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Who Has Stronger Teeth: Girls or Boys?

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Dentists and scientists often find it difficult to determine why some people’s teeth are affected by dental erosion and others not, despite similar drinking and eating habits. Many studies show more severe dental erosion in men than in women. Studies have been carried out on dental erosion in wine tasters and people suffering from eating disorders with vomiting. These people frequently expose their teeth to acid and therefore have a high risk of developing dental erosion. However, research shows that not all of these patients at risk have dental erosion. Researchers at the Faculty of Dentistry, University of Oslo, are now attempting to find an explanation for this.

Not just acid

How do we explain that some individuals may have no signs of dental erosion despite frequently exposing their teeth to acid, while certain individuals who seem to do everything right, still develop dental erosion? Ph.D. candidate Marte-Mari Uhlen has been taking a closer look at this in her doctoral work.

“As dentists and researchers, we are often facing cases of dental erosion that we have difficulties explaining, and we meet patients who don’t have dental erosion although their lifestyle indicates that they should. It is also a general assumption that boys tend to have more erosion and more severe erosive lesions than girls. We believe that this disparity is due to something more than just the acidic effect,” explains Uhlen.

Clinical study

Uhlen and her colleagues conducted a clinical study on 66 patients with eating disorders and vomiting. The study consisted of a clinical examination and a questionnaire-based survey in which the patients were interviewed about their illness. The questionnaire included questions about the duration of the eating disorder and frequency of vomiting as well as the participants’ general health, oral hygiene habits and eating and drinking habits.

“The results from the study showed that 70 percent of the patients had dental erosion and that those who had been ill the longest had more dental erosion and more severe lesions than the ones with a shorter duration of disease. This finding confirms our assumptions that dental erosion is a common problem in patients with eating disorders and vomiting. Nevertheless, we were surprised to find that a third of the patients had no sign of dental erosion at all, even patients who had vomited regularly for up to 32 years”, explains Uhlen.

The researchers also examined the oral environment and the tooth enamel. The oral environment includes the volume of saliva, the contents of the saliva as well as the dental pellicle, which is a protein film that covers the surface of the teeth. All these elements are important factors in protecting the teeth against acid attacks. Dental enamel consists mainly of minerals, and the formation and structure of enamel are controlled by genes.

Simulating vomiting episodes in the laboratory

In their next study, the scientists collected teeth from eight people and placed samples of enamel from these teeth on a plate in the mouth of six other volunteers.

The plates with the enamel samples were subjected to simulated vomiting episodes: The plates were removed from the mouth and washed in hydrochloric acid twice a day for a total of nine days.

“We hoped to see how the teeth would respond to being exposed to acid in a different mouth than the one they came from,” explains Uhlen. “In this way, we could examine the protecting effect of both the oral environment and of the enamel itself”

The results revealed that susceptibility to dental erosion seems to be influenced both by the quality of the dental enamel and the oral environment: While in some subjects the degree of protection by the oral environment appeared to be most important, in others, the strength or weakness of their dental enamel was more significant.

Association with enamel formation genes

Then, the attention was aimed at genetics. Could a strong or weak enamel be inheritable? The hypothesis was that the genes responsible for enamel formation may give us more information about why a person develops dental erosion or not. Results from previous studies suggest that variations in these enamel formation genes could influence the susceptibility to dental caries and dental erosion.

The researchers then collected a tooth and a saliva sample from 90 people. Samples of enamel from these teeth were then mounted on a plate and exposed to acid. The amount of enamel loss was then measured using an advanced microscope.

The scientists extracted DNA from the saliva samples to investigate whether enamel formation genes might play a role in the susceptibility to dental erosion. Seven genes were selected.

“We selected these particular genes because they are important in different phases in the formation of the enamel”, says Uhlen.

Genetic variation affects susceptibility

Comparing the amount of enamel loss and the variation in the selected genes, the scientists discovered that some gene variations involved in the formation of the enamel seem to influence the susceptibility to dental erosion. The results from the genetic analyses also indicated that enamel from female donors is more protected against dental erosion than enamel from male donors. This supported the results from the eating disorder study, namely that the enamel in girls are genetically more protected against dental erosion than the enamel in boys.

