Participants' Experiences of Being Treated for Peri-Implant Mucositis-A Qualitative Interview Study.

OBJECTIVE: To describe participants' experiences of being treated for peri-implant mucositis. METHODS: A qualitative study with nine individual, semistructured interviews was performed. The interview guide was based on a focus group interview. The participants had recently been treated for peri-implant mucositis on one dental implant in a randomised controlled trial (RCT). The treatment included information, oral hygiene instructions, nonsurgical treatment with Er:YAG laser or ultrasonic scaler and professional cleaning in several sessions over 6 months. The interviews performed were analysed using qualitative manifest and latent content analysis. RESULTS: The manifest results showed that learning how to brush the teeth, and repeated feedback, was appreciated, and increased the motivation to improve oral hygiene habits. Most participants experienced no discomfort from the treatment. The participants had an understanding that a longer treatment time was required to ensure the quality of the treatment. Respect and attention were important elements of the personal treatment. The latent results suggest that treatment with a laser or an ultrasonic scaler was not perceived as the most important part of the treatment. Participants felt that receiving information about the treatment process was more important; moreover, a person-centred approach gave a feeling of good and safe care. CONCLUSIONS: The present study highlights factors of importance in treatment of peri-implant mucositis with laser and ultrasonic scaler. A person-centred approach with respect and attention is important for a good and safe experience and may be important factors in future treatments.

Oral Health Status Using the Revised Oral Assessment Guide and Mortality in Older Orthopaedic Patients: A Cross-Sectional Study.

Purpose: Orthogeriatric hospitalised patients with fractures of the lower limb constitute a vulnerable population with increased risk of morbidity, polypharmacy, and mortality as well as impaired oral health. The aim of this cross-sectional study was to investigate whether any relationship existed between oral health issues in older orthopaedic patients and mortality. Material and Methods: The study population consisted of older orthopedic patients emergently admitted to a hospital in southern Sweden due to mainly fractures of the hip. Their oral health at admission was assessed by trained nurses using the revised oral assessment guide (ROAG), as well as examined by dental hygienists. Medical and demographic data were collected from medical records and mortality from the national population registry. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Data were analysed using foremost dichotomized data derived from mean values and then processed using multiple logistic regression adjusted for identified probable confounders. Results: Of the 187 study patients (≥65 years) with a mean age of 81 (SD 7.9) years, 71% were women, mean CCI score was 6.7 and 90-days mortality 12.3%. Oral health issues (ROAG >8, 73%) consisted mainly of problems with teeth/dentures (41%), tongue (36%), lips (35%), and saliva (28%). In patients with any oral health impairment (ROAG >8) the 90-days mortality was significantly increased (p=0.040), using logistic regression analysis adjusted for age, gender, comorbidity, and use of ≥5 drugs. In patients with a ROAG score ≥10 (≥mean) the association remained at 90-days (p=0.029) and 180-days (p=0.013). Decayed teeth were present in 24% and was significantly associated with ROAG >8 (p=0.020). Conclusion: The main finding of this study was a possible relationship between oral health impairment at admission and early mortality in orthogeriatric hospitalised patients. The opportunity to identify their oral health problems can help improving further care planning and care.

Impaired Oral Health in Older Orthopaedic In-Care Patients: The Influence of Medication and Morbidity.

INTRODUCTION: Fall-related injuries are prevalent in older patients and often lead to increased morbidity, medication, and impaired functions. We studied older trauma patients with the aim to describe their oral health in comparison to morbidity and medication. MATERIAL AND METHODS: The study included 198 patients, ≥65 years, admitted with an orthopedic trauma. Oral examinations included number of natural teeth, dental implants, missing, decayed and restored teeth, root remnants, and pocket depth. Data on comorbidities and medication were assembled. Statistical analyses were carried out with logistic regression models, adjusted for age, gender, comorbidity, and polypharmacy. RESULTS: Overall, 198 patients participated, 71% women, mean age 81 years (±7.9), 85% resided in their own homes, 86% had hip fractures. Chronic diseases and drug use were present in 98.9%, a mean of 6.67 in Charlson comorbidity index (CCI), 40% heart diseases, 17% diabetes, and 14% dementia. Ninety-one percent were dentate (181), mean number of teeth 19.2 (±6.5), 24% had decayed teeth, 97% filled teeth, 44% <20 teeth, and 26% oral dryness. DFT (decayed, filled teeth) over mean were identified in patients with diabetes (p=0.037), COPD (p=0.048), polypharmacy (p=0.011), diuretics (p=0.007), and inhalation drugs (p=0.032). Use of ≥2 strong anticholinergic drugs were observed in patients with <20 teeth and DFT over mean (p=0.004, 0.003). Adjusted for age, gender, CCI, and polypharmacy. CONCLUSION: The study showed that impaired oral health was prevalent in older trauma patients and that negative effects on oral health were significantly associated with chronic diseases and drug use. The results emphasize the importance of identifying orthogeriatric patients with oral health problems and to stress the necessity to uphold good oral care during a period when functional decline can be expected.

Citrullination of extracellular histone H3.1 reduces antibacterial activity and exacerbates its proteolytic degradation.

BACKGROUND: Cystic fibrosis (CF), involves excessive airway accumulation of neutrophils, often in parallel with severe infection caused by Pseudomonas aeruginosa. Free histones are known to possess bactericidal properties, but the degree of antibacterial activity exerted on specific lung-based pathogens is largely unknown. Neutrophils have a high content of peptidyl deiminase 4 (PADI4), which citrullinate cationic peptidyl-arginines. In histone H3.1, several positions in the NH2-terminal tail are subject to citrullination. METHODS: Full-length and segmented histone subunit H3.1 was investigated for bactericidal activity towards P. aeruginosa (strain PAO1). PADI4-induced citrullination of histone H3.1 was assessed for antibacterial activity towards P. aeruginosa. Next, the effect of neutrophil elastase (NE)-mediated proteolysis of histone H3.1 was investigated. Finally, PADI4, H3.1, and citrullinated H3.1 were examined in healthy control and CF patient lung tissues. RESULTS: Full-length histone H3.1 and sections of the histone H3.1 tail, displayed bactericidal activity towards P. aeruginosa. These antibacterial effects were reduced following citrullination by PADI4 or proteolysis by NE. Interestingly, citrullination of histone H3.1 exacerbated NE-mediated degradation. In CF lung tissue, citrullinated histone H3.1 and PADI4 immunoreactivity was abundant. Degraded histone H3.1 was detected in the sputum of CF patients but was absent in the sputum of healthy controls. CONCLUSIONS: Citrullination impairs the antibacterial activity of histone H3.1 and exacerbates its proteolytic degradation by NE. Citrullination is likely to play an important role during resolution of acute inflammation. However, in chronic inflammation akin to CF, citrullination may dampen host defense and promote pathogen survival, as exemplified by P. aeruginosa.

Early depletion of contact system in patients with sepsis: a prospective matched control observational study.

Activation of the contact system generates bradykinin from high-molecular-weight kininogen and has been suggested to participate in the pathophysiology of sepsis. To test this, we prospectively measured bradykinin and high-molecular-weight kininogen levels in a cohort of sepsis patients requiring intensive care. From 29 patients meeting criteria for sepsis or septic shock according to Sepsis-3, blood was sampled within 24 h and on the fourth day following admittance to intensive care. Patients planned for neurosurgery served as matched controls. Sequential organ failure assessment score and 90-day mortality was registered. Bradykinin levels (median [interquartile range]) were lower in sepsis patients (79 [62-172] pg/ml) compared to controls (130 [86-255] pg/ml, p < 0.025) and did not correlate with mortality or severity of circulatory derangement. High-molecular-weight kininogen levels were lower in sepsis patients (1.6 [0.8-4.8] densitometry units) compared to controls (4.4 [2.9-7.7] densitometry units, p < 0.001), suggesting previous contact system activation. High-molecular-weight kininogen levels were lower in non-survivors than survivors (p = 0.003) and negatively correlated to severity of circulatory derangement. We conclude that a role for bradykinin in later stages of severe sepsis must be challenged. Low high-molecular-weight kininogen concentrations suggest that the decrease in bradykinin is due to substrate depletion.

Dental patients' perceptions and motivation in smoking cessation activities.

OBJECTIVE: The aim of the present study was to investigate smokers' perceptions of and motivation for smoking cessation activities in dentistry. MATERIALS AND METHODS PATIENTS: who smoked were consecutively recruited from general as well as specialist dental care clinics in Sweden. After a dental visit the patients completed a questionnaire about self-perceived oral health, smoking habits, motivation, reasons to quit and not to quit smoking, support to quit, smoking cessation activities and questions about smoking asked by dentists and dental hygienists. RESULTS: The sample consisted of 167 adult patients (≥ 20 years) who smoked daily. During the last 6 months, 81% of the patients had experienced oral health problems. The most common complaints were discolourations of the teeth, periodontal problems and dry mouth (38%, 36% and 33%, respectively). Improved general health was a major reason to quit smoking (89%). It was also stated that it was important to avoid oral health problems. 71% of the patients preferred to quit by themselves and 16% wanted support from dentistry. High motivation to quit smoking was reported by 20%. Occurrence of periodontitis during the last 6 months was significantly associated with being highly motivated to stop smoking (OR = 3.0, 95% CI = 1.03-8.55). CONCLUSIONS: This study revealed that, although it was important to quit smoking to avoid oral health problems, the patients were not aware that tobacco cessation activities can be performed in dentistry. Periodontal problems seem to be the most motivating factor among the patients who were highly motivated to stop smoking.

Tobacco cessation interventions by Swedish dental hygienists--a questionnaire study.

The aim of the study was to investigate tobacco cessation interventions by Swedish dental hygienists and their perception of the importance of tobacco cessation to oral health. A questionnaire was mailed to 400 randomly selected dental hygienists (DH) in Sweden. The questions covered such topics as tobacco cessation interventions, perceived barriers, and their perception of the importance of tobacco cessation in relation to caries, gingivitis, periodontitis and dental implants. The response rate was 57%. Tobacco habits were routinely recorded by 94% of the respondents. 52% of the dental hygienists reported time constraints, 50% reported insufficient competence and 43% answered that they had lack of experience to work with tobacco cessation. All respondents perceived tobacco cessation to be an important determinant of treatment outcomes in patients with dental implants and periodontitis. Bivariate analysis showed an association between training courses in tobacco cessation and tobacco cessation interventions (OR 3.25, CI 95% 1.80-5.85). A logistic multivariate regression model disclosed two other factors significantly correlated with tobacco cessation interventions: competence (OR 2.4, 95% CI 1.16-4.85), and experience (OR 2.1, 95% CI 1.06-4.28). The analyses were adjusted for age, length of undergraduate training course, and dental care organization. The dental hygienists considered tobacco cessation to be very important in patients with periodontitis and in those with dental implants. Most of the DH in this study undertook some tobacco cessation interventions, though not extensive; the main barriers reported were lack of time, competence and experience.

Peptidylarginine deiminases present in the airways during tobacco smoking and inflammation can citrullinate the host defense peptide LL-37, resulting in altered activities.

Bacterial colonization of the lower respiratory tract is frequently seen in chronic obstructive pulmonary disease (COPD), and may cause exacerbations leading to disease progression. Antimicrobial peptides comprise an important part of innate lung immunity, and not least the cathelicidin human cationic antimicrobial protein-18/LL-37. Peptidylarginine deiminases (PADIs) post-translationally modify proteins by converting cationic peptidylarginine residues to neutral peptidylcitrulline. An increased presence of PADI2 and citrullinated proteins was demonstrated in the lungs of smokers. In this study, preformed PADI4, stored in granulocytes and extracellularly in the lumina of bronchi, was found in lung tissue of individuals suffering from COPD. In vitro, recombinant human PADI2 and PADI4 both caused a time- and dose-dependent citrullination of LL-37. The citrullination resulted in impaired antibacterial activity against Staphylococcus aureus, Streptococcus pneumoniae, and nontypable Haemophilus influenzae, but less so against Pseudomonas aeruginosa. Using artificial lipid bilayers, we observed discrete differences when comparing the disrupting activity of native and citrullinated LL-37, suggesting that differences in cell wall composition are important during interactions with whole bacteria. Furthermore, citrullinated LL-37 showed higher chemotactic activity against mononuclear leukocytes than did native LL-37, but was less efficient at neutralizing lipolysaccharide, and also in converting apoptotic neutrophils into a state of secondary necrosis. In addition, citrullinated LL-37 was more prone to degradation by proteases, whereas the V8 endopetidase of S. aureus cleaved the modified peptide at additional sites, compared with native LL-37. Together, these findings demonstrate novel mechanisms whereby the inflammation-dependent deiminases PADI2 and PADI4 can alter the activites of antibacterial polypeptides, affecting the course of inflammatory disorders such as COPD.

Randomized healthservices study of human papillomavirus-based management of low-grade cytological abnormalities.

Human papillomavirus (HPV)-based management of women with borderline atypical squamous cells of undetermined significance (ASCUS) or mildly abnormal cervical intraepithelial neoplasia (CINI) cervical cytology has been extensively studied in the research setting. We wished to assess safety and health care resource use of a real-life health care policy using HPV triaging. All 15 outpatient clinics involved in the organized population-based screening program in Stockholm, Sweden screening program were randomized to either continue with prior policy (colposcopy of all women with ASCUS/CINI) or to implement a policy with HPV triaging and colposcopy only of HPV-positive women. The trial enrolled the 3,319 women who were diagnosed with ASCUS (n = 1,335) or CINI (n = 1,984) in Stockholm during 17th March 2003 to 16th January 2006. Detection of high-grade cervical lesions (CINII+) and health care cost consumption was studied by registry linkages. The proportion of histopathology-verified CINII+ was similar for the two policies (395 of 1,752 women (22.5%; 95% Confidence interval [CI]: 20.6-24.6%) had CINII+ diagnosed with HPV triaging policy, 318 of 1,567 women (20.3%; 95%CI: 18.3-22.4%) had CINII+ with colposcopy policy). Sixty-four percent of women with ASCUS and 77% of women with CINI were HPV positive. HPV-positivity was age-dependent, with 81% of women below 35 years of age and 44% of women above 45 years of age testing HPV-positive. HPV triaging was cost-effective only above 35 years of age. In conclusion, a real-life randomized healthservices study of HPV triaging of women with ASCUS/CINI demonstrated similar detection of CINII+ as colposcopy of all women.

Oral impacts on daily performances: associations with self-reported general health and medication.

OBJECTIVE: The aim of the present study was to examine the impact of general diseases and medication on oral health-related quality of life (OHRQoL) in a Swedish adult population using the Swedish version of Oral Impacts on Daily Performances (OIDP). MATERIAL AND METHODS: A three-site sample of 200 adults (20-86 years; participation rate 70%) was interviewed using the OIDP, and a medical anamnesis was performed in 2006-7. A self-reported questionnaire provided complementary socio-economic data. RESULTS: The burden of medical diagnoses and medications was greatest among the older participants in the study. The mean number of medicines in regular users was: ≥60 years, 3.6 (SD 2.6); 40-59 years, 1.9 (SD 1.5); and 20-40 years, 1.9 (SD 1.8) (p =0.013). There were no gender differences in general health or medication variables. Self-reported health, medical diagnoses and medication were significantly and consistently associated with the OIDP score: subjects with ≥1 diagnosis, OR 2.22 (95% CI 1.19-4.14) and subjects with ≥1 medicines, OR 1.85 (95% CI 1.01-3.40) versus those without diagnoses or medication. However, there was a clear gradient: OIDP scores increased with increasing numbers of diagnoses and medicines. CONCLUSION: The Swedish version of the OIDP was found useful for measuring impacts of general health and medication on OHRQoL. Dental care should pay special attention to patients with medical conditions or who are on medication, because these patients are more likely to experience oral impacts on daily performances.

Comparison between the Hybrid Capture II test and a PCR-based human papillomavirus detection method for diagnosis and posttreatment follow-up of cervical intraepithelial neoplasia.

Human papillomavirus (HPV) infection is the major cause of cervical cancer and its precursor, cervical intraepithelial neoplasia (CIN), and HPV testing has therefore been proposed for improved triaging and follow-up of women treated for CIN. We compared two common HPV DNA detection tests (Hybrid Capture II [HCII] and PCR-enzyme immunosorbent assay (EIA) using the primers GP5+/GP6+ followed by HPV typing with reverse dot blot hybridization) for sensitivity and specificity for detection of CIN and of CIN recurrence after treatment. Two hundred and thirty-nine women referred to the Department of Obstetrics and Gynaecology in Västerås, Sweden, were enrolled because of atypical Pap smears; 177 of these were later treated for dysplasia by conization or loop diathermy. Samples for HPV DNA testing were taken before and 4 to 6 months after treatment. There was substantial agreement between the HCII and PCR-EIA (kappa, 0.70 before treatment and 0.72 after treatment). The sensitivity for histopathologically confirmed CIN III was 100.0% for PCR-EIA and 95.6% for HCII. For patients with CIN II or worse (CIN II+), the sensitivities were 92.9% (PCR-EIA) and 91.8% (HCII). The specificities for CIN II+ in the pretreatment setting were 30.4% for PCR-EIA and 24.1% for HCII. After treatment, the sensitivities for CIN III in cytology were 100.0% by both methods, and for CIN II+, sensitivities were 80.0% by both methods. The specificities for CIN II+ in the posttreatment setting were 83.5% for PCR and 85.4% for HCII. In conclusion, the sensitivities of both PCR-EIA and HCII are high and almost equal, suggesting that both methods are suitable as tools for detection and posttreatment follow-up of CIN II-III.

Cocaine use in Europe - a multi-centre study: patterns of use in different groups.

AIM: The study investigates patterns of cocaine powder and crack cocaine use of different groups in nine European cities. DESIGN, SETTING, PARTICIPANTS: Multi-centre cross-sectional study conducted in Barcelona, Budapest, Dublin, Hamburg, London, Paris, Rome, Vienna, and Zurich. Data were collected by structured face-to-face interviews. The sample comprises 1,855 cocaine users out of three subgroups: 632 cocaine users in addiction treatment, mainly maintenance treatment; 615 socially marginalized cocaine users not in treatment, and 608 socially integrated cocaine users not in treatment. MEASUREMENTS: Use of cocaine powder, crack cocaine and other substances in the last 30 days, routes of administration, and lifetime use of cocaine powder and crack cocaine. FINDINGS: The marginalized group showed the highest intensity of cocaine use, the highest intensity of heroin use and of multiple substance use. 95% of the integrated group snorted cocaine powder, while in the two other groups, injecting was quite prevalent, but with huge differences between the cities. 96% of all participants had used at least one other substance in addition to cocaine in the last 30 days. CONCLUSIONS: The use of cocaine powder and crack cocaine varies widely between different groups and between cities. Nonetheless, multiple substance use is the predominating pattern of cocaine use, and the different routes of administration have to be taken into account.

Human eosinophils produce the T cell-attracting chemokines MIG and IP-10 upon stimulation with IFN-gamma.

Eosinophils participate in allergic inflammation, where expression of T helper cell type 2 (Th2) cytokines such as interleukin (IL)-4 and IL-5 are seen. However, eosinophils sometimes accumulate during disease with expression of Th1 cytokines [i.e., interferon-gamma (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), and IL-1beta]. In this study, we investigated whether eosinophils can respond with expression of the IFN-inducible C-X-C chemokines monokine induced by IFN-gamma [MIG; CXC chemokine ligand 9 (CXCL9)], IFN-gamma-inducible protein (IP-10/CXCL10), and IFN-inducible T cell alpha chemoattractant (I-TAC/CXCL11). These chemokines share the ability to recruit and activate T cells and natural killer cells to sites of inflammation. We found that IFN-gamma induced rapid and sustained gene expression of MIG, IP-10, and I-TAC in eosinophils, as detected by quantitative reverse transcriptase-polymerase chain reaction. During incubation, IFN-gamma-stimulated eosinophils released MIG and IP-10, as detected by enzyme-linked immunosorbent assay, while I-TAC could not be detected in the medium. TNF-alpha but not IL-1beta enhanced the IFN-gamma-induced production of MIG and IP-10. Conversely, addition of the Th2 cytokine IL-4 down-regulated IFN-gamma-induced synthesis of MIG and IP-10 in eosinophils. Crohn's disease is characterized by a Th1-polarized inflammation and presence of eosinophils. In lesions from this disease, MIG was detected in eosinophils by immunohistochemistry. Taken together, the results point to immunoregulatory roles for eosinophils during some diseases with Th1-polarized inflammation.

Peptidoglycan induces mobilization of the surface marker for activation marker CD66b in human neutrophils but not in eosinophils.

Peptidoglycan from Staphylococcus aureus mobilized CD66b in human neutrophils but did not upregulate surface activation markers in eosinophils. In addition, Toll-like receptor 2, implicated in the recognition of peptidoglycan, was detected on the surface of resting neutrophils but not on eosinophils. These findings suggest roles for neutrophils but not eosinophils in innate recognition of peptidoglycan.

Expression and production of the CXC chemokine growth-related oncogene-alpha by human eosinophils.

Eosinophils are seen together with neutrophils at sites of inflammation. However, their roles are not clear. In addition, eosinophils infiltrate tumor tissue in some neoplastic diseases. In this study, we show that large amounts of the neutrophil-activating CXC chemokine growth-related oncogene (GRO)-alpha can be produced by human eosinophils. Eosinophils showed presence of preformed GRO-alpha in the crystalloid-containing specific granules (190 pg/2 x 10(6) cells). During incubation, a strong increase in GRO-alpha gene expression was seen. At a low cell density, addition of TNF-alpha or IL-1 beta increased the production of GRO-alpha in eosinophils, which was not the case at a higher cell density. Eosinophils can produce TNF-alpha themselves, and neutralizing Abs against TNF-alpha significantly inhibited GRO-alpha production. This suggests that autocrine and paracrine effects from TNF-alpha can be important when up-regulating GRO-alpha gene expression. In contrast, IFN-gamma, a prototypic Th1-cytokine, down-regulated expression of GRO-alpha. This may be important during resolution of inflammation but also suggests different roles for eosinophils depending on the inflammatory context. Tumor-infiltrating eosinophils in Hodgkin's disease of the nodular sclerosing type are associated with a poor prognosis. Eosinophils from such tumor tissue showed an abundant expression of GRO-alpha. The GRO-alpha receptor CXCR2 was also detected in tumor tissue, proposing interactions between eosinophils and the tumor. Our findings suggest that eosinophils can promote inflammation through recruitment of CXCR2-bearing cells. In addition, this feature of the eosinophils indicates a role for these cells in the biology of certain tumors.