Persistent Toothache Despite Multiple Dental-related Treatments: How Could this Be?

Patients with recurrent or persistent dentoalveolar pain usually believe that endodontic treatment or extracting a tooth will alleviate it, and most cannot conceive that the pain might not be tooth related. Understanding that dental procedures of any kind will be ineffective when a tooth-related pathology is ruled out and that a nonodontogenic etiology best explains the "toothache" pain goes against their beliefs. In this article, we present an overview of basic concepts to help manage such cases by briefly outlining possible causes of nonodontogenic pain as well as diagnostic pitfalls that may lead to questionable treatments. The decision to provide dental treatment is justified only when definitive peripheral mechanisms driving the pain are uncovered and the multitude of factors that might contribute to the various presentations of persistent dental pain have been considered. Otherwise, patients might be managed with treatments that are not the norm for those with unremitting tooth pain in general dental practice. We also make suggestions for clinicians to assure that patients with recurrent or persistent dental pain receive a thorough work-up that considers odontogenic and nonodontogenic sources to arrive at the correct diagnosis before treatment, taking psychosocial factors into account when devising the treatment plan.

Constructing the brief diagnostic criteria for temporomandibular disorders (bDC/TMD) for field testing.

BACKGROUND: Despite advances in temporomandibular disorders' (TMDs) diagnosis, the diagnostic process continues to be problematic in non-specialist settings. OBJECTIVE: To complete a Delphi process to shorten the Diagnostic Criteria for TMD (DC/TMD) to a brief DC/TMD (bDC/TMD) for expedient clinical diagnosis and initial management. METHODS: An international Delphi panel was created with 23 clinicians representing major specialities, general dentistry and related fields. The process comprised a full day workshop, seven virtual meetings, six rounds of electronic discussion and finally an open consultation at a virtual international symposium. RESULTS: Within the physical axis (Axis 1), the self-report Symptom Questionnaire of the DC/TMD did not require shortening from 14 items for the bDC/TMD. The compulsory use of the TMD pain screener was removed reducing the total number of Axis 1 items by 18%. The DC/TMD Axis 1 10-section examination protocol (25 movements, up to 12 sets of bilateral palpations) was reduced to four sections in the bDC/TMD protocol involving three movements and three sets of palpations. Axis I then resulted in two groups of diagnoses: painful TMD (inclusive of secondary headache), and common joint-related TMD with functional implications. The psychosocial axis (Axis 2) was shortened to an ultra-brief 11 item assessment. CONCLUSION: The bDC/TMD represents a substantially reduced and likely expedited method to establish (grouping) diagnoses in TMDs. This may provide greater utility for settings requiring less granular diagnoses for the implementation of initial treatment, for example non-specialist general dental practice.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for adolescents.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for use in adults is in use worldwide. Until now, no version of this instrument for use in adolescents has been proposed. OBJECTIVE: To present comprehensive and short-form adaptations of the adult version of DC/TMD that are appropriate for use with adolescents in clinical and research settings. METHODS: International experts in TMDs and experts in pain psychology participated in a Delphi process to identify ways of adapting the DC/TMD protocol for physical and psychosocial assessment of adolescents. RESULTS: The proposed adaptation defines adolescence as ages 10-19 years. Changes in the physical diagnosis (Axis I) include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for adolescents, (ii) adding two general health questionnaires, one for the adolescent patient and one for their caregivers and (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire. Changes in the psychosocial assessment (Axis II) include (i) adapting the language of the Graded Chronic Pain Scale to be developmentally appropriate for adolescents, (ii) adding anxiety and depression assessment that have been validated for adolescents and (iii) adding three constructs (stress, catastrophizing and sleep disorders) to assess psychosocial functioning in adolescents. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II for adolescents, is appropriate to use in clinical and research settings. This adapted first version for adolescents includes changes in Axis I and Axis II requiring reliability and validity testing in international settings. Official translations of the comprehensive and short-form to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Classification and Diagnosis of Temporomandibular Disorders and Temporomandibular Disorder Pain.