“Our findings indicate that the susceptibility to dental erosion varies from individual to individual. Factors related to both the oral environment and the quality of the enamel seem to influence the susceptibility. In addition, the susceptibility to dental erosion appears to be affected by genetic variation”, Uhlen explains.

Furthermore, the findings confirm an assumption long held by clinicians and researchers that men are more prone to dental erosion than women.

Clinical significance

The results from these studies indicate that what is generally considered a normal intake of acidic food and beverages may cause dental erosion in subjects at risk. It is important that clinicians and researchers recognize this difference in susceptibility and inform their patients.

“Recognition of the fact that some people are more vulnerable or susceptible to dental erosion as well as an awareness of males possibly being particularly susceptible, dental professionals can distribute their resources better and devote more time to the patients who need it the most,” concludes Uhlen.

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The Effectiveness Of Chlorhexidine Is Limited In Preventing Infections In Oral Procedures

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The human oral cavity is colonised by a huge variety of bacteria. When surgical procedures such as a tooth extraction are carried out, the bacteria can pass into the bloodstream causing bacteraemia that is generally transient. What is not yet clear is how significant this presence of bacteria in the blood is in terms of the origin and evolution of infectious processes such as endocarditis of the heart valves, prosthetic valves, hip and knee joint replacements generally, and in local infection.

Numerous studies have shown that a mouthwash containing chlorhexidine has a powerful antimicrobial effect on saliva microflora and bacterial plaque.

“On the basis of this hypothesis we can assume that antimicrobial mouthwashes used before the dental procedure should reduce the number of micro-organisms that pass into the patient’s bloodstream, yet this is a hotly debated issue,” said the members of the UPV/EHU’s research group.

In 1997 the American Heart Association (AHA) suggested that patients at risk of infectious endocarditis should use an antimicrobial mouthwash before a dental procedure. In 2006, the British Society for Antimicrobial Chemotherapy (BSAC) recommended a single mouthwash with 0.2% chlorhexidine (CHX) (10 ml for 1 minute) before the carrying out of dental procedures associated with bacteraemia in patients at risk. Yet in 2007 the AHA recommended against adopting any antiseptic prophylaxis protocol.

In an effort to shed scientific light on this issue, the UPV/EHU research group comprising Iciar Arteagoitia, Carlos Rodriguez-Andrés and Eva Ramos decided to conduct a systematic review and meta-analysis of random controlled trials (RCT), following the PRISMA Statement. The aim was to assess the effectiveness of chlorhexidine in preventing bacteraemia following a tooth extraction. The research was conducted in collaboration with the UPV/EHU’s Department of Epidemiology and was published in Plos One.

In the study that included 8 clinical trials with 523 patients there were 267 in the group treated with chlorhexidine, in which 145 cases of bacteraemia were recorded, and 256 in the control group, in which there were 156 cases of bacteraemia. The results of the research therefore indicate that the percentage of cases of bacteraemia that can be prevented if a population undergoes chlorhexidine-based prevention is 12%. The NNT, the number of patients that need to be treated to prevent bacteraemia, is 16.

The results point to the relative and not particularly significant effectiveness of the use of chlorhexidine when it comes to preventing the bacteria present in the mouth from passing into the bloodstream when dental extraction is carried out.

“Yet, given its low cost and the absence of adverse reactions and complications, we would recommend a mouthwash with chlorhexidine before a procedure of this type is carried out,” concluded the UPV/EHU’s research group.

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Effective Diagnosis Of Persistent Facial Pain Will Benefit Patients And Save Money

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Patients with persistent facial pain are costing the economy more than £3,000 each per year, new research has revealed.

Experts at Newcastle University, UK, say introducing an electronic referral system to speed up diagnosis and treatment is likely to improve quality of life and save money.

The team has assessed the hidden costs of people suffering from long-term face and mouth pain that wasn’t caused by toothache.

Findings, published today in the Journal of Dental Research, show patients’ out-of-pocket costs are more than £650 a year, including prescription charges and travel expenses to and from appointments.

Meanwhile, costs to employers can be almost £2,500 every 12 months, due to aspects such as absenteeism and workers’ loss of productivity as a result of dealing with pain.

Screening patients

This research adds weight to growing evidence that there is a need to screen patients with a Graded Chronic Pain Scale (GCPS) to ensure those most severely affected receive specialist care quickly.

A previous study, by the same team at Newcastle University, showed that a well-established graded pain scale could help reduce costs by providing a better structured system of care.

Justin Durham, Professor of Orofacial Pain and Deputy Dean of Clinical Medicine, at Newcastle University, led the two-year study which was funded by the National Institute for Health Research.

He said: “Our research shows that people have to go around the proverbial ‘mulberry bush’, visiting lots of different healthcare professionals to even get close to obtaining a diagnosis never mind beginning treatment for their condition.

“A better and more defined care pathway would improve care for those with persistent facial pain and help reduce their costs and those to the economy.”

It is estimated that 7% of the population have Persistent Orofacial Pain (POFP), including temporomandibular disorders, phantom tooth pain, burning mouth syndrome, trigeminal neuralgia and atypical facial pain.

This research has revealed how patients attend a large number of appointments with different healthcare professionals but fail to obtain effective diagnosis or treatment plan quickly.

Professor Durham added: “Persistent facial pain is like having toothache every day of the week and, therefore, understandably has a profound and debilitating impact on people’s lives, and our research has highlighted the hidden costs of this condition.”

Data collected

Experts asked 200 patients suffering long-term face and or mouth pain to complete questionnaires every six months for two years to assess how individuals used the NHS for their pain.

The team collected the costs of the care patients received, such as what the NHS paid to provide medication, surgery or other treatments, how much patients paid out of their own pockets and how their condition affected their ability to work.

Within a six month period, participants reported an average of nine healthcare appointments, and those employed reported missing almost two days off work. This absenteeism equates to an average employer cost of £174 per person per six-months.

While the findings suggest that most study participants were unlikely to have a large number of days off work because of their pain, they did report experiencing pain while working for nearly 35 days in a six-month period, during which they noted a decrease in their productivity whilst at work that could cost employers more than £1,000.

Professor Durham said: “We’re calling for the introduction of an electronic referral system which uses a Graded Chronic Pain Scale — a simple seven item questionnaire.

“This scale would be a reliable way to determine who to fast-track to specialists and who should begin care immediately at their dentists or GP, meaning direct referrals would be made electronically to the best service local to the patient rather than relying on healthcare professionals’ knowledge of who manages persistent facial pain in their locality.”

Further research is expected to focus on how care pathways can be designed to better meet the needs of patients.

In partnership with the British Dental Association, the Newcastle University team is helping dentists and GPs manage persistent facial pain by setting up study days for next year.

Peter Dyer, Chair of the British Dental Association’s Central Committee for Hospital Dental Staff, said: “Dentists working in hospitals will have seen patients who have failed to get priority, some on the verge of suicide in the face of unmanageable pain.

“This important research is a timely reminder that facial pain carries a huge personal and financial cost, and patients need not face barriers securing care.

“When so many people have been laid low by this condition GPs and high street dentists need a clear pathway to ensure patients can get the right treatment, when they need it.”

Patient’s story

Father-of-two Joe Buckham’s life was turned upside down when he began to get severe facial pain a decade ago.

The extraction of a wisdom tooth left the former school teacher in agony as he suffered a fractured jaw during the procedure and a subsequent bone infection.

Mr Buckham was pushed from pillar to post as healthcare professionals struggled to identify the problem despite extensive tests, scans and investigations.

He spent a lot of money on hospital trips, including return train fares to a specialist in Oldham up to eight times, and private treatment, such as acupuncture and sports massage therapy.

It was not until he was referred to Professor Justin Durham, an Honorary Consultant Oral Surgeon at Newcastle upon Tyne Hospitals NHS Foundation Trust, that his problem was unearthed.

The 52-year-old has received treatment at Newcastle Hospitals’ orofacial pain referral service and is on medication to help him deal with the pain.

The foster carer, of Rowlands Gill, Gateshead, said: “I believe had I been given the correct treatment quicker than I was, then I would have continued to work as a teacher.

“Sadly I had to retire because I couldn’t do the job due to the seriousness of the pain — even things such as heat and antibiotics make it much worse.

“The pain I get in my face is severe and it can be very debilitating, sometimes it’s so bad I just want to lie in a darkened room.

“Persistent facial pain is a hidden condition as no-one can see the problem and people don’t understand it’s so serious that it can ruin lives and you’re stuck with it forever.

“The specialist service in Newcastle is fantastic and the research being done into facial pain is very much welcomed to help raise awareness of the condition.

“I feel that if medical healthcare professionals were able to use a Graded Chronic Pain Scale it would help ensure patients like me got the best treatment as soon as possible.”

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Researchers Are First To Sequence Rare Bacteria That Causes Rampant Tooth Decay

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The most prevalent chronic disease in both children and adults, tooth decay occurs when the good and bad bacteria in our mouth become imbalanced. The bad bacteria, Streptococcus mutans, forms a biofilm (aka tartar), then takes the sugars we eat and ferments them into acid, which decalcifies our teeth and causes cavities.

Scientists know, though, that there is a second harmful bacteria called Streptococcus sobrinus that accelerates tooth decay in some people, but very little is known about this microbe. This will soon change because a team of Illinois Bioengineering researchers led by Assistant Professor Paul Jensen has successfully sequenced the complete genomes of three strains of S. sobrinus.

According to Jensen, S. sobrinus is difficult to work with in the lab and it is not present in all people, so researchers have instead focused their efforts over the years on understanding the more stable and prevalent S. mutans, which was sequenced in 2002.

“Although it is rare, S. sobrinus produces acid more quickly and is associated with the poorest clinical outcomes, especially among children,” noted Jensen, a researcher at the Carl R. Woese Institute for Genomic Biology on campus.

“If S. sobrinus is present along with S. mutans, you’re at risk for rampant tooth decay, which means there’s some level of communication or synergy between the two that we don’t understand yet.”

Now that the S. sobrinus sequencing is complete, Jensen and his students are building computational models to better understand how the two bacteria interact and why S. sobrinus can cause such potent tooth decay when combined with S. mutans.

Already they have confirmed, for example, that S. sobrinus lacks complete pathways for quorum sensing, which is the ability bacteria have to sense and react to nearby bacteria, and ultimately proliferate.

According to Jensen, S. mutans bacteria send out feelers in the form of a peptide to find out how many other S. mutans cells are nearby. Once the S. mutans cells reach a certain threshold, they attack and create an imbalance in a person’s mouth between good and bad bacteria, which leads to rapid cavity formation.

S. sobrinus doesn’t have a complete system to do this,” said Jensen.

“We’re really curious to explore this further and find out what is missing and why.”

Interestingly, the entire S. sobrinus genome sequencing was completed by a team of Bioengineering undergraduates and students enrolled in the one-year Master of Engineering (M.Eng.) program, rather than doctoral candidates who typically conduct this type of research over several years.

“For the S. sobrinus field, this is groundbreaking work because the field was plagued by a lack of information,” said Jensen.

“In 2018, it is surprising that we had a whole species [of bacteria] that causes disease and no complete genome of it. Yet, an ambitious team of undergrads and M.Eng. students completed the sequencing in a year.”

Mia Sales, who graduated with her bachelor’s degree this past May, completed the assemblies of two of the species of S. sobrinus. Sales also built the computer that other team members used to do the initial genome assemblies.

Fellow undergraduate Will Herbert worked on the annotation part of the project, finding genes in the strings of approximately 2 million adenine (A), cytosine (C), guanine (G), and thymine (T) nucleotides that make up the S. sobrinus genomes.

Other contributors to the research include M.Eng. students Yuting Du, Amitha Sandur, and Naaman Stanley.

“This work exemplifies the students’ ability to synthesize their learning experience with a completely new insight, resulting in an original research publication,” said Professor Dipanjan Pan, director of the M.Eng. program.

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