Role of oral and gut microbiome in nitric oxide-mediated colon motility.

Periodontal disease (PD), a severe form of gum disease, is among the most prevalent chronic infection in humans and is associated with complex microbial synergistic dysbiosis in the subgingival cavity. The immune system of the body interacts with the microbes as the plaque extends and propagates below the gingival sulcus. Once bacteria reach the gingival sulcus, it can enter the blood stream and affect various areas of the human body. The polymicrobial nature of periodontal disease, if left untreated, promotes chronic inflammation, not only within the oral cavity, but also throughout the human body. Alterations seen in the concentrations of healthy gut microbiota may lead to systemic alterations, such as gut motility disorders, high blood pressure, and atherosclerosis. Although gut microbiome has been shown to play a vital role in intestinal motility functions, the role of oral bacteria in this setting remains to be investigated. It is unclear whether oral microbial DNA is present in the large intestine and, if so, whether it alters the gut microbiome. In addition, polybacterial infection induced PD reduced nitric oxide (NO) synthesis and antioxidant enzymes in rodent colon. In this review, we will discuss the interactions between oral and gut microbiome, specifics of how the oral microbiome may modulate the activities of the gut microbiome, and possible ramifications of these alterations.

Elder Abuse in the African Diaspora: A Review.

BACKGROUND: As with many other populations, abuse of older adults is a growing problem across the Africa Diaspora. Modernization and urbanization are eroding the traditional values of respect for older adults. Also, older adults living in environments with limited social and economic resources, and having no means of economic support create a recipe for elder abuse and neglect. METHODS: This article reviews the current literature on the epidemiology, risk factors, and interventions used for elder abuse across the African Diaspora. RESULTS: Reports of elder abuse range from 24.9% to 81.1% across the Diaspora. Risk factors include cognitive and physical impairment, social isolation, lack of resources and widowhood. CONCLUSION: Community-based programs using the unique social networks of older populations of African descent can provide a venue to improve caregiver training and support, reinforce traditional filial and informal caregiving practices, increase the utilization of available governmental and institutional.

Influence of Intimate Partner Violence (IPV) Exposure on Cardiovascular and Salivary Biosensors: Is There a Relationship?

BACKGROUND/PURPOSE: Intimate partner violence (IPV) is a global public health epidemic that initiates/exacerbates health consequences affecting a victim's lifespan. IPV can significantly predispose women to a lifetime risk of developing cardiovascular disease (CVD) due to the effects of stress and inflammation. This study investigates the correlation among IPV exposure, in-vivo CVD events, and inflammatory biomarkers as predictor indices(s) for CVD in female dental patients. METHODS: Of 37 women enrolled in this study, 19 were African-American (AA) and 18 non-African-American (non-AA) and their ages ranged from 19 to 63 years. IPV-exposure and stress-induced in-vivo CVD events such as Chest Pain (CP) and Heart palpitations were recorded from all enrolled subjects. Cardiovascular events were obtained through surveys by patient self-report. Saliva specimens were obtained from all women and were analyzed for CVD biomarkers using multiplex-ELISA. RESULTS: The prevalence of IPV was 51% (19/37) and statistically equivalent for AA and non-AA. The results show differences in experience of 1) CP (p < 0.01) and 2) heart palpitations (p < 0.02) when IPV + participants are compared with IPV- AA and non-AA cohorts. Of 10 CVD biomarkers analyzed, significant correlations between IPV+ and IPV- subjects were observed for biomarkers that include Interleukin-1ß/sCD40L; TNFα/sCD40L; Myoglobin/IL-1ß; CRP/sCD40L; CRP/IL-6; CRP/TNFα; TNFα/siCAM; CRP/MMP9; TNF-α/Adiponectin (p < 0.01). DISCUSSION/IMPLICATIONS: Analysis of in vivo CVD status showed that significant race/health disparities exist in IPV + cohorts, as well as increased expression of inflammatory mediators, specifically CRP, IL-1ß, IL-6, MMP9. Women who have experienced IPV may be a target cohort for primary prevention of CVD. The use of salivary biomarkers and our protocol may provide a less invasive method to help increase identification of victims at risk for IPV and CVD and potentially decrease other health injuries associated with IPV exposure.

