World Workshop on Oral Medicine VIII: Barriers to research in oral medicine: results from a global survey

OBJECTIVES

To explore factors influencing research interest and productivity and perceived barriers to conducting research in Oral Medicine (OM).

METHODS

Invitations to participate in an online survey were e-mailed to a network of international OM practitioners and related professional organizations. Questions captured respondents' demographic/professional variables and gauged research interest, productivity, and perceived barriers to conducting research specifically in OM. Statistical analysis was conducted via descriptive, logistic regression, and multivariate modeling.

RESULTS

Five hundred and ninety-three OM practitioners from 55 countries completed the survey, with 54%, 25%, and 21% practicing in high, upper-middle, and lower-middle-income countries, respectively. Eighty-six percent of respondents were interested in conducting research. Age (less interest with an increase in age), working in academia, and practicing in a lower-middle vs high-income country were significant predictors of research interest. Self-reported research productivity was significantly greater among males, those working in academia, and those who graduated from programs that mandated research presentation/publication. Obtaining research funding was a significant barrier among respondents from lower and upper-middle-income countries, whereas finding time for research was a reported barrier by respondents from high-income countries.

CONCLUSION

The results of this survey identified perceived barriers to conducting research in OM and highlighted solutions to address such barriers.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Oral Lichen Planus: A Systematic Review of Outcome Domains

OBJECTIVE

There is a lack of consensus regarding clinician- and patient-reported oral lichen planus (OLP) outcomes. The World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research (WONDER) Project aims to develop a core outcome set (COS) for OLP, which would inform the design of clinical trials and, importantly, facilitate meta-analysis, leading to the establishment of more robust evidence for the management of this condition and hence improved patient care.

STUDY DESIGN

Ovid MEDLINE, Embase, CINAHL, CENTRAL, and Clinicaltrials.gov were searched for interventional studies (randomized controlled trials, controlled clinical trials, and case series including ≥5 participants) on OLP and oral lichenoid reactions published between January 2001 and March 2022 without language restriction. All reported primary and secondary outcomes were extracted.

RESULTS

The searches yielded 9,135 records, and 291 studies were included after applying the inclusion criteria. A total of 422 outcomes were identified. These were then grouped based on semantic similarity, condensing the list to 69 outcomes. The most frequently measured outcomes were pain (51.9%), clinical grading of the lesions (29.6%), lesion size/extension/area (27.5%), and adverse events (17.5%).

CONCLUSION

As a first step in developing a COS for OLP, we summarized the outcomes that have been used in interventional studies over the past 2 decades, which are numerous and heterogeneous.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Oral Lichen Planus: The Patient Perspective

OBJECTIVE

This study aimed to explore the lived experience of patients with oral lichen planus (OLP) and investigate what treatment-related outcomes are the most important to them and should be included in a core outcome set (COS) for OLP.

STUDY DESIGN

A qualitative study involving focus group work with 10 participants was conducted. Interviews with each focus group were held twice: session 1 explored the lived experience of patients with OLP, and session 2 allowed patients to review a summary of the outcome domains used in the OLP literature to date. The discussions were recorded, transcribed verbatim, and analyzed using framework analysis.

RESULTS

In session 1, 4 themes and 8 sub-themes emerged from the data analysis. An additional outcome, 'knowledge of family and friends,' was suggested in session 2.

CONCLUSIONS

We have gained valuable insight into the lived experience of patients with OLP via this qualitative study. To our knowledge, this study is the first to explore the patient perspective on what should be measured in clinical trials on OLP, highlighting an important additional suggested outcome. This additional outcome will be voted upon in a consensus process to determine a minimum COS for OLP.

World Workshop on Oral Medicine VII: Oral adverse effects to biologic agents in patients with inflammatory disorders. A scoping review

BACKGROUND

Biologic agents are rapidly emerging as an effective therapy to treat autoimmune and other chronic diseases. The use of these agents is poorly characterized, resulting in a lack of guidance for dental practitioners. Case reports of oral adverse events have begun to emerge. However, their scope and frequency have not been summarized and analysed to date. The objective of this review was to characterize the literature on oral adverse effects associated with biological therapy when used for autoimmune and inflammatory disorders.

