which was not significantly different from that of both types of samples from the caries-active subjects (Group I).(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for cigarette smoking as a major risk factor for periodontitis

The role of smoking as a risk factor for periodontitis was assessed separately in diabetic and nondiabetic study groups. Subject listings stratified for age (19 to 40 years) and sex were obtained for subjects with insulin-dependent diabetes mellitus (IDDM) and nondiabetic subjects. For both the IDDM group (n = 132) and the nondiabetic group (n = 95), age and sex stratified samples were constructed by random selection of subjects from each subject listing. Patients were recruited by phone, examined, and their medical and dental histories obtained. Among nondiabetic subjects, the prevalence of periodontitis was markedly higher among current smokers compared with never smokers (P < or = 0.005) in both the 19 to 30 year-old (46% vs. 12%) and 31 to 40 year-old groups (88% vs. 33%). The subject mean percent of sites with gingival pocket depth > or = 4 mm was higher among current smokers than never smokers (P = 0.001) in the 19 to 30 (8.2% vs. 3.4%) and 31 to 40 (14.3% vs. 4.3%) age groups. The effects of smoking among IDDM subjects were similar to that observed in the nondiabetic population. There were no differences between current and never smokers in the proportion of sites positive for plaque. Attributable risk percents from prevalence data suggest that among nondiabetic subjects, a large proportion, perhaps as much as 51% of the periodontitis in the 19 to 30 year old group and 32% of the periodontitis in the 31 to 40 year old group, is associated with smoking.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of age on immunoglobulin content and volume of human labial gland saliva

Stimulated lower labial (LLGF) and parotid salivary volumes and IgG, IgA, and IgM concentrations were measured in 264 subjects whose ages ranged from 17 to 76 years. A significant (p < 0.001) age-related decline in LLGF output was observed for subjects over this age range. Sixty-three percent of the subjects in the 18-20-year-old group (n = 46) secreted at least 10 microL of labial saliva in a 7-10-minute period, while approximately 70% of the subjects in the two oldest groups (61-70 and 71-76 years old) secreted less than 1 microL of LLGF during this time period (n = 64). No significant gender-based differences occurred in the volumes of labial saliva secreted. Stimulated parotid salivary flow showed no age-related trend in these subjects. Lower labial gland salivary IgA concentrations in an older population (mean age +/- SD = 55.6 yr +/- 1.3) were significantly lower (p < 0.025) than IgA concentrations in a younger population (20.7 yr +/- 0.8), when IgA was expressed as microgram/mL LLGF collected. Immunoglobulin A concentrations in parotid saliva and IgG and IgM concentrations in labial and parotid saliva were not significantly different when the two age populations were compared. These data suggest that the physiological and immunological potential of labial gland saliva may decrease with age.

Humoral IgG antibodies to oral microbiota in a population at risk for root-surface caries

Mutans streptococci have been strongly implicated in the initiation of dental caries on coronal surfaces. Their role in development of root-surface caries is less clear. The etiologic agents of both types of dental caries are likely to elicit systemic immune responses. The objective of the present study, therefore, was to study the association of clinical variables of disease with humoral IgG antibodies to nine oral micro-organisms in 314 adult subjects, aged 45-65 years, who were at risk for root-surface caries. Antibody activity to Streptococcus mutans strain Ingbritt, S. mutans/S. sobrinus GTFs, S. faecalis strain 19433, Actinomyces viscosus strain WVU 626, Actinomyces naeslundii strain 12, Lactobacillus casei, Actinobacillus actinomycetemcomitans strain Y4, Porphyromonas gingivalis strain 381, Eikenella corrodens strain 1073, and Wolinella recta strain 371 was measured by ELISA. Pearson correlation coefficients among log10 antibody levels within subjects revealed marked positive correlations among subgingival bacteria, generally weak positive correlations among supragingival micro-organisms, and no correlations between elements of the supragingival battery with the subgingival battery. IgG antibody levels to mutans streptococcal antigens were significantly correlated with subject DMF scores (r = 0.23; p less than 0.0001). No significant correlation was seen between DMF scores and antibody to any other supragingival micro-organism tested. Further relationships between levels of S. mutans antibody and individual clinical variables were analyzed by step-wise multiple linear regression, resulting in a model that was highly significant (p = 0.0001), with an r2 = 0.14. Numbers of missing teeth, coronal caries, root-surface caries, and root-surface restorations were each positively associated with antibody levels to mutans streptococci.(ABSTRACT TRUNCATED AT 250 WORDS)

Microbiology of healthy and diseased periodontal sites in poorly controlled insulin dependent diabetics

A group of poorly-controlled insulin dependent diabetes mellitus (IDDM) patients were examined in a cross-sectional design for total microbial levels, microbial incidence, and the percent levels of selected periodontal microorganisms. These organisms were selected on the basis of prior reports that associated them with either periodontal disease or health. One periodontally-healthy and one periodontally-diseased site were examined in each IDDM patient. Increased levels of the periodontal pathogens Prevotella intermedia, P. melaninogenica spp., Bacteroides gracilis, Eikenella corrodens, Fusobacterium nucleatum and Campylobacter rectus (formerly Wolinella recta) were found at the periodontal diseased sites. Increased prevalence of the organisms P. intermedia, P. melaninogenica spp., and C. rectus were found at the diseased sites. A significantly higher percentage of P. intermedia was found at the sites exhibiting deep pockets and attachment loss.

