Caries clusters at lesion-severity thresholds: A Sierra Leone case study.

OBJECTIVES: Despite being almost entirely preventable, globally, dental caries is extremely prevalent. Moreover, dental caries will continue to present an even larger challenge for lower income countries, particularly those in the African context, as they transition to a more Western diet. Hence, epidemiological data providing insight into disease patterns and trends is critical to inform public health action. The purpose of this study was to examine dental caries clusters by caries detection threshold among 15-year-old adolescents in Sierra Leone, using data from the latest national survey, and to explore associated sociodemographic factors. METHODS: This paper presents a secondary analysis of oral health data on 490 15-year-olds from the Sierra Leone national oral health survey of schoolchildren. Hierarchical cluster analysis of dental caries experience was conducted across all surfaces at four decay detection thresholds using the International Caries Detection and Assessment System (ICDAS) (clinical: ICDAS 2-6, cavitated: ICDAS 3-6, obvious: ICDAS 4-6 and extensive obvious: ICDAS 5-6 decay) across the four regions of Sierra Leone. Ordered logistic regression was used to estimate the association of sociodemographic factors with generated clusters relating to clinical and obvious decay experience. These are of both clinical and epidemiological relevance. RESULTS: A 3-cluster decay pattern representing a 'low' to 'high' decay experience distribution was observed under each decay detection threshold across surfaces. For clinical decay (including visual enamel caries), 28.8% had low, 55.1% medium and 15.9% high caries status. In the adjusted model, the only significant risk factor across obvious and clinical decay thresholds was region, with adolescents outside the Western region more likely to experience decay. CONCLUSION: This study suggests that adolescents in Sierra Leone fall into three distinct caries clusters: low, medium to high decay experience distribution, regardless of decay threshold. It reinforces the importance of recognizing dental caries detection thresholds and the use of contemporary epidemiological methodology. This suggests that adolescents outside the Western region are likely to have higher caries experience. The data also provides insight to the nature of adolescents in each cluster and should help to inform policy and planning of the integration of oral health into primary care and school systems.

Unmet need in Sierra Leone: a national oral health survey of schoolchildren.

OBJECTIVE: Sierra Leone (SL), in West Africa, with a population of over 7.5 million people has suffered the effects of a civil war previously, and more recently Ebola & Covid-19. Dental care is very limited, mostly in the capital Freetown and the private sector. No dental education is available in the country. The objective of this research was to investigate the oral health needs of schoolchildren at key ages, to inform future action. MATERIALS AND METHODS: This first national oral health survey of schoolchildren at 6-, 12- and 15-years was conducted in urban and rural settings across all four regions using a multi-stage cluster sampling in line with the WHO guidelines, adapted according to contemporary survey methods to include 'International Caries Detection and Assessment System (ICDAS)'. Whilst parents were invited to complete a questionnaire for 6-year-old children, 12- and 15-year-olds self-completed a questionnaire. Data were weighted according to age and regional population and analysed using STATA v.15 and SPSS v.22. RESULTS: A total of 1174 children participated across 22 schools from all four regions. Dental caries was prevalent (over 80% of all age-groups having clinical decay; ICDAS score ≥ 2) and largely untreated. No children had fillings and only 4% had missing teeth. Amongst 6, 12 and 15-year-olds, average decay levels at ICDAS > 3 threshold was 3.47 (primary teeth), 2.94 and 4.30 respectively. Almost, 10% (n = 119) of all children reported experiencing pain in their teeth with 7% (n = 86) children having PUFA lesions present. At least one in five children required one or more dental extractions. 'Age' was a significant predictor of dental caries experience and the odds of having dental caries experience was higher in rural areas at D3-6MFT (p < 0.05). CONCLUSION: The findings demonstrate a vast unmet oral health need in the children of SL. Using ICDAS as an epidemiological tool in a low-income country provides valuable insight to the pattern of oral disease to inform health service planning. Urgent action is required to address this silent epidemic.

Validation of an Oral Disease Severity Score (ODSS) tool for use in oral mucous membrane pemphigoid.