METHODS

This review was developed in accordance with scoping review recommendations. Search strategies were developed and employed for six databases. Studies were selected using a systematic search process but with broad inclusion of study types given the paucity of information available. Reports of oral adverse events were analysed descriptively according to agent, mechanism of action, underlying disease, and oral adverse effect observed.

RESULTS

Our search returned 2080 articles and 51 met our inclusion criteria, of which most were case reports. The most frequent adverse effects included angioedema, oral lichenoid lesions, osteonecrosis of the jaw, and oral infections. There were also cases of oral malignancies associated with use of biologic agents. Less common effects such as pigmentation were also described.

CONCLUSIONS

Oral adverse events have been reported in patients on biologic therapy, albeit in small numbers to date. This limits the generalizability of these results, which should not be used to generate a clinical guideline as they are based primarily on case reports. However, this study presents the first review characterizing the adverse effects observed. Large multi-center studies will be necessary to further define the oral and dental complications caused by biologic agents.

Influence of topical corticosteroids on malignant transformation of oral lichen planus

BACKGROUND

Oral lichen planus (OLP) is considered an oral potentially malignant disorder. While OLP has been associated with the development of oral squamous cell carcinoma (OSCC), little is known about the role of topical corticosteroids therapy (TCT) in the promotion of carcinogenesis. The study aimed to determine if TCT influences the time of malignant transformation of OLP to OSCC. The study also investigates this correlation in the presence or absence of Candida overgrowth, and in the context of conventional OSCC risk factors such as smoking, alcohol use, and male gender.

METHODS

A retrospective analysis of electronic health records at a tertiary care academic medical center was performed. Patients with OLP and OSCC were considered for inclusion. The diagnosis of OLP required both clinical and histological documentation.

RESULTS

Eighty-two patients met inclusion criteria, consisting of 48 women (58.25%) and 34 men (41.5%) and the mean patient age was 65.9 years (SD = 13.25). Forty-five patients (54.9%) received TCT for OLP before they developed OSCC. The time between the OLP and OSCC diagnoses increased by four years in patients who received topical steroid therapy for OLP (p < 0.001) and decreased by three years (p = 0.010) in those with Candida overgrowth. Gender, smoking, and alcohol use did not have a statistically significant influence on the time between OLP and OSCC.

CONCLUSION

The management of OLP using TCT potentially delayed cancer development in our study. Conversely, it appears that Candida may play a role in the field cancerization of OLP patients.

World Workshop of Oral Medicine VII: A systematic review of immunobiologic therapy for oral manifestations of pemphigoid and pemphigus

OBJECTIVE

To assess the evidence for treatment of oral involvement of pemphigus and pemphigoid with biologics.

STUDY DESIGN

This systematic review used a comprehensive search strategy to identify literature describing oral involvement of pemphigus or pemphigoid treated with a biologic agent. The primary outcome measures were efficacy and safety of biologic therapy.

RESULTS

Inclusion criteria were met by 154 studies including over 1200 patients. Treatment of pemphigus with a total of 11 unique biologic agents and 3 unique combinations of agents is reported. Five randomized controlled trials (RCT) were included in the final analysis that investigated infliximab, IVIg, rituximab, and autologous platelet-rich plasma therapy for pemphigus vulgaris. Three non-RCT studies reported on successful rituximab or IVIg therapy for mucous membrane pemphigoid. Studies demonstrated considerable heterogeneity in agent, methods, and quality.

CONCLUSIONS

Evidence clearly describing oral tissue response to biologic therapy is sparse. Two RCTs support use of rituximab, one supports use of IVIg, and one pilot study suggests intralesional injection of autologous platelet-rich plasma aids healing of oral PV lesions. As oral lesions of pemphigus and pemphigoid can be refractory to systemic therapy, drug trials including biologic therapies should document details regarding response of the oral lesions to therapy.

World Workshop on Oral Medicine VII: Immunobiologics for salivary gland disease in Sjögren's syndrome: A systematic review

OBJECTIVE

This systematic review evaluated the efficacy of immunobiologics for the management of oral disease in Sjögren's syndrome (SS).

MATERIALS AND METHODS

MEDLINE^® , Embase, Scopus, and the Cochrane Library were searched for evidence on the use of immunobiologics for management of glandular disease in SS. Primary outcomes were xerostomia and salivary gland dysfunction, assessed via visual analogue scales, disease-specific scales for SS, measurement of salivary flow, ultrasound data, and quality of life measures.