Designing classification systems and developing diagnostic criteria for temporomandibular disorders is difficult. An appreciation of the utility and applicability of these entities requires an understanding of the importance of each, the differences between the two, and how they may be optimally operationalized for both clinical and research activities in light of their inherent advantages and limitations. In addition, consideration for adopting newer approaches, such as following ontological and precision-based medicine principles, accounting for genetics/epigenetic and neurobiological factors, and the inclusion of biomarkers will potentially result in more thorough and comprehensive classification systems and diagnostic criteria.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed. OBJECTIVE: The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings. METHODS: Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children. RESULTS: The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Diagnostic criteria for temporomandibular disorders in children and adolescents: An international Delphi study-Part 2-Development of Axis II.

BACKGROUND: Unlike the psychosocial assessment established for adults in the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), a standardised psychosocial assessment for children and adolescents with TMD complaints has not yet been established. OBJECTIVES: To develop a new standardised instrument set to assess the psychosocial functioning in children and adolescents by adapting the psychosocial status and pain-related disability (Axis II) of the adult DC/TMD and by including new instruments. METHODS: A modified Delphi method was used to survey 23 international TMD experts and four international experts in pain-related psychological factors for consensus regarding assessment tools for psychosocial functioning and pain-related disability in children and adolescents. The TMD experts reviewed 29 Axis II statements at round 1, 13 at round 2 and 2 at round 3. Agreement was set at 80% for first-round consensus level and 70% for each of the second and third rounds. The psychological experts completed a complementary Delphi survey to reach a consensus on tools to use to assess more complex psychological domains in children and adolescents. For the psychological experts, the first round included 10 open-ended questions on preferred screening tools for depression, anxiety, catastrophising, sleep problems and stress in children (ages 6-9 years old) and adolescents (ages 10-19 years old) as well as on other domains suggested for investigation. In the second round, the psychological experts received a 9-item questionnaire to prioritise the suggested instruments from most to least recommended. RESULTS: The TMD experts, after three Delphi rounds, reached consensus on the changes of DC/TMD to create a form to evaluate Axis II in children and adolescents with TMD complaints. The psychological experts added tools to assess depression and anxiety, sleep disorders, catastrophising, stress and resilience. CONCLUSION: Through international expert consensus, this study adapted Axis II of the adult DC/TMD to assess psychosocial functioning and pain-related disability in children and adolescents. The adapted Axis II protocols will be validated in the target populations.

Diagnostic criteria for temporomandibular disorders (DC/TMD) for children and adolescents: An international Delphi study-Part 1-Development of Axis I.

BACKGROUND: Since in children and adolescence prevalence is assessed mainly on self-reported or proxy-reported signs and symptoms; there is a need to develop a more comprehensive standardised process for the collection of clinical information and the diagnosis of TMD in these populations. OBJECTIVE: To develop new instruments and to adapt the diagnostic criteria for temporomandibular disorders (DC/TMD) for the evaluation of TMD in children and adolescents. METHOD: A modified Delphi method was used to seek international consensus among TMD experts. Fourteen clinicians and researchers in the field of oro-facial pain and TMD worldwide were invited to participate in a workshop initiated by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM scientific network) at the General Session of the International Association for Dental Research (IADR, London 2018), as the first step in the Delphi process. Participants discussed the protocols required to make physical diagnoses included in the Axis I of the DC/TMD. Thereafter, nine experts in the field were added, and the first Delphi round was created. This survey included 60 statements for Axis I, and the experts were asked to respond to each statement on a five-item Likert scale ranging from 'Strongly disagree' to 'Strongly agree'. Consensus level was set at 80% agreement for the first round, and at 70% for the next. RESULTS: After three rounds of the Delphi process, a consensus among TMD experts was achieved and two adapted DC/TMD protocols for Axis I physical diagnoses for children and adolescents were developed. CONCLUSION: Through international consensus among TMD experts, this study adapted the Axis I of the DC/TMD for use in evaluating TMD in children and adolescents.

Mind the Gap: A Systematic Review of Implementation of Screening for Psychological Comorbidity in Dental and Dental Hygiene Education.

The biopsychosocial model is advocated as part of a more comprehensive approach in both medicine and dentistry. However, dentists have not traditionally been taught psychosocial screening as part of their predoctoral education. The aim of this systematic review was to provide an overview of published studies on the implementation of screening for psychological comorbidity in dental and dental hygiene education. The term "psychological comorbidity" refers to the degree of coexisting anxiety, depression, or other mental health problems in a patient presenting with a physical condition. The review followed a protocol registered in PROSPERO (CRD42016054083) and was carried out in accordance with the PRISMA guidelines. The methodological quality of the included studies was assessed using a ten-item tool developed for medical education. The electronic search in PubMed, Scopus, and PsycINFO from the inception of each database until December 31, 2016, together with a hand search, identified 1,777 articles. After abstracts were screened, 52 articles were reviewed in full text applying inclusion and exclusion criteria; four articles remained for the qualitative synthesis. Generally, the reported data on specific methods or instruments used for psychological screening were limited. Only one of the included articles utilized a validated screening tool. The results of this systematic review show that published data on the implementation of psychological patient assessment in dental and dental hygiene education are limited. To address this gap, the authors recommend short screening tools such as the Graded Chronic Pain Scale and the Patient Health Questionnaire for Depression and Anxiety. Educating dental and dental hygiene students about easy-to-use, reliable, and validated screening tools for assessing psychological comorbidity warrants more research attention and greater implementation in educational curricula.

Benefits of implementing pain-related disability and psychological assessment in dental practice for patients with temporomandibular pain and other oral health conditions.

BACKGROUND: Evidence in the field of dentistry has demonstrated the importance of pain-related disability and psychological assessment in the development of chronic symptoms. The Diagnostic Criteria for Temporomandibular Disorders offer a brief assessment for the diagnostic process in patients with orofacial pain (Axis II). The authors describe relevant outcomes that may guide general oral health care practitioners toward tailored treatment decisions and improved treatment outcomes and provide recommendations for the primary care setting. METHODS: The authors conducted a review of the literature to provide an overview of knowledge about Axis II assessment relevant for the general oral health care practitioner. RESULTS: The authors propose 3 domains of the Axis II assessment to be used in general oral health care: pain location (pain drawing), pain intensity and related disability (Graded Chronic Pain Scale [GCPS]), and psychological distress (Patient Health Questionnaire-4 [PHQ-4]). In the case of localized pain, low GCPS scores (0-II), and low PHQ-4 scores (0-5), patients preferably receive treatment in primary care. In the case of widespread pain, high GCPS scores (III-IV), and high PHQ-4 scores (6-12), the authors recommend referral to a multidisciplinary team, especially for patients with temporomandibular disorder (TMD) pain. CONCLUSIONS: The authors recommend psychological assessment at first intake of a new adult patient or for patients with persistent TMD pain. The authors recommend the pain-related disability screening tools for all TMD pain symptoms and for dental pain symptoms that persist beyond the normal healing period. PRACTICAL IMPLICATIONS: A brief psychological and pain-related disability assessment for patients in primary care may help the general oral health care practitioner make tailored treatment decisions.

Temporomandibular Lavage Versus Nonsurgical Treatments for Temporomandibular Disorders: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the efficacy of temporomandibular joint (TMJ) lavage (arthrocentesis or arthroscopy) for the treatment of temporomandibular disorders in reducing pain and improving jaw motion. PATIENTS AND METHODS: We performed a systematic review of the literature and meta-analysis of randomized controlled trials (RCTs) comparing TMJ lavage with conservative measures. The data sources were MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), Scopus, Web of Science, and reference lists of relevant articles. Two independent reviewers identified RCTs by using controlled vocabulary (MeSH, Emtree) and free text terms. Data extracted from the selected studies included population characteristics, interventions, outcomes, and funding sources. Risk of bias was assessed with the Cochrane Collaboration risk assessment tool for RCTs. RESULTS: Five studies met the inclusion criteria, for a total of 308 patients. Of these studies, 3 were categorized as having a high risk of bias and 2 had a low risk. The summary effect of the 5 studies showed a reduction in pain in the intervention group at 6 months (-0.63; 95% confidence interval [CI], -0.90 to -0.37; P < .00001; I2 = 88%) and 3 months (-0.47; 95% CI, -0.75 to -0.19; P = .001; I2 = 85%). This was not the case at 1 month. No difference in mouth opening was observed at 6 months (-0.21; 95% CI, -1.82 to 1.40; P < .80; I2 = 74%), 3 months (0.20; 95% CI, -1.81 to 2.20; P = .85; I2 = 68%), and 1 month (-1.18; 95% CI, -2.90 to 0.55; P = .18; I2 = 0%). CONCLUSIONS: Given the relatively small number of patients included in this meta-analysis, the high risk of bias in 3 studies, and the statistical and clinical heterogeneity of the included studies, the use of TMJ lavage for the treatment of temporomandibular disorders should be recommended with caution because of the lack of strong evidence to support its use.

Dental pain induced by an ambient thermal differential: pathophysiological hypothesis.

Dental pain triggered by temperature differential is a misrecognized condition and a form of dental allodynia. Dental allodynia is characterized by recurrent episodes of diffuse, dull and throbbing tooth pain that develops when returning to an indoor room temperature after being exposed for a long period to cold weather. The pain episode may last up to few hours before subsiding. Effective treatment is to properly shield the pulpal tissue of the offending tooth by increasing the protective layer of the dentin/enamel complex. This review underscores the difference in dentin hypersensitivity and offers a mechanistic hypothesis based on the following processes. Repeated exposure to significant positive temperature gradients (from cold to warm) generates phenotypic changes of dental primary afferents on selected teeth with subsequent development of a "low-grade" neurogenic inflammation. As a result, nociceptive C-fibers become sensitized and responsive to innocuous temperature gradients because the activation threshold of specific TRP ion channels is lowered and central sensitization takes place. Comprehensive overviews that cover dental innervation and sensory modalities, thermodynamics of tooth structure, mechanisms of dental nociception and the thermal pain are also provided.

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†.

AIMS: The original Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been demonstrated to be reliable. However, the Validation Project determined that the RDC/TMD Axis I validity was below the target sensitivity of ≥ 0.70 and specificity of ≥ 0.95. Consequently, these empirical results supported the development of revised RDC/TMD Axis I diagnostic algorithms that were subsequently demonstrated to be valid for the most common pain-related TMD and for one temporomandibular joint (TMJ) intra-articular disorder. The original RDC/TMD Axis II instruments were shown to be both reliable and valid. Working from these findings and revisions, two international consensus workshops were convened, from which recommendations were obtained for the finalization of new Axis I diagnostic algorithms and new Axis II instruments. METHODS: Through a series of workshops and symposia, a panel of clinical and basic science pain experts modified the revised RDC/TMD Axis I algorithms by using comprehensive searches of published TMD diagnostic literature followed by review and consensus via a formal structured process. The panel's recommendations for further revision of the Axis I diagnostic algorithms were assessed for validity by using the Validation Project's data set, and for reliability by using newly collected data from the ongoing TMJ Impact Project-the follow-up study to the Validation Project. New Axis II instruments were identified through a comprehensive search of the literature providing valid instruments that, relative to the RDC/TMD, are shorter in length, are available in the public domain, and currently are being used in medical settings. RESULTS: The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for detecting any pain-related TMD as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity ≥ 0.86, specificity ≥ 0.98) and for one intra-articular disorder (sensitivity of 0.80 and specificity of 0.97). Diagnostic criteria for other common intra-articular disorders lack adequate validity for clinical diagnoses but can be used for screening purposes. Inter-examiner reliability for the clinical assessment associated with the validated DC/TMD criteria for pain-related TMD is excellent (kappa ≥ 0.85). Finally, a comprehensive classification system that includes both the common and less common TMD is also presented. The Axis II protocol retains selected original RDC/TMD screening instruments augmented with new instruments to assess jaw function as well as behavioral and additional psychosocial factors. The Axis II protocol is divided into screening and comprehensive self report instrument sets. The screening instruments' 41 questions assess pain intensity, pain-related disability, psychological distress, jaw functional limitations, and parafunctional behaviors, and a pain drawing is used to assess locations of pain. The comprehensive instruments, composed of 81 questions, assess in further detail jaw functional limitations and psychological distress as well as additional constructs of anxiety and presence of comorbid pain conditions. CONCLUSION: The recommended evidence-based new DC/TMD protocol is appropriate for use in both clinical and research settings. More comprehensive instruments augment short and simple screening instruments for Axis I and Axis II. These validated instruments allow for identification of patients with a range of simple to complex TMD presentations.

Diagnostic criteria for headache attributed to temporomandibular disorders.

AIMS: We assessed and compared the diagnostic accuracy of two sets of diagnostic criteria for headache secondary to temporomandibular disorders (TMD). METHODS: In 373 headache subjects with TMD, a TMD headache reference standard was defined as: self-reported temple headache, consensus diagnosis of painful TMD and replication of the temple headache using TMD-based provocation tests. Revised diagnostic criteria for Headache attributed to TMD were selected using the RPART (recursive partitioning and regression trees) procedure, and refined in half of the data set. Using the remaining half of the data, the diagnostic accuracy of the revised criteria was compared to that of the International Headache Society's International Classification of Headache Diseases (ICHD)-II criteria A to C for Headache or facial pain attributed to temporomandibular joint (TMJ) disorder. RESULTS: Relative to the TMD headache reference standard, ICHD-II criteria showed sensitivity of 84% and specificity of 33%. The revised criteria for Headache attributed to TMD had sensitivity of 89% with improved specificity of 87% (p < 0.001). These criteria are (1) temple area headache that is changed with jaw movement, function or parafunction and (2) provocation of that headache by temporalis muscle palpation or jaw movement. CONCLUSION: Having significantly better specificity than the ICHD-II criteria A to C, the revised criteria are recommended to diagnose headache secondary to TMD.

Removable acrylic resin disk as a sampling system for the study of denture biofilms in vivo.

STATEMENT OF PROBLEM: The adhesion of microorganisms to a denture surface can result in denture stomatitis. PURPOSE: The purpose of this study was to evaluate denture biofilm in vivo using a new sampling system to gain a better understanding of plaque organization in Candida-induced denture stomatitis. Removable acrylic resin disks were used with self-adhesive paper disks to compare biofilm formation and retention efficacy of both sampling systems. MATERIAL AND METHODS: Twenty-one subjects with a complete maxillary denture were recruited, 12 with a clinical diagnosis of chronic denture stomatitis and 9 with a clinically healthy palatal mucosa. A custom-made autopolymerized 3.0-mm-diameter acrylic resin disk inlay was inserted in a cavity prepared within the intaglio surface of the maxillary denture in contact with either normal or inflamed mucosa. Next to the acrylic resin disk, a self-adhesive paper disk was placed for comparison of the 2 sampling techniques. Denture biofilms were collected within variable time periods of 1 hour to several months, and descriptive data were provided by means of scanning electron microscopy analyses. The method of retention and recovery of specimen disks were evaluated between both sampling techniques using a chi-square test to assess significant differences (alpha=.05). RESULTS: Early event features of denture biofilms showed differences in biofilm organization between the 2 sampling techniques but became subtler with increased time periods. Regardless of the sampling technique, interparticipant variations could be observed as to rate, microorganism density, and architectural pattern. In general, denture biofilm formation was increased when the sampling disks were localized in areas affected by denture stomatitis. CONCLUSION: The new sampling technique provides reliable information with controlled formation time of denture biofilm in its natural environment.

Towards a new taxonomy of idiopathic orofacial pain.

There is no current consensus on the taxonomy of the different forms of idiopathic orofacial pain (stomatodynia, atypical odontalgia, atypical facial pain, facial arthromyalgia), which are sometimes considered as separate entities and sometimes grouped together. In the present prospective multicentric study, we used a systematic approach to help to place these different painful syndromes in the general classification of chronic facial pain. This multicenter study was carried out on 245 consecutive patients presenting with chronic facial pain (>4 months duration). Each patient was seen by two experts who proposed a diagnosis, administered a 111-item questionnaire and filled out a standardized 68-item examination form. Statistical processing included univariate analysis and several forms of multidimensional analysis. Migraines (n=37), tension-type headache (n=26), post-traumatic neuralgia (n=20) and trigeminal neuralgia (n=13) tended to cluster independently. When signs and symptoms describing topographic features were not included in the list of variables, the idiopathic orofacial pain patients tended to cluster in a single group. Inside this large cluster, only stomatodynia (n=42) emerged as a distinct homogenous subgroup. In contrast, facial arthromyalgia (n=46) and an entity formed with atypical facial pain (n=25) and atypical odontalgia (n=13) could only be individualised by variables reflecting topographical characteristics. These data provide grounds for an evidence-based classification of idiopathic facial pain entities and indicate that the current sub-classification of these syndromes relies primarily on the topography of the symptoms.

Mechanisms associated with unusual orofacial pain.

This article presents an overview of possible mechanisms associated with pain perception, with a specific focus on understanding unusual manifestations of orofacial pain associated with nerve insult. It includes recent evidence concerning neurobiological changes that occur in the periphery at tissue and nerve sites, or within the central nervous system, and that may involve chemical and inflammatory responses, sensitization, or alterations of cellular function. Moreover, the contribution of the autonomic nervous system, changes in emotional reactivity and vigilance, the roles of high brain centers such as the basal ganglia (nigro-striatal) system, and the influence of aging and gender, are briefly described.

Involvement of interleukin-18 in the inflammatory response against oropharyngeal candidiasis.

BACKGROUND: Oral candidiasis is a collective name for a group of disorders caused by the dimorphic fungus Candida albicans (C. albicans). Host defenses against C. albicans essentially fall into two categories: specific immune mechanisms and local oral mucosal epithelial cell defenses. The rationale of this study was to investigate the involvement of IL-18 in the inflammatory response against oral candidiasis. MATERIAL/METHODS: We first used human oral mucosa tissue and saliva to assess the production of Il-18. Second, we engineered human oral mucosa using only normal human oral epithelial cells and fibroblasts. Tissues were infected with C. albicans at different time points. RESULTS: Tissue and saliva analyses demonstrated that constitutively produced and secreted IL-18 was up-regulated following Candida-infection. With our engineered model, we showed that C. albicans significantly increased the secretion of active IL-18 by infected epithelial cells. Interestingly, a significant secretion of IFNg functionally supported the up-regulation of active IL-18 in C. albicans-infected tissues. We also showed that rhIL-18 increased the expression and production of endogenous IL-18 and ICE in C. albicans-infected tissues, which was paralleled by a significant increase in IFNg secretion. CONCLUSIONS: These data suggest that (i) oral epithelial cells are involved in local host defenses against C. albicans infections, via IFNg induced-IL-18, and (ii) that IL-18 and IFNg secretions may be related to epithelial cells. Given that our experimental model closely mimics the natural interface between the oral mucosa and C. albicans, it appears that IL-18 meets the requirements of being a cytokine that epithelial cells use to control C. albicans infections.

Reassessing the presence of Candida albicans in denture-related stomatitis.

OBJECTIVE: The aim of this study was to reevaluate the link between Candida albicans and denture-related stomatitis according to a modified Newton classification, which reflects the classic types of inflammation as well as the extent to which the tissue is affected. STUDY DESIGN: Two groups of denture wearers were evaluated for denture-related stomatitis. The presence and number of yeasts on the dentures, the identification of the Candida species present, and the amount of plaque coverage were determined. Putative risk factors were included in the study. Relations between these variables and stomatitis were analyzed statistically. RESULTS: According to Newton's classification, the presence of yeast on the denture was not linked to whether subjects had stomatitis. But with our classification, higher prevalence of yeast carriers, yeast colony number, and plaque coverage were found on the dentures of individuals with the most extensive inflammation, regardless of Newton type. Among risk factors evaluated, wearing dentures at night and smoking were associated with the most extensive inflammation. We also demonstrated that the presence of C albicans as well as the cohabitation of different Candida species was more frequent in denture-related stomatitis. The differences were statistically significant. CONCLUSIONS: Statistical analysis of microbiologic data from different denture-related stomatitis categories according to our modified classification showed that the presence of yeast on dentures was significantly associated with the extent of the inflammation, rather than with the Newton type. Our findings suggest that the inflammatory process of stomatitis favors the colonization of Candida. These results could have new implications for diagnosis and management of the condition.