Mutans streptococci and non-mutans streptococci acidogenic at low pH, and in vitro acidogenic potential of dental plaque in two different areas of the human dentition

Samples of human dental plaque were obtained from sound tooth surfaces in the lower anterior and upper posterior areas of each of 11 subjects with various degrees of caries experience. Both types of plaque were compared for: (1) their pH-lowering potential [pH at 10 and 60 min after sugar addition and the pH drop between 0 and 10 min (delta pH)] with an in vitro method involving dispersed plaque suspensions and excess glucose supply; (2) the proportions of mutans streptococci; and (3) the distribution of the predominant non-mutans streptococci according to their final pH in glucose broth. Compared with plaque from the lower anterior area, plaque from the upper posterior area exhibited a significantly higher pH-lowering potential, i.e., a lower pH at 10 and 60 min and a greater delta pH and significantly higher levels of mutans streptococci. The final pH values for the non-mutans streptococci exhibited a wide range from about 4.4 to over 5.0. The proportions of such organisms designated as capable of acidogenesis at low pH (final pH less than 4.6), whether expressed as a percentage of the total non-mutans streptococci or of the total plaque flora, were significantly increased in plaque from the upper posterior area. The proportions of non-mutans streptococci capable of acidogenesis at low pH in plaque from the upper posterior area were also significantly increased, with decreasing pH values at 10 and 60 min.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro acidogenic potential and mutans streptococci of human smooth-surface plaque associated with initial caries lesions and sound enamel

Samples of human dental plaque were pooled from several "white spot" smooth tooth surface areas as well as from several clinically-sound tooth surface areas in each of 12 caries-positive college students. Each of the two samples from each subject was used for the determination of: (1) pH-lowering potential in vitro involving dispersed plaque suspensions, excess glucose supply, and a 60-minute test, and (2) the proportions of mutans streptococci and lactobacilli. When all subjects were considered, plaques from "white spot" areas, as compared with samples from sound surface areas, were characterized by significantly higher proportions of mutans streptococci, a lower starting ("resting") pH, a faster rate of pH drop between pH 6.0 and 5.0, and a lower minimum pH of the suspension; the lactobacillus proportions were generally very low in both types of plaques. For individual subjects, however, the proportions of mutans streptococci in plaque associated with "white spot" areas showed a wide range (0.001-10.0%), and samples with high as well as low levels of these micro-organisms could exhibit a high rate of pH drop and a low pH minimum. This suggests that, besides mutans streptococci and lactobacilli, other bacteria capable of acidogenesis at a low pH may contribute to the high pH-lowering potential exhibited by many plaques.

The prevalence of root caries in a diabetic population

The objective of this study was to assess the level of root caries in a population of diabetic adults. Diabetics are of special interest because they are alleged to be periodontally compromised and have atypical patterns of refined carbohydrate ingestion. Diabetic subjects were patients of the Joslin Diabetic Center in Boston and had significantly elevated blood glucose and glycosylated hemoglobin levels over at least a ten-year period. Eligible subjects had to be between the ages of 45 and 65 and have a minimum of ten teeth and three sites with recession. Data were collected on coronal caries, oral hygiene, gingivitis, pocket depth, recession, and root caries and were compared with data from control subjects from a larger non-diabetic study group. There were 88 diabetics and 185 controls with mean ages of 55.7 and 56.3 years, respectively. The groups were found to be similar with respect to the numbers of buccal surface sites with gingival recession and the numbers of carious root lesions. There was a distinct difference, however, with respect to restored root surfaces: 1.76 mean filled surfaces were observed in the controls, as compared with 0.49 in the diabetics. A Katz Root Caries Index (for which lesions are calculated as a percentage of the numbers of exposed root surfaces) was determined to be 15.2 for the controls and 7.1 for the diabetics. A reasonable inference is that these differences are the result of a restricted ingestion of refined carbohydrates by the diabetic group. This was confirmed by a dietary survey of subsamples from the diabetic and non-diabetic groups.

CaF2 in enamel biopsies 6 weeks and 18 months after fluoride treatment

Fluoride concentrations were studied in enamel biopsies from maxillary central incisors 6 weeks and 18 months after fluoride treatment. In the short-term study biopsies were obtained prior to and after treatment with acidic sodium or ammonium fluoride. The findings showed that large amounts of fluoride were deposited in enamel from NH4F treatment (mean concentration 84,723 ppm), indicating substantial CaF2 formation. NaF treatment resulted in mean fluoride concentrations of 7,818 ppm. In the 18-month study, biopsies from 58 placebo-treated teeth were analyzed for total fluoride (mean 1,733 ppm). Twenty-five additional biopsies from placebo-treated and 58 from NH4F-treated teeth were analyzed for KOH-soluble (CaF2) and KOH-nonsoluble (apatitic) fluoride. The mean values for total fluoride were 1,669 and 2,085 ppm in the placebo-treated and in the NH4F-treated groups, respectively. The corresponding mean values for KOH-nonsoluble fluoride were 1,467 and 1,731 ppm and for KOH-soluble fluoride 202 and 354 ppm, respectively. The increase in enamel fluoride after fluoride treatment was only marginally significant. Biopsies from the ammonium fluoride treated group were significantly more likely to have high (30 vs. 8%) and moderate (28 vs. 16%) CaF2 levels and less likely to have low levels than biopsies of placebo-treated teeth (chi-square = 8.0 with 2 d.f.; p = 0.018). It is concluded that very substantial amounts of CaF2 are present in enamel 6 weeks after treatment, and small amounts may persist in the surface enamel for as long as 18 months.