RESULTS

Seventeen studies (11 randomized controlled trials and 6 observational studies) met inclusion criteria. Rituximab showed efficacy in improving salivary gland function but not xerostomia. Abatacept showed promise in improving both xerostomia and salivary flow. Belimumab exhibited long-term improvement of salivary flow and subjective measures. The novel agent CFZ533 improved both disease activity and patient-reported indexes.

CONCLUSIONS

There is strong evidence pointing to the efficacy of rituximab in the management of oral disease in SS. Future controlled trials may elucidate the efficacy of belimumab and abatacept. The new drug CFZ533 is a promising alternative for the management of SS and its salivary gland involvement. In considering these agents, the promise of efficacy must be balanced against the harmful effects associated with biologic agents.

The Global Footprint of Oral Medicine Specialists: The University of Pennsylvania Experience

The aim of this study was to analyze the global footprint of oral medicine specialists who graduated from the University of Pennsylvania oral medicine residency program. In 2016, a cross-sectional electronic survey was distributed to 53 graduates of that program, asking about their current geographical location and professional status. Of those 53 graduates, 23 (43%) completed the survey with 22 reporting their current location and 21 reporting their current professional status. The results showed that 17 graduates were located within the U.S., and five were located internationally. Twelve graduates were in full-time academic positions, three were in part-time academic positions/part-time private practice, three were in full-time private practice, two were in postdoctoral training programs, and one was not employed. This study found that oral medicine specialists trained at the University of Pennsylvania were located both domestically and internationally. The majority held faculty positions at academic institutions with fewer involved in private practice. This program may thus be considered a source of future dental academicians.

Perceived Stability of Trait Labels

Subjects (n = 207) rated the stability of 115 traits. A positivity bias was found (r = .62) such that traits which were perceived as stable tended to be those that connote likableness. Also, traits relating to positive ability (e.g., intelligent, bright) were perceived as more stable than effort traits (e.g., motivated, industrious). However, no difference was found between negative ability traits (e.g., unintelligent, stupid) and effort traits. Implications for person perception research were discussed.

Effect of Passage of Time on Reactions to Help and Harm

Reactions of 91 female Ss to being either helped or harmed were assessed over a period of 1 wk. Results showed that reactions to help and harm were significantly different and that there was no dissipation of these reactions over time.

Temporomandibular disorders: evaluation and management

Temporomandibular disorders remain a common cause of visits to primary care physicians, internists, pediatricians, and emergency departments. Advances in the clinical diagnosis, radiographic imaging, and classification of these disorders have improved long-term management. There are several types of disorders of the masticatory muscles and the temporomandibular joint as well as associated structures and each may have a complex cause, clinical course, and response to therapy. Host susceptibility plays a role at several stages of these disorders. Future research offers greater possibility in defining this heterogeneous group of disorders and providing more focused and effective treatment strategies.

Reliability and validity of mobile teledermatology in human immunodeficiency virus-positive patients in Botswana: a pilot study

IMPORTANCE

Mobile teledermatology may increase access to care.

OBJECTIVE

To determine whether mobile teledermatology in human immunodeficiency virus (HIV)-positive patients in Gaborone, Botswana, was reliable and produced valid assessments compared with face-to-face dermatologic consultations.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study conducted in outpatient clinics and public inpatient settings in Botswana for 76 HIV-positive patients 18 years and older with a skin or mucosal condition that had not been evaluated by a dermatologist.

MAIN OUTCOMES AND MEASURES

We calculated the κ coefficient for diagnosis, diagnostic category, and management for test-retest and interrater reliability. We also determined sensitivity and specificity for each diagnosis.

RESULTS

The κ coefficient for test-retest reliability ranged from 0.47 (95% CI, 0.35 to 0.59) to 0.78 (0.67 to 0.88) for the primary diagnosis, 0.29 (0.18 to 0.42) to 0.73 (0.61 to 0.84) for diagnostic category, and 0.17 (-0.01 to 0.36) to 0.54 (0.38 to 0.70) for management. The κ coefficient for interrater reliability ranged from 0.41 (95% CI, 0.31 to 0.52) to 0.51 (0.41 to 0.61) for the primary diagnosis, 0.22 (0.14 to 0.31) to 0.43 (0.34 to 0.53) for diagnostic category, and 0.08 (0.02 to 0.15) to 0.12 (0.01 to 0.23) for management. Sensitivity and specificity for the top 10 diagnoses varied from 0 to 0.88 and 0.84 to 1.00, respectively.

