Salivary gland dysfunction ('dry mouth') in patients with cancer: a consensus statement.

A group of interested professionals was convened to develop some evidence-based recommendations on the management of salivary gland dysfunction (SGD) in oncology patients. A Medline search was performed to identify the literature on SGD. The abstracts of all identified papers were read, and the full texts of all relevant papers were reviewed. The evidence was graded according to the Scottish Intercollegiate Guidelines Network grading system for recommendations in evidence-based guidelines. The summary of the main recommendations are: (1) patients with cancer should be regularly assessed for SGD (grade of recommendation - D); (2) the management of SGD should be individualised (D); (3) consideration should be given to strategies to prevent the development of radiation-induced SGD (C); (4) consideration should be given to treatment of the cause(s) of the SGD (C); (5) the treatment of choice for the symptomatic management of SGD is use of an appropriate saliva stimulant (C); (6) consideration should be given to prevention of the complications of the SGD (D); (7) consideration should be given to treatment of the complications of the SGD (D); and (8) patients with SGD should be regularly reassessed (D).

Mixed Candida albicans and Candida glabrata populations associated with the pathogenesis of denture stomatitis.

INTRODUCTION: Oral yeasts are an important component of the resident microbial ecology of the oral cavity, but they are also associated with various forms of oral candidosis, such as denture stomatitis. Although Candida albicans is the predominant oral fungal pathogen, other species may also play an integral role in pathogenesis. The aim of this study was to examine the mycological ecology in patients with denture stomatitis, using an improved sampling technique, to determine whether species diversity and species quantity were related to oral pathology. METHODS: Thirty-seven patients attending the Glasgow Dental Hospital were enrolled in this study following informed consent. A full clinical history was obtained, including details of their oral hygiene practices and the levels of erythema based on Newton's classification scale. Oral rinse, denture sonicate, and swab samples were taken, which were processed for quantitative and qualitative analysis of oral yeasts. RESULTS: The proportion of patients with no inflammation or Newton's Types I, II, and III were 31, 33, 25, and 14%, respectively. Denture sonication was a superior sampling procedure, with statistically greater quantities of yeasts isolated using this methodology (P < 0.01). The predominant oral yeasts isolated were C. albicans (75%) and Candida glabrata (30%), which were isolated in higher proportions in patients with the highest grades of inflammation (100 and 80%), and in combination from 80% of these patients. CONCLUSIONS: This study has demonstrated that mixed C. albicans and C. glabrata biofilms may play an important role in the pathogenesis associated with severe inflammation in denture wearers.

Molecular identification of bacteria on the tongue dorsum of subjects with and without halitosis.

AIM: Compare the microbial profiles on the tongue dorsum in patients with halitosis and control subjects in a UK population using culture-independent techniques. MATERIALS AND METHODS: Halitosis patients were screened according to our recently developed recruitment protocol. Scrapings from the tongue dorsum were obtained for 12 control subjects and 20 halitosis patients. Bacteria were identified by PCR amplification, cloning and sequencing of 16S rRNA genes. RESULTS: The predominant species found in the control samples were Lysobacter-type species, Streptococcus salivarius, Veillonella dispar, unidentified oral bacterium, Actinomyces odontolyticus, Atopobium parvulum and Veillonella atypica. In the halitosis samples, Lysobacter-type species, S. salivarius, Prevotella melaninogenica, unidentified oral bacterium, Prevotella veroralis and Prevotella pallens were the most commonly found species. For the control samples, 13-16 (4.7-5.8%) of 276 clones represented uncultured species, whereas in the halitosis samples, this proportion increased to 6.5-9.6% (36-53 of 553 clones). In the control samples, 22 (8.0%) of 276 clones represented potentially novel phylotypes, and in the halitosis samples, this figure was 39 (7.1%) of 553 clones. CONCLUSIONS: The microflora associated with the tongue dorsum is complex in both the control and halitosis groups, but several key species predominate in both groups.

Use of safety syringes for administration of local anaesthesia among a sample of UK primary care dental professionals.