Periodontitis may contribute to poor control of hypertension in older adults.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Periodontal disease, hypertension, and blood pressure among older adults in Puerto Rico. Rivas-Tumanyan S, Campos M, Zevallos JC, Joshipura KJ. J Periodontol 2013;84:203-11. REVIEWER: Janet H. Southerland, DDS, MPH, PhD PURPOSE/QUESTION: To determine the association between clinically measured periodontal disease and clinically assess hypertension in a representative sample of elderly Puerto Ricans SOURCE OF FUNDING: National Institute of Dental and Craniofacial Research (NIDCR) - G12RR03051, and National Institutes of Health (NIH) - K24DE16884 TYPE OF STUDY/DESIGN: Cross-sectional LEVEL OF EVIDENCE: Level 2: limited-quality patient-oriented evidence STRENGTH OF RECOMMENDATION GRADE: Not applicable.

Saliva as a diagnostic tool to measure polycyclic aromatic hydrocarbon exposure in dental patients exposed to intimate partner violence (IPV).

BACKGROUND: Social habits such as tobacco use, alcohol consumption, and chemically contaminated diet contribute to poor oral health. Intimate Partner Violence (IPV) is a global public health epidemic which can exacerbate the prevalence of health conditions affecting a victim's lifespan. This study investigates using saliva as a biomarker for detecting levels of benzo(a)pyrene [B(a)P]; a toxicant present in cigarette smoke and barbecued meat in a population of IPV + female patients. METHODS: A cross-sectional IRB-approved study utilized 63 female participants (37 African Americans [AA], and 26 non-African Americans [NAA]), who provided consent for the study. Participants submitted samples of saliva, as well as questionnaires about demographics, health history, and a well-validated (IPV) screen. RESULTS: The prevalence of IPV was greater in AA compared to NAA. While the concentrations of PAHs/B(a)P detected in saliva of IPV samples in NAA were generally within the range of B(a)P reported for saliva from elsewhere, the concentrations were high in some IPV positive samples. Among the B(a)P metabolites, the concentrations of B(a)P 7,8-diol, B(a)P 3,6- and 6,12-dione metabolites were greater than the other metabolite in both AA and non-AA groups who were positive. CONCLUSION: Our study supports the use of saliva as a potential "diagnostic rheostat" to identify toxicants that may exacerbate/precipitate systemic disease in female victims of IPV. In addition, our study is the first to report that IPV may precipitate the accumulation of B(a)P in oral cavity that can alter inflammatory cascades and increase risk of poor health outcomes in this population of patients.

Knowledge of human papillomavirus among dental providers: A mixed methods study.

Dental professionals are encouraged by the American Dental Association (ADA) to recommend the HPV vaccine to eligible patients. To better understand their comfort level in following this recommendation, we conducted a mixed methods study of dentists and dental hygienists. A total of 173 providers were surveyed and 8 interviewed. The majority felt they had an important role in preventing HPV-related OPC and that they should educate their patients and encourage HPV vaccination. However, most providers had low knowledge about HPV and expressed a need to obtain more information on the topic. In particular, they desired information about the HPV vaccine, its connection to cancer and where to refer patients for vaccination. They also wanted access to visual aids to help them bring up the topic. This study demonstrates the need to develop and disseminate educational programs for dental providers so they can assist with efforts to raise HPV vaccination rates.

An unusual odontogenic infection due to Clostridium subterminale in an immunocompetent patient: A case report and review of the literature.

Clostridium subterminale is an anaerobic spore-forming bacterium usually associated with infections in patients who are immunocompromised. This case report focuses on a rare presentation of a multifascial space odontogenic infection associated with the bacterial isolate Clostridium subterminale. The management of an odontogenic infection associated with an isolate of Clostridium subterminale in an immunocompetent female is described, as well as a review of the literature.

Racial/Ethnic Differences in Those Accompanying Medicare Patients to the Doctor: Insights from the 2013 Medicare Current Beneficiary's Survey.