CONCLUSIONS AND RELEVANCE

Our results suggest that while the use of mobile teledermatology technology in HIV-positive patients in Botswana has significant potential for improving access to care, additional work is needed to improve the reliability and validity of this technology on a larger scale in this population.

Report on World Workshops on Oral Medicine (WWOM) IV and V: research themes and citation impact: WWOM VI steering committee

The first World Workshop on Oral Medicine (WWOM) was held in 1988. The portfolio has continued to expand in scope and impact over the past 26 years. Five World Workshops were conducted between 1988 and 2010, focusing on creation of systematic reviews in biomedicine and health care of importance to the international oral medicine community. WWOM VI was conducted in April 2014 and further extended this modeling. This most recent Workshop also fostered creation of the inaugural joint meeting between the American Academy of Oral Medicine and the European Association of Oral Medicine, together with The British Society for Oral Medicine and the Oral Medicine Academy of Australasia. The goal of the WWOM portfolio is to strategically enhance international oral medicine research, education, and clinical practice. To this end, this report summarizes subject areas for WWOM IV (2004) and research recommendations for WWOM V (2010), as well as citation metrics relative to publications from these two conferences. The information is designed to provide research and clinical context for key issues in oral medicine as delineated by the WWOM portfolio over the past 10 years, as well as for projected outcomes of WWOM VI over the next 12 months.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.

Clinical assessment of patients with orofacial pain and temporomandibular disorders

Accurate diagnosis of chronic pain disorders of the mouth, jaws, and face is frequently complex. It is common for patients with chronic orofacial pain to consult multiple clinicians and receive ineffective treatment before a correct diagnosis is reached. This problem is a significant public health concern. Clinicians can minimize error by starting the diagnostic procedure with a careful, accurate history and thorough head and neck examination followed by a thoughtfully constructed differential diagnosis. The possibility that the patient has symptoms of a life-threatening underlying disease rather than a more common dental, sinus, or temporomandibular disorder must always be considered.

Oral medicine: defining an emerging specialty in the United States

Oral medicine is a specialized area of study within the scope of dental medicine. This discipline is often viewed as the crossroads between medicine and dentistry and has become integral in both pre-and postdoctoral dental education. Oral medicine is recognized as a dental specialty throughout most of the world and currently represents an emerging specialty in the United States. Historically, oral medicine has been loosely defined in the United States without a clear consensus definition. Recent published studies regarding international oral medicine postdoctoral programs and clinical practice have helped to provide more specific information regarding oral medicine from many perspectives. This article will review the literature relevant to defining oral medicine in the United States and present a new definition of this important discipline based on recent studies.

Local drug delivery for oral mucosal diseases: challenges and opportunities

There are few topical formulations used for oral medicine applications most of which have been developed for the management of dermatological conditions. As such, numerous obstacles are faced when utilizing these preparations in the oral cavity, namely enzymatic degradation, taste, limited surface area, poor tissue penetration and accidental swallowing. In this review, we discuss common mucosal diseases such as oral cancer, mucositis, vesiculo-erosive conditions, infections, neuropathic pain and salivary dysfunction, which could benefit from topical delivery systems designed specifically for the oral mucosa, which are capable of sustained release. Each condition requires distinct penetration and drug retention profiles in order to optimize treatment and minimize side effects. Local drug delivery may provide a more targeted and efficient drug-delivery option than systemic delivery for diseases of the oral mucosa. We identify those mucosal diseases currently being treated, the challenges that must be overcome and the potential of novel therapies. Novel biological therapies such as macromolecular biological drugs, peptides and gene therapy may be of value in the treatment of many chronic oral conditions and thus in oral medicine if their delivery can be optimized.

Persistent orofacial muscle pain

The pathophysiology of persistent orofacial myalgia has been the centre of much controversy. In this article we suggest a novel descriptive term; 'persistent orofacial muscle pain' (POMP) and review current evidence that supports the hypothesis that the induction of POMP involves the interplay between a peripheral nociceptive source in muscle, a faulty central nervous system component and decreased coping ability. In this context it is widely accepted that a complex interaction of variable intrinsic and extrinsic factors act to induce POMP and dysfunction.

Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy

OBJECTIVE

To identify and compare clinical and neuroimaging predictors of primary lobar intracerebral hemorrhage (ICH) recurrence, assessing their relative contributions to recurrent ICH.

METHODS

Subjects were consecutive survivors of primary ICH drawn from a single-center prospective cohort study. Baseline clinical, imaging, and laboratory data were collected. Survivors were followed prospectively for recurrent ICH and intercurrent aspirin and warfarin use, including duration of exposure. Cox proportional hazards models were used to identify predictors of recurrence stratified by ICH location, with aspirin and warfarin exposures as time-dependent variables adjusting for potential confounders.

RESULTS

A total of 104 primary lobar ICH survivors were enrolled. Recurrence of lobar ICH was associated with previous ICH before index event (hazard ratio [HR] 7.7, 95% confidence interval [CI] 1.4-15.7), number of lobar microbleeds (HR 2.93 with 2-4 microbleeds present, 95% CI 1.3-4.0; HR = 4.12 when >or=5 microbleeds present, 95% CI 1.6-9.3), and presence of CT-defined white matter hypodensity in the posterior region (HR 4.11, 95% CI 1.01-12.2). Although aspirin after ICH was not associated with lobar ICH recurrence in univariate analyses, in multivariate analyses adjusting for baseline clinical predictors, it independently increased the risk of ICH recurrence (HR 3.95, 95% CI 1.6-8.3, p = 0.021).

CONCLUSIONS

Recurrence of lobar ICH is associated with previous microbleeds or macrobleeds and posterior CT white matter hypodensity, which may be markers of severity for underlying cerebral amyloid angiopathy. Use of an antiplatelet agent following lobar ICH may also increase recurrence risk.

Spouses' cardiovascular reactivity to their partners' suffering

A laboratory study of older adults with osteoarthritis and their spouses was conducted to examine the unique influence of exposure to suffering on caregivers' risk for impaired psychological and physical health. Spouses' blood pressure (BP) and heart rate (HR) were monitored during 2 tasks designed to capture their partners' suffering. First, spouses watched their partners (and a stranger) carry heavy logs across an 8-ft space for 3 min, a task that elicited pain expression. Second, spouses spoke about their partners' suffering (and also about a typical meal with their partners). Results showed that spouses' BP and HR increased when watching and talking about their partners' suffering, and exposure to a partner's suffering was more physiologically stressful than to a stranger's suffering. These findings suggest that heightened physiological stress caused by exposure to a loved one's suffering may be one pathway to caregivers' increased risk for cardiovascular disease.

Effects of Cognitive Adaptation on the Expectation-Burnout Relationship Among Nurses1

Burnout has traditionally been thought to result from unrealistically high expectations although research has provided only equivocal support. We explored the impact of cognitive adaptation disposition, including mastery, optimism, and self-esteem, on the expectations-burnout relationship. Nurses (N = 341) who were recruited at professional conferences completed questionnaires that assessed cognitive adaptation, burnout, and initial and current expectations of control. As expected, cognitive adaptation predicted fewer unmet expectations of control, which in turn predicted lower burnout. In addition, optimism and self-esteem predicted lower burnout regardless of perceived initial expectations, whereas mastery lessened the negative consequences of initially high expectations on burnout.

Recurrent aphthous stomatitis

The cause of recurrent aphthous stomatitis (RAS) remains unknown despite considerable research. This article reviews the evidence for current theories regarding this disorder, including possible suspected relationships with microbial and immunologic factors, and presents medical diseases that mimic RAS lesions in certain patients. Topical management of the common form of minor RAS is described along with systemic therapy currently available to patients with severe forms of this disease.

Property crime victims' decision to notify the police: social, cognitive, and affective determinants

Previous research suggests that 3 general processes underlie the decision of property crime victims to notify the police: One that is cognitively driven by reward/cost considerations, one that is affectively driven, and another that is socially driven. This study is the first to employ a community sample of crime victims to compare the 3 processes within a single study. Computer-assisted interviews were conducted with 422 property crime victims (n = 129 burglary, n = 293 theft) located via a random digit dialing procedure. Logistic regression analyses showed that each process independently accounted for a significant amount of the variance in victim reporting, and that there were no interactions among the three processes in predicting reporting. Of the 3 processes, social influence was the best predictor of reporting. Analysis of the affect-driven process showed that reporting was primarily a function of the level of fear rather than anger or the level of generalized arousal upon discovering the crime.

Update on herpesvirus infections

Herpesviruses are responsible for many illnesses that affect the oral and maxillofacial region. The most common of these are primary or recurrent HSV infection, but knowledge of the manifestations of the eight herpesviruses that cause infections in humans will provide clinicians with a better understanding and basis for diagnosing and managing patients with these diseases. Immunocompromised patients are at greater risk for serious illness: therefore, clinicians treating transplant patients, patients receiving cancer chemotherapy, or HIV-infected individuals should be aware of the various clinical manifestations of infection with herpesviruses.

Seizure disorders: update of medical and dental considerations

Seizure disorders and epilepsy represent neurologic conditions that commonly are seen among patients requiring dental treatment. When dentists possess a working knowledge of seizures, in addition to an understanding of updated therapies for seizure management and oral complications associated with pharmacological therapy, they are able to treat patients with these disorders more effectively. Neurologic consultations and selecting an appropriate venue for treatment may need to be addressed prior to treatment, depending on the level of seizure control. Laboratory tests designed to evaluate medication levels, leukocyte counts, and clotting ability also may be required. Frequent recall visits may be necessary for seizure disorder patients who display adverse oral complications from medication, such as gingival hypertrophy, xerostomia, and oral yeast infections.

Etiology and Management of Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is an ulcerative condition that affects the oral mucosa without evidence of an underlying medical disorder. RAS is characterized by the appearance of round, shallow ulcerations surrounded by inflammation that chiefly involves the nonkeratinized mucosa. The etiology of RAS is unknown, but has a strong hereditary component and appears to be related to an immune reaction against the oral mucosa. RAS must be distinguished from other diseases that cause recurring oral ulcers such as Behçet's syndrome, systemic lupus erythematosus, and Crohn's disease. This paper reviews the current theories regarding the etiology of RAS, the clinical evaluation of patients with recurring aphthous ulcers, and describes current treatment options for this condition.

Biological responses of Lumbriculus variegatus exposed to fluoranthene-spiked sediment

Lumbriculus variegatus was used as a bioassay organism to examine the impact of the sediment-associated polycyclic aromatic hydrocarbon (PAH) fluoranthene on behavior, reproduction, and toxicokinetics. The number of worms increased between the beginning and end of the experiment at 59 microg x g(-1) fluoranthene, but at the next higher treatment (108 microg x g(-1)) the number of worms found was lower and not different from the control. Worms exposed to 95 microg x g(-1) also exhibited increased reproduction when fed a yeast-cerophyl-trout chow mixture. On a total biomass basis, only the 95 microg x g(-1) exposure with food exhibited a statistically significant increase over the nonfed control. Evaluation of reproduction at the two highest treatments was compromised by a brief aeration failure 2 days before the end of the experiment. The behavioral responses were followed as changes in biological burial rate (sediment reworking rate) of a 137Cs-labeled marker layer. The biological burial rate increased toward a plateau as the concentration increased from the control (3.9 microg x g(-1) dry weight total PAH) to 355 microg x g(-1) dry weight fluoranthene in sediment. The aeration failure had minimal impact on the determination of reworking rate because all the data for the rate determination were collected prior to the aeration failure. Uptake and elimination rates declined with increasing treatment concentration across the range of fluoranthene concentrations, 59-355 microg x g(-1) dry weight sediment. The disconnect between the increasing biological burial rates and the decreasing toxicokinetics rates with increasing exposure concentration demonstrates that the toxicokinetic processes are dominated by uptake and elimination to interstitial water. The bioaccumulation factor (concentration in the organisms on a wet weight basis divided by the concentration in sediment on a dry weight basis) ranged from 0.92 to 1.88 on day 10 and declined to a range of 0.52 to 0.99 on day 28 with the lowest value at the highest dose.