Background: Safer sharps devices (SSDs) are commercially available and their use is mandated through UK legislation. Aim: To identify the current usage of SSDs in UK primary care dentistry. Method: A cross-sectional survey was administered to delegates at the 2017 British Dental Association (BDA) Conference and Exhibition in Manchester, and at the 2017 BDA Scottish Conference and Exhibition in Glasgow. The survey covered a range of questions relating to sharps injuries and use of traditional and safety syringes for delivery of local anaesthesia. Statistical analyses were conducted using SPSS Version 22 (IBM Corp., 2013) and included chi-square and Fisher's exact tests. Results: Seven hundred and ninety-six delegates participated, of whom 396 (49.7%) were using safety syringes for delivery of local anaesthesia. Of the 166 participants who had experienced a sharps injury in the past year, 76 (45.8%) worked in facilities that most commonly used SSDs for delivery of local anaesthesia. Conclusion: Our results indicate that a significant number of dental practices in our sample have not adopted SSDs and suggest sharps injuries are still being sustained in some practices using SSDs. Further epidemiological research is required to provide strong evidence for the effectiveness of SSDs and reasons why SSDs have not been fully adopted in UK primary dental care.

Oral health care and status of elderly care home residents in Glasgow.

OBJECTIVES: To investigate variations in reported oral health care provision and unmet dental need within a sample of care homes for the elderly in Glasgow. BASIC RESEARCH DESIGN: Two-phase study of a 50% random sample of 120 care homes (n = 60). Phase 1: telephone interviews with care home managers. Phase 2: oral examinations of residents and face-to-face interviews with care staff, in a sub-sample of 10 homes. CLINICAL SETTING: Care homes in Greater Glasgow. PARTICIPANTS: Residents and staff. RESULTS: Phase 1: data were collected from 58 of 60 care home managers approached (response rate: 97%). Oral assessment of residents on admission was reported for 78% of nursing homes and 24% of residential homes, and annual screening by a dentist for 85% and 76% respectively. Only 58% of nursing homes and 8% of residential homes had a formal mouth care policy. Staff training in mouth care was not universal and often carried out "in-house". All managers believed dental support was available when required. Phase 2: 288 oral examinations and 22 staff interviews took place within 10 homes selected. Examinations revealed high levels of oral disease. When interviewed, staff accepted that mouth care was within their remit but failed to document it within patient care plans. Further training on oral health and disease was requested from all levels of staff. CONCLUSIONS: Oral disease is common among elderly care home residents in Glasgow. Increased emphasis on implementation of standard oral care protocols and improved education of staff is essential if the oral health of elderly institutionalised residents is to improve.

The Flipped Classroom for pre-clinical dental skills teaching - a reflective commentary.

A Flipped Classroom method for teaching of adult practical pre-clinical dental skills was introduced to the BDS curriculum in Glasgow during the 2015/2016 academic session. This report provides a commentary of the first year of employing this method - from the identification of the need to optimise teaching resources, through the planning, implementation and development of the method, with an early indication of performance.

No longer 'written off' - times have changed for the BBV-infected dental professional.

There is a recognised potential risk of transmission of blood-borne viruses (BBVs) from infected healthcare workers to patients during exposure prone procedures (EPPs). The restrictions placed on performance of EPPs by infected clinicians in the UK have had a particularly significant impact on dentists because of the exposure-prone nature of most dental procedures and the difficulties in identifying alternative career pathways in the profession that do not involve EPPs. More recently, the significant positive impact of antiviral drugs on viral load, together with a re-categorisation of EPPs in dentistry have resulted in evolution of the guidance with a consequent significant improvement to the career prospects of dentists infected with BBVs. This paper provides an update for practitioners on the progress that has been made and outlines the current position with respect to practice restrictions.

Residual protein levels on reprocessed dental instruments.

Reduction of the initial bioburden on instruments, prior to sterilization, is believed to reduce transmission risks of iatrogenic Creutzfeldt-Jakob disease. Endodontic files are used in the preparation of root canals and are likely to have close contact and become contaminated with neural material from branches of the maxillary and mandibular cranial nerves. This study examined methods used by 22 dental practices to clean endodontic files, and scored visible debris and residual protein levels adhering to 220 dental endodontic files that had been used, cleaned, autoclaved and were deemed ready for re-use. Visible debris was scored after examination under a dissecting light microscope. Residual protein was quantified using a fluorescent assay based on reaction of proteins with o-phthaldialdehyde/N-acetyl cysteine. There was wide variation in the methods used by practices to clean endodontic files. The cleaning process varied from a wipe with an alcohol-impregnated cloth to hand scrubbing and/or use of an ultrasonic bath. Surface debris was visually detected on 98% of files. Residual protein was detected on all the files examined (median amount: 5.4 microg; range: 0.5-63.2 microg). These results demonstrate that the cleaning of some instruments reprocessed routinely in primary care is incomplete, and such instruments cannot be excluded as a potential source of cross-infection.