BACKGROUND: Mucous membrane pemphigoid (MMP) is a rare autoimmune bullous disease predominantly affecting the oral mucosa. Optimal management relies upon thorough clinical assessment and documentation at each visit. OBJECTIVES: The primary aim of this study was to validate the Oral Disease Severity Score (ODSS) for the assessment of oral involvement in MMP. We also compared its inter- and intraobserver reliability with those of the oral parts of the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Physician's Global Assessment (PGA). METHODS: Fifteen patients with mild-to-moderately severe oral MMP were scored for disease severity by 10 oral medicine clinicians from four U.K. centres using the ODSS, the oral sections of MMPDAI and ABSIS, and PGA. Two clinicians rescored all patients after 2 h. RESULTS: In terms of reliability, the interobserver ODSS total score intraclass correlation coefficient (ICC) was 0·97, MMPDAI activity 0·59 and damage 0·15, ABSIS total 0·84, and PGA 0·72. The intraobserver ICCs (two observers) for ODSS total were 0·97 and 0·93; for MMPDAI activity 0·93 and 0·70 and damage 0·93 and 0·79; for ABSIS total 0·99 and 0·94; and for PGA 0·92 and 0·94. Convergent validity between ODSS and MMPDAI was good (correlation coefficient 0·88). The mean ± SD time for completion of ODSS was 93 ± 31 s, with MMPDAI 102 ± 24 s and ABSIS involvement 71 ± 18 s. The PGA took < 5 s. CONCLUSIONS: This study has validated the ODSS for the assessment of oral MMP. It has shown superior interobserver agreement over MMPDAI, ABSIS and PGA, and superior intraobserver reliability to MMPDAI. It is quick and easy to perform. What's already known about this topic? There are no validated scoring methodologies for oral mucous membrane pemphigoid (MMP). Proposed disease activity scoring tools for MMP include the Mucous Membrane Disease Area Index (MMPDAI) and the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). The Oral Disease Severity Score (ODSS) has been validated for use in oral pemphigus vulgaris (PV). It has been shown to be reliable and sensitive in both lichen planus (LP) and MMP. What does this study add? The ODSS has been shown to be a thorough, sensitive and reproducible, yet quick scoring tool for the assessment of oral involvement in MMP. Its versatility for use in oral PV, MMP and LP is an added advantage over other scoring methodologies. What are the clinical implications of this work? We propose that the ODSS be used as a clinical scoring tool for monitoring activity in oral MMP in clinical practice as well as for use in multicentre studies.

An Oral Disease Severity Score validated for use in oral pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) is a rare autoimmune bullous disease, which can present with recalcitrant oral mucosal lesions. Optimal management of PV relies upon careful clinical assessment and documentation. OBJECTIVES: The primary aim of this study was to validate the Oral Disease Severity Score (ODSS) for the assessment of oral involvement in PV. A secondary aim was to compare its inter- and intraobserver variability and ease of use with the Physician's Global Assessment (PGA) and the oral scoring methods used in the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and the Pemphigus Disease Area Index (PDAI). METHODS: Fifteen patients with mild-to-moderately severe oral PV were scored for disease severity by 10 oral medicine clinicians using the ODSS, the PGA and the oral sections of ABSIS and PDAI. Two clinicians rescored all patients after a minimum 2-h interval. RESULTS: Interobserver reliability was assessed using an intraclass correlation coefficient (ICC). For the ODSS total score the ICC was 0·83, for PDAI (oral total activity) 0·79, ABSIS (oral total) 0·71 and PGA 0·7. Intraobserver agreement between initial scoring and rescoring of the same patient by two clinicians demonstrated an ICC for each of 0·97 and 0·96 for ODSS total score; 0·99 and 0·82 for PDAI oral activity; 0·86 and 0·45 for ABSIS total; and 0·99 and 0·64 for PGA. Convergent validity was good, with a correlation coefficient > 0·5 (P < 0·001). The mean ± SD times taken to complete each scoring method were ODSS 76 ± 37 s, PDAI 117 ± 16 s and ABSIS 75 ± 19 s. CONCLUSIONS: This study has validated the ODSS for the assessment of oral PV. It has shown superior inter- and intraobserver reliability to PDAI, ABSIS and PGA and is quick to perform.

HIV/AIDS in India: an overview of the Indian epidemic.