Surprisingly little current, population-level detail exists regarding companion accompaniment for health care among Medicare beneficiaries, particularly by race/ethnicity. For respondents in the 2013 Medicare Current Beneficiary's Survey Access to Care public use data (N = 12,253), multivariable models predicted accompaniment to the doctor by race/ethnicity, adjusting for confounders. Chi square analyses compared, by race/ethnicity, who was accompanying and why. Overall, 37.5% of beneficiaries had accompaniment. In multivariable analyses, non-Hispanic blacks (OR 1.18; 95% CI 1.03-1.36) and Hispanics (OR 1.47; 95% CI 1.25-1.74) were significantly more likely than non-Hispanic whites to have accompaniment. Over 35% of all three groups had someone to "take notes," "ask questions," and/or "explain things," which did not vary by race/ethnicity; significant differences were seen for "explain instructions," "translate," and "moral support." Hispanics had the highest percentages for all three. Many Medicare beneficiaries have accompaniment to doctors' appointments, particularly in minority racial/ethnic groups, which should be considered in policy and practice.

Identification of Specific Oral and Gut Pathogens in Full Thickness Colon of Colitis Patients: Implications for Colon Motility.

Impaired colon motility is one of the leading problems associated with inflammatory bowel disease (IBD). An expanding body of evidence supports the role of microbiome in normal gut function and in progression of IBD. The objective of this work is to determine whether diseased full thickness colon specimens, including the neuromuscular region (critical for colon motility function), contain specific oral and gut pathogens. In addition, we compared the differences in colon microbiome between Caucasians (CA) and African Americans (AA). Thirty-nine human full thickness colon (diseased colon and adjacent healthy colon) specimens were collected from Crohn's Colitis (CC) or Ulcerative Colitis (UC) patients while they underwent elective colon surgeries. We isolated and analyzed bacterial ribosomal RNA (rRNA) from colon specimens by amplicon sequencing of the 16S rRNA gene region. The microbiome proportions were quantified into Operational Taxonomic Units (OTUs) by analysis with Quantitative Insights Into Microbial ecology (QIIME) platform. Two hundred twenty-eight different bacterial species were identified by QIIME analysis. However, we could only decipher the species name of fifty-three bacteria. Our results show that proportion of non-detrimental bacteria in CC or UC colon samples were altered compared to adjacent healthy colon specimens. We further show, for the first time in full thickness colon specimens, that microbiome of CC and UC diseased specimens is dominated by putative oral pathogens belonging to the Phyla Firmicutes (Streptococcus, Staphylococcus, Peptostreptococcus), and Fusobacteria (Fusobacterium). In addition, we have identified patterns of differences in microbiome levels between CA and AA specimens with potential implications for health disparities research. Overall, our results suggest a significant association between oral and gut microbes in the modulation of colon motility in colitis patients.

Cardiovascular Health Disparities in Underserved Populations.

African Americans are at increased risk for hypertension, hyperlipidemia, obesity, and diabetes, which contribute to the burden of cardiovascular disease (CVD). The disparities of CVD in underserved populations require targeted attention from primary care clinicians to eliminate. Primary care can provide this targeted care for their patients by assessing cardiovascular risk, addressing blood pressure control, and selecting appropriate intervention strategies. Using community resources is also effective for addressing CVD disparities in the underserved population.

Access to medications for medicare enrollees related to race/ethnicity: Results from the 2013 Medicare Current Beneficiary Survey.

BACKGROUND: Prescription medications are taken by millions of Americans to manage chronic conditions and treat acute conditions. These medications, however, are not equally accessible to all. OBJECTIVE: To examine medication access by race/ethnicity among Medicare beneficiaries. METHODS: Using the 2013 Medicare Current Beneficiary Survey (n = 10.515), this study examined access to medications related to race/ethnicity, comparing non-Hispanic blacks and Hispanics to whites. Multivariable logistic regression models were estimated, controlling for age, gender, income, education, chronic conditions, and type of drug coverage. RESULTS: Non-Hispanic blacks were less satisfied than whites with amount paid for prescriptions [OR = 0.69,95%CI(0.55,0.86)], the list of drugs covered by their plan [OR = 0.69,95%CI(0.56,0.85)], and finding a pharmacy that accepts their drug coverage [OR = 0.59,95%CI(0.48,0.72)], after adjustment. Low-income individuals were more likely to report not filling a prescription and taking less medication than prescribed. Compared to beneficiaries with excellent health, those with poor, fair, or good health were less satisfied with access. Access was also diminished for patients with depression, diabetes, and chronic obstructive pulmonary disease, emphysema or asthma. CONCLUSION: Possible interventions for non-Hispanic blacks might include assisting them in finding the best drug plan to meeting their needs, connecting them to medication assistance programs, and discussing convenience of pharmacy with patients.

Conscious Intravenous Sedation in Dentistry: A Review of Current Therapy.

Several sedation options are used to minimize pain, anxiety, and discomfort during oral surgery procedures. Minimizing or eliminating pain and anxiety for dental care is the primary goal for conscious sedation. Intravenous conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate as well as cardiovascular function. Patients must retain their protective airway reflexes, and respond to and understand verbal communication. The drugs and techniques used must therefore carry a broad margin of safety.

Interprofessional Collaborative Practice Models in Chronic Disease Management.

Interprofessional collaboration in health has become essential to providing high-quality care, decreased costs, and improved outcomes. Patient-centered care requires synthesis of all the components of primary and specialty medicine to address patient needs. For individuals living with chronic diseases, this model is even more critical to obtain better health outcomes. Studies have shown shown that oral health and systemic disease are correlated as it relates to disease development and progression. Thus, inclusion of oral health in many of the existing and new collaborative models could result in better management of chronic illnesses and improve overall health outcomes.

Effects of Diabetes on Salivary Gland Protein Expression of Tetrahydrobiopterin and Nitric Oxide Synthesis and Function.

BACKGROUND: Xerostomia is defined as dry mouth resulting from a change in the amount or composition of saliva and is often a major oral health complication associated with diabetes mellitus (DM). Studies have shown that xerostomia is more common in females at the onset of DM. Evidence suggests that nitric oxide (NO) plays a critical role in healthy salivary gland function. However, the specific mechanisms by which NO regulates salivary gland function at the onset of DM have yet to be determined. This study has two aims: 1) to determine whether protein expression or dimerization of NO synthase enzymes (neuronal [nNOS] and endothelial [eNOS]) are altered in the onset of diabetic xerostomia; and 2) to determine whether the changes in nNOS/eNOS protein expression or dimerization are correlated with changes in NO cofactor tetrahydrobiopterin (BH4) biosynthetic enzymes (guanosine triphosphate cyclohydrolase-1 and dihydrofolate reductase). METHODS: Functional and Western blot studies were performed in streptozotocin-induced and control Sprague-Dawley female rats with DM (type 1 [t1DM]) using standardized protocols. Confirmation of xerostomia was determined by increased water intake and decreased salivary flow rate. RESULTS: The results showed that in female rats with DM, salivary hypofunction is correlated with decreased submandibular and parotid gland sizes. The results also show a decrease in NOS and BH4 biosynthetic enzyme in submandibular glands. CONCLUSIONS: These results indicate that a decrease in submandibular NO-BH4 protein expression may provide insight pertaining to mechanisms for the development of hyposalivation in DM-induced xerostomia. Furthermore, understanding the role of the NO-BH4 pathway may give insight into possible treatment options for the patient with DM experiencing xerostomia.

Dental management in patients with hypertension: challenges and solutions.

Hypertension is a chronic illness affecting more than a billion people worldwide. The high prevalence of the disease among the American population is concerning and must be considered when treating dental patients. Its lack of symptoms until more serious problems occur makes the disease deadly. Dental practitioners can often be on the frontlines of prevention of hypertension by evaluating preoperative blood pressure readings, performing risk assessments, and knowing when to consider medical consultation of a hypertensive patient in a dental setting. In addition, routine follow-up appointments and patients seen on an emergent basis, who may otherwise not be seen routinely, allow the oral health provider an opportunity to diagnose and refer for any unknown disease. It is imperative to understand the risk factors that may predispose patients to hypertension and to be able to educate them about their condition. Most importantly, the oral health care provider is in a pivotal position to play an active role in the management of patients presenting with a history of hypertension because many antihypertensive agents interact with pharmacologic agents used in the dental practice. The purpose of this review is to provide strategies for managing and preventing complications when treating the patient with hypertension who presents to the dental office.

Knowledge of oral cancer risk factors and diagnostic concepts among North Carolina dentists. Implications for diagnosis and referral.

BACKGROUND: Dentists play a critical role in the early detection of oral and pharyngeal cancer (OPC). The authors administered a survey that assessed the level of knowledge among dentists regarding risk factors and diagnostic concepts. METHODS: In 2002, the authors mailed a 38-item, pretested survey to a random sample of 1,115 licensed dentists practicing in North Carolina. Three-level (low, medium, high) composite index scores for knowledge of risk factors and diagnostic concepts were created using previously developed scales. The authors formulated multivariable models for risk factor and diagnostic knowledge indexes. RESULTS: Of the 584 respondents, only 181 (31 percent) had consistent medium-to-high levels of knowledge on both highly correlated indexes. Dentists who had higher risk factor and diagnostic knowledge scores were significantly (P < .05) more likely to have heard of one or more diagnostic aids (odds ratio [OR], 2.7), to have graduated from dental school within the previous 20 years (OR, 1.8) and to have performed biopsies or referred five or more patients with suspicious lesions per year (OR, 1.7 and 1.5, respectively) than were less-knowledgeable respondents. CONCLUSIONS: More education is needed in dental schools, postgraduate programs and continuing education programs to enhance dental professionals' knowledge of OPC risk factors and diagnostic concepts. Such programs should include information about adjunctive diagnostic aids. PRACTICE IMPLICATIONS: Greater knowledge of risk factors and diagnostic concepts may result in more frequent patient referrals, biopsy procedures or both, thus aiding in the early diagnosis and treatment of patients with OPC.

Polybacterial Periodontal Pathogens Alter Vascular and Gut BH4/nNOS/NRF2-Phase II Enzyme Expression.

Periodontal disease is a highly prevalent chronic inflammatory disease and is associated with complex microbial infection in the subgingival cavity. Recently, American Heart Association supported a century old association between periodontal disease and atherosclerotic vascular disease. We have recently shown that polybacterial periodontal infection led to aortic atherosclerosis and modulation of lipid profiles; however the underlying mechanism(s) has not been yet demonstrated. Altered nitric oxide (NO) synthesis and tetrahydrobiopterin (BH4), a cofactor for nitric oxide synthases (NOS) has long been shown to be associated with vascular dysfunction and gastrointestinal motility disorders. We sought to examine the mechanism of periodontal infection leading to altered vascular and gastrointestinal smooth muscle relaxation, focusing on the BH4/nNOS pathways. In addition, we also have investigated how the antioxidant system (NRF2-Phase II enzyme expression) in vascular and GI specimens is altered by oral infection. Eight week old male ApoEnull mice were either sham-infected or infected orally for 16 weeks with a mixture of major periodontal bacteria Porphyromonas gingivalis, Treponema denticola and Tannerella forsythia to induce experimental periodontitis. Serum, vascular (mesenteric), stomach, and colon specimens were collected at the end of periodontal pathogen infection. Bacterial infection induced significant (p<0.05) reductions in the levels of BH4,in ratio of BH4:BH2+B and also in nitric oxide levels compared to sham-infected controls. In addition, we identified a significant (p<0.05) reduction in eNOS dimerization, nNOS dimerization and protein expression of BH4 biosynthesis enzymes; GCH-1, DHFR and NRF2 & Phase II enzymes in infected mice versus controls in both mesenteric artery and colon tissues. However, we found no differences in nNOS/BH4 protein expression in stomach tissues of infected and sham-infected mice. This suggests that a polybacterial infection can cause significant changes in the vascular and colonic BH4/nNOS/NRF2 pathways which might lead to impaired vascular relaxation and colonic motility.

Oral cancer knowledge and examination experiences among North Carolina adults.

OBJECTIVE: This study assesses knowledge of oral cancer risk factors, clinical signs, and oral cancer examination experience among North Carolina adults. METHODS: A statewide random digit dial, computer-assisted telephone interview was conducted in 2002. Data from 1,096 respondents, with a response rate of 62 percent, were poststratified to 2000 census data by sex, race, and age group to produce population-based estimates. Knowledge of one sign of oral cancer, four or more risk factors for oral cancer, and having ever had an oral cancer examination were compared in logistic regression models using normalized weights. RESULTS: Fourteen (95% confidence interval [CI] +/-2) percent of adults had never heard of oral or mouth cancer. Risk factor knowledge was high for 56 percent (95% CI+/-3) and associated in a logistic regression model with younger age, feeling personal factors cause cancer, and nonuse of snuff. One sign of oral cancer (sore/lesion, red or white patch in mouth, and bleeding in the mouth) was correctly identified by 53 percent (95% CI+/-3) with significantly more correct responses from younger people, nonsmokers, and some college education. Only 29 percent (95% CI+/-3) reported ever having had an oral cancer examination when this procedure was described. Most respondents reported exams performed by dentists. In a weighted logistic regression model, older age, being dentate, nonsmokers, alcohol users, and those with some college education were significantly more likely to report having ever had an oral cancer examination. CONCLUSIONS: Although there is moderate knowledge of signs and risk factors for oral cancer among North Carolina adults, knowledge deficits remain. Oral cancer examinations need to be increased, particularly among tobacco smokers.

Periodontitis and diabetes associations with measures of atherosclerosis and CHD.

OBJECTIVE: Diabetes has been linked with more severe periodontal disease and with coronary heart disease (CHD). The purpose of this study was to determine if periodontal infection was a significant modifier in the risk that diabetes poses for increased carotid artery intimal-medial wall thickness (IMT) and more advanced atheroma lesions as reflected in atherosclerotic plaque calcification measured by acoustic shadowing. METHODS AND RESULTS: Comparisons for analyses of cardiovascular outcomes were performed based upon periodontitis and diabetes status. Periodontitis was measured using pocket depth and attachment loss at six sites per tooth. Cross-sectional data on 6048 persons aged 52-74 years were obtained from the Dental Atherosclerosis Risk in Communities Study. Participants without diabetes (n=5257) were compared to those with diabetes (n=791). Dependent variables were thick IMT (>1 mm), presence of acoustic shadowing, and prevalent CHD. All models were adjusted for the following covariates: gender, age, race/center, LDL and HDL cholesterol, BMI, triglycerides, hypertension, smoking, income and education. For multivariate model building, all non-normally distributed variables were transformed and multivariable logistic regression analyses were performed to evaluate the relationship between periodontal infection, diabetes, and cardiovascular outcomes. Individuals with diabetes and with severe periodontitis were found to be significantly more likely to have IMT>1 mm [OR=2.2, (1.4-3.5)], acoustic shadowing [OR=2.5, (1.3-4.6)], and CHD [OR=2.6, (1.6-4.2)] compared to those without diabetes or periodontal disease. CONCLUSION: Results from this study suggest that among people with diabetes, periodontal disease may increase the likelihood of subclinical atherosclerotic heart disease and CHD.

Diabetes educators' knowledge, opinions and behaviors regarding periodontal disease and diabetes.

PURPOSE: The purpose of this study was to determine certified diabetes educators' (CDE) knowledge, behaviors and opinions about periodontal disease and diabetes. METHODS: A 33 item questionnaire was distributed to CDEs who provide counseling and education services to patients with diabetes. Questions were open and closed-ended and Likert-scale. A total of 298 CDEs participated in the survey. Descriptive statistics were utilized. RESULTS: Most (62%) agreed that CDEs need to collaborate with dental professionals in disease management and 84% indicated interest in an oral health component being added to their continuing education. Only 20% felt confident in providing an oral health screening to their patients, while 51% discussed oral health with their patients and 64% said they have referred a patient to a dentist within the past year. Most (79%) have not received formal oral health education. CONCLUSION: The findings indicate that CDEs are aware of and agree that there is a link between oral health and systemic health and that collaboration with the dental profession would be a positive outcome for their patients, as would oral health topics being added to their continuing education courses. By introducing inter-professional collaboration between dental professionals and CDEs, and adding an oral health component to CE courses, CDEs' ability to educate their patients regarding the oral/systemic link could improve.