Detection of bacteraemias during non-surgicalroot canal treatment.

UNLABELLED: Some dental procedures initiate a bacteraemia. In certain compromised patients, this bacteraemia may lead to distant site infections, most notably infective endocarditis. OBJECTIVE: To investigate whether a detectable bacteraemia was produced during non-surgical root canal therapy. METHODS: Thirty patients receiving non-surgical root canal therapy were studied. Three blood samples were taken per patient: pre-operatively, peri-operatively and post-operatively. In addition, a paper point sample was collected from the root canal. The blood samples were cultured by pour plate and blood bottle methods. The isolated organisms were identified by standard techniques. Blood samples were analysed for the presence of bacterial DNA by the polymerase chain reaction (PCR). In two cases where the same species of organism was identified in the root canal and the bloodstream, the isolates were typed by pulsed field gel electrophoresis (PFGE). RESULTS: By conventional culturing, a detectable bacteraemia was present in 9 (30%) of the 30 patients who had no positive pre-operative control blood sample. In 7 (23.3%) patients, the same species of organism was identified in both the bloodstream and in the paper point sample from the root canal system. Overall, PCR gave lower detection rates compared with conventional culture, with 10 of 90 (11%) of the blood samples displaying bacterial DNA. PFGE typing was undertaken for two pairs of culture isolates from blood and paper points; these were found to be genetically identical. CONCLUSIONS: Non-surgical root canal treatment may invoke a detectable bacteraemia.

A study of visual and blood contamination on reprocessed endodontic files from general dental practice.

OBJECTIVE: This study examined methods used for reprocessing endodontic instruments in general dental practice and determined the degree of residual visual contamination and blood contamination on 250 reprocessed files collected from 25 general dental practices. MATERIALS AND METHODS: A questionnaire was administered to 25 general dental practitioners to obtain information on the re-processing of used endodontic files. Ten files which had been used and reprocessed were also collected from each practice. These were examined visually under a dissecting light microscope for residual contamination and then tested for blood deposits using the Kastle-Meyer test. RESULTS: Nineteen of the 25 practices used stainless steel hand files. No practitioners used endodontic files as single use devices. Ninety-two per cent of the practitioners discarded and replaced files when they were bent or damaged. Several decontamination methods were reported. The two combinations employed most frequently were manual cleaning and autoclaving or manual cleaning, followed by ultrasonic cleaning and autoclaving. Of the 250 files, 75% showed some degree of visual contamination and seven percent tested positive for residual blood. Blood contaminated files were significantly more heavily contaminated when examined visually. Large variations were found in residual contamination of files collected from practices using the same methods of decontamination. CONCLUSIONS: While all practitioners re-used endodontic files, the variations in decontamination methods reported indicate a lack of clarity on best practice. This study demonstrates that endodontic files are not reliably decontaminated by methods currently employed in dental practice.

Dentists, antibiotics and Clostridium difficile-associated disease.

Dentists prescribe significant volumes of antimicrobial drugs within primary care settings. There is good evidence that many of the prescriptions are not justified by current clinical guidance and that that there is considerable misuse of these drugs in dentistry. One of the risks associated with antibiotic administration is Clostridium difficile-associated disease (CDAD), an entity of which many healthcare workers, including dentists, have little knowledge or understanding. This review seeks to identify the extent and nature of the problem and provides an up to date summary of current views on CDAD, with particular reference to community acquired disease. As for all healthcare workers, scrupulous attention to standard infection control procedures and reducing inappropriate antibiotic prescribing are essential to reduce the risks of CDAD, prevent emergence of further resistant strains of microorganisms and maintain the value of the arsenal of antibiotics currently available to us.

The ecology of Staphylococcus species in the oral cavity.