The first cases of HIV infection in India were detected in 1986 among female sex workers in Chennai. A rapid increase followed in many states. The current national prevalence is about 0.26% compared with a global average of 0.2%, but the figure in most high-risk groups including female sex workers is much higher (up to 7%). New HIV infections reached a peak in 1998 and have since declined by 60%, although the total number of HIV-positive persons remains stable at 2.1 million, largely probably due to the increased life expectancy following antiretroviral therapy. The Indian epidemic is characterized by low levels in the general population and elevated concentrations among high-risk groups. Transmission is mainly heterosexually driven, with differential burdens across the states. The four main drivers of HIV infection in India differ in order from those elsewhere in the world and are commercial sex work, general heterosexual intercourse, injecting drug use and unprotected anal sex between men who have sex with men. There are distinct differences from state to state in the prevalence of HIV, with some around the national norm of 0.21% but others with over 1% infected. India has embarked on a targeted HIV prevention strategy in recent years which is strongly associated with a fall in infection rate in both low- and high-risk groups.

The social impact of HIV/AIDS in India.

This paper is based on the last public lecture given by Dr Solomon at the 7th World Workshop on Oral Health & Disease in HIV/AIDS, held in Hyderabad, India, in November 2014. It examines the social impact of HIV in India and the founding of the Y.R. Gaitonde Center for AIDS Research and Education (YRG CARE) clinic in Chennai, India, by Dr Suniti Solomon and her colleagues. This is a story of prejudice and ignorance throughout the various social levels in India. Reports of India's first AIDS case surfaced in 1986, when female sex workers were found to be HIV positive. The first voluntary counseling and testing center, part of a sexually transmitted diseases (STD) clinic, was set up to increase awareness about the epidemic. To address the rapid spread of HIV infection in Tamil Nadu and the existing stigma in society and hospitals, Dr Solomon established YRG CARE in 1993. She recognized that fear and panic about HIV led to widespread social prejudice against HIV-positive patients, even within hospitals. By the end of 2014, over 34 000 patients had accessed these services and 20 000 HIV+ patients had been registered, nearly 40% of whom were females. The team embarked on a statewide awareness program on HIV and sexuality, covering over two hundred schools and colleges educating them about prevention strategies and combating the social stigma attached. The grass-root work of YRG CARE in the management of HIV infections revealed a widespread prejudice, due largely to the lack of awareness about the subject. It is estimated that even in 2015, as little as 40% of HIV-infected people are formally diagnosed and have access to care. In a country as socially and culturally diverse as India, there is much more to be carried out to build on the pioneering work of Dr Solomon.

Global oral inequalities in HIV infection.

Analysis of the prevalence and incidence of HIV infection globally reveal striking variances with regard to continent, country, region and gender. Of the global total of 33 million people infected with HIV, approximately 65% are in sub-Saharan African countries and 15% in South and South-East Asia with the remaining 20% spread over the rest of the world. As a percentage of the population, the Caribbean at 1.1% is second only to sub-Saharan Africa (5.5%). The majority of the world's HIV is in women. Deaths from HIV are twenty-fold greater in Africa than in Europe or the USA. Individual countries in sub-Saharan Africa show huge variances in the HIV+ prevalence with most West African countries having a rate of less than 2% whilst southern African countries including Swaziland and Botswana have rates of around 25%. Environment, education and social habits all contribute to the HIV infection rates. Similar variations between countries are seen in SE Asia with Cambodia and Papua New Guinea having rates three times greater than Pakistan. One of the most striking examples of inequality is in life years added to HIV populations as a result of antiretroviral therapy. UN AIDS figures over 1996-2008 suggest an average of 2.88 added years in the USA and Europe, but only 0.1 in sub-Saharan Africa, a thirty-fold difference largely due to accessibility to ART. ART leads to a reduction in oral lesions but it is estimated that some 10 million HIV+ subjects do not have access to oral care. Thus, inequalities exist both for HIV infection and for the associated oral lesions, mainly related to ART access. HIV infection and oral mucosal lesions both appear to be related to general social determinants of health. Oral HCW must be part of mainstream healthcare teams to address these inequalities.

Serum and salivary IgG and IgA antibodies to desmoglein 3 in mucosal pemphigus vulgaris.

BACKGROUND: The use of saliva for the diagnosis of pemphigus vulgaris (PV) by enzyme-linked immunosorbent assay (ELISA) using desmoglein (Dsg)3 antigen has not been extensively documented, nor has the detection of serum IgA antibodies to Dsg3. OBJECTIVES: (i) To establish whether whole saliva might provide a suitable alternative to serum for diagnosing and monitoring PV; (ii) to investigate whether anti-Dsg3 IgA antibodies can be detected in serum and saliva and (iii) to establish whether there is an association between serum or saliva anti-Dsg3 antibodies and disease severity. METHODS: Precoated Dsg3 ELISA plates were used to test serum and/or saliva for IgG and IgA antibodies. Matched serum and whole saliva samples were collected from 23 patients with PV, 17 healthy subjects and 19 disease controls. All patients with PV, disease controls and six healthy controls provided matched parotid saliva. RESULTS: Whole saliva IgG antibodies to Dsg3 were detected in 14 of 23 patients (61%) and serum IgG antibodies were detected in 17 of 23 (74%) with a strong positive correlation. Serum IgA antibodies were detected in 14 of 23 patients with PV (61%) with a combined positivity (IgG and/or IgA antibodies to Dsg3) of 78% (18 of 23). We were unable to show IgA anti-Dsg3 antibodies in either whole or parotid saliva of patients with PV. Sequential samples showed that changes in IgG antibody titres in whole saliva were associated with a change in disease severity scores. CONCLUSIONS: Assay of salivary IgG antibodies to Dsg3 offers a diagnostic alternative to serum in the diagnosis and monitoring of PV. The role of anti-Dsg3 IgA antibodies requires further elucidation in the pathogenesis of PV.

Salivary IgA and IgG antibodies to bullous pemphigoid 180 noncollagenous domain 16a as diagnostic biomarkers in mucous membrane pemphigoid.

BACKGROUND: Mucous membrane pemphigoid (MMP) is an uncommon mucocutaneous immunobullous disorder. Use of saliva for diagnosis by enzyme-linked immunosorbent assay (ELISA) using the noncollagenous (NC) domain 16a of bullous pemphigoid antigen II (BP180) is not well described. OBJECTIVE: To establish whether whole or parotid saliva is a suitable alternative to serum for diagnosis of MMP. METHODS: Precoated BP180-NC16a ELISA plates were used to test serum, and whole and parotid saliva for IgG, IgA and secretory IgA antibodies. Patients with MMP (n = 64) provided matched serum and whole saliva. In addition 18 of the MMP patients also provided matched parotid saliva. Healthy controls (n = 50) provided matched serum and whole saliva and 6 of these additionally provided matched parotid saliva. An additional 16 disease controls provided matched serum, and whole and parotid saliva. RESULTS: In whole saliva, IgG antibodies were detected in 11/64 (17%), IgA in 23/64 (36%) and a combined positivity in 29/64 (45%). In parotid saliva, IgA antibodies were found in 8/18 (44%). Serum IgG antibodies were detected in 27/64 (42%), serum IgA antibodies in 18/64 (28%) and a combined positivity in 33/64 (52%). Combined use of serum and saliva increased detection of specific antibodies by 30%. Control samples were all negative (positive predictive value of 100% for all tests). The negative predictive values were 62% for IgA saliva, 65% for IgG serum, 59% for IgA serum and 56% for IgG saliva. CONCLUSIONS: IgG and IgA antibodies may provide a suitable diagnostic marker in MMP. Assay of salivary IgA antibodies to NC16a offers a similar diagnostic predictive value to serum.

Epithelioid Haemangioendothelioma of the mandibular gingiva: case report and literature review.

INTRODUCTION: Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm that exhibits the potential for recurrence and metastasis but rarely involves the oral cavity. PRESENTATION OF CASE: We report the management and long term follow up of recurrent EHE in a 23- year-old woman. The lesion initially presented as a small area of erythematous gingival swelling with localised bone loss around the lower anterior teeth. It was treated by buccal and lingual stripping of the gingival tissues. The patient suffered local recurrence after 7 years and was treated with a wider surgical excision of the buccal and lingual gingivae, conserving the adjacent teeth and bone with an excellent cosmetic outcome. Over 21 years later, there have been no further recurrences. DISCUSSION: This case highlights the management challenges of EHE and is the only case in the literature to have reported a case of mandibular gingivae with a long review period of 21 years. CONCLUSION: Oral EHE is an unpredictable lesion with a relatively benign course, unlike non-oral EHE where up to one third of cases may metastasise. Because of the propensity to recur locally after excision and curettage, a wide local excision with close clinical follow has been suggested in the literature as the treatment of choice for oral lesions. However, the lack of metastases from oral lesions, the small size, mandibular site and bland histology in this case suggests that a limited soft tissue excision and bone curettage, with long term follow-up would be appropriate for similar gingival lesions in future.

Development of a low phenolic acid diet for the management of orofacial granulomatosis.

BACKGROUND: Orofacial granulomatosis (OFG) is a rare disease of unknown cause. A cinnamon- and benzoate-free diet is successful in up to 72% of patients. Phenolic acids are among the chemical constituents restricted in this diet, which avoids some but not all of these structurally similar compounds. The present study aimed to: (i) develop a novel diet low in phenolic acids; (ii) implement this in a small clinical trial; and (iii) assess its nutritional adequacy. METHODS: A literature review identified 10 papers quantifying phenolic acids from which 91 10-mg phenolic acid exchanges were devised. A phenolic acid exclusion diet with precautionary micronutrient supplementation was designed and implemented in 10 patients. Phenolic acids were excluded for 6 weeks and were reintroduced at a rate of one exchange every second day for 6 weeks. Wilcoxon matched pairs tests analysed disease outcomes measured by an oral disease severity scoring tool at weeks 0, 6 and 12. Nutritional adequacy was assessed, excluding micronutrient supplementation, at weeks 0 and 6, and compared intakes with dietary reference values. RESULTS: The diet was nutritionally inadequate for a range of micronutrients. Seven of 10 patients responded. Mean [standard deviation (SD)] severity scores improved from week 0-6 [20.8 (9.39) and 10.1 (5.72); P = 0.009] and were maintained in five patients who completed the reintroduction [6.6 (3.13) and 7.2 (5.54); P = 0.713]. CONCLUSIONS: A low phenolic acid diet with micronutrient supplementation holds promise of a novel dietary treatment for OFG. Further work is required in larger studies to determine long-term outcomes.

Professor Thomas Lehner: archetypal translational scientist.

Professor Thomas Lehner is one of the most distinguished oral and dental researchers to have come out of the UK. Over the past 40 years, he has made an astonishing number of discoveries which have had an impact on our understanding of the pathogenesis of a variety of mucosal diseases. He has consistently practiced both basic and clinical research and built an integrated group of clinical and non-clinical researchers, which allowed him easy transition from the laboratory to the clinic. Tom Lehner was among the early scientists studying mucosal immunology, initially exploring oral diseases, with special emphasis on the immunobiology of Streptococcus mutans, leading to active and passive vaccination against dental caries. He was the first to demonstrate cellular immunity as the immunopathological basis of periodontal diseases, recurrent aphthous stomatitis, and candidiasis. Over the past 20 years, his expertise in mucosal immunobiology has been applied to the immunology of HIV/SIV infections. His seminal contributions include regional innate mucosal immunity, prevention of SIV infection in macaques by secretory IgA antibodies, up-regulation of CC chemokines, and the first demonstration of protective CCR5 antibodies. Arguably, his leadership, his students, and the establishment of immunology applied to oral mucosal diseases will be his greatest legacy. His contributions continue unabated.

Dietary intervention for oral allergy syndrome as a treatment in orofacial granulomatosis: a new approach?

BACKGROUND: Orofacial granulomatosis (OFG) is a chronic granulomatous condition of the mouth, face and lips. Recent work demonstrates a high rate of atopy and silver birch sensitisation from skin prick testing (SPT). Oral allergy syndrome (OAS) is an acute oro-pharyngeal IgE mediated reaction, triggered by foods that cross react with pollens, most commonly silver birch. The aim of this study was to determine if patients with OFG and positive SPT to common OAS associated pollens responded to avoidance of cross reactive foods. METHODS: Patients with OFG and positive SPT to silver birch, grass, mugwort, ragweed and latex were required to avoid cross reacting foods, for 6 weeks and, in those who responded, for a total of 12 weeks. All had standardized oral examinations and were given severity scores (SS) at each appointment. RESULTS: Twenty two of 47 (47%) patients had one or more positive SPT and 13/22 completed 6 weeks on the diet. No difference was seen in SS between weeks 0 (14.62 ± 11.16) and 6 (13.31 ± 10.33; P = 0.656). Six of 14 (43%) had significantly improved SS (week 0; 19.17 ± 12.95, week 6; 10.83 ± 4.99, P = 0.027). Five completed 12 weeks and no further improvement was seen (week 6; 11 ± 5.57, week 12; 10.4 ± 9.94; P = 0.068). Two patients required no further treatments. CONCLUSIONS: On an intention to treat basis, only 2/14 patients improved and required no further intervention. Whilst this diet cannot be recommended routinely, the improvement seen in some patients raises questions about the role of OAS in patients with OFG.