Whilst the diversity of organisms present in the oral cavity is well accepted, there remains considerable controversy as to whether Staphylococcus spp. play a role in the ecology of the normal oral flora. Surprisingly little detailed work has been performed on the quantitative and qualitative aspects of colonisation or infection either by coagulase-negative staphylococci (CNS) or S. aureus. The latter is especially interesting in the light of present difficulties in eradicating carriage of methicillin-resistant S. aureus (MRSA) from the oropharynx in affected individuals. This paper reviews the current knowledge of staphylococcal colonisation and infection of the oral cavity in health and disease. S. aureus has been isolated from a wide range of infective oral conditions, such as angular cheilitis and parotitis. More recently, a clinical condition classified as staphylococcal mucositis has emerged as a clinical problem in many debilitated elderly patients and those with oral Crohn's disease. Higher carriage rates of both CNS or S. aureus, or both, in patients prone to joint infections raises the interesting possibility of the oral cavity serving as a potential source for bacteraemic spread to compromised joint spaces. In conclusion, there is a surprising paucity of knowledge regarding the role of oral staphylococci in both health and disease. Further work in this area may lead to benefits, such as improved decolonisation regimens for eradication of MRSA and acknowledgement of the mouth as a source of bacteraemic staphylococci.

Origins of Staphylococcus epidermidis and Streptococcus oralis causing bacteraemia in a bone marrow transplant patient.

Coagulase-negative staphylococcal bacteraemia in immunocompromised patients is often associated with the use of central venous catheters, while the proposed origin of viridans streptococci causing bacteraemia in this patient group is the oral cavity. This report describes an episode of polymicrobial bacteraemia caused by Staphylococcus epidermidis and Streptococcus oralis followed by several further episodes of S. epidermidis bacteraemia in a 15-year-old boy after bone marrow transplantation. Pulsed-field gel electrophoresis (PFGE) of SmaI chromosomal DNA digests was used to compare blood culture and oral isolates of S. epidermidis and Str. oralis. The results indicated that the mouth was the source of both S. epidermidis and Str. oralis causing the first episode of bacteraemia. PFGE further demonstrated that the central venous catheter was the origin of a second strain of S. epidermidis responsible for subsequent episodes of staphylococcal bacteraemia. Both the oral mucosa and central venous lines should be considered as potential sources of organisms, including coagulase-negative staphylococci, associated with bacteraemia in immunocompromised patients.

A laboratory assessment of the antimicrobial effectiveness of glove washing and re-use in dental practice.

This study has assessed the ability of five hand-washing agents, Hibisol, Hibiscrub, Betadine, 70% isopropyl alcohol and bar soap, to decontaminate the surfaces of Biogel D, Surgikos Microtouch and Ansell Gammex latex medical gloves after repeated inoculation with Staphylococcus aureus. The glove and hand-washing agents were compared in a Latin Square experiment, and a standardized handwashing regime followed. Each of the gloves used in the study was later tested electrically for micropuncture formation. On the basis of microbial recovery, no specific combination of glove and hand washing agent proved superior, the marker organism being isolated on a sporadic basis. In addition, 17% of the gloves showed evidence of micropunctures after five sequential inoculations and washings. These results suggest that, even under strictly controlled conditions, glove surfaces cannot be reliably and consistently cleaned of microbial contamination, nor can they be guaranteed to remain puncture-free. Ideally, therefore, a new pair of gloves should be worn for each patient.

Contaminated dental instruments.

There is current concern in the UK over the possible transmission of prions via contaminated surgical instruments. Some dental instruments (endodontic files) raise particular concerns by virtue of their intimate contact with terminal branches of the trigeminal nerve. A visual assessment using a dissecting light microscope and scanning electron microscopy of endodontic files after clinical use and subsequent decontamination was performed. The instruments examined were collected from general dental practices and from a dental hospital. Seventy-six per cent (22/29) of the files retrieved from general dental practices remained visibly contaminated, compared with 14% (5/37) from the dental hospital. Current methods for decontaminating endodontic instruments used in dentistry may be of an insufficient standard to completely remove biological material. Improved cleaning methods and the feasibility of single use endodontic instruments require further investigation.

Use of chlorine dioxide to disinfect dental unit waterlines.

This paper describes a trial of chlorine dioxide in dental unit waterlines to produce potable quality water. Four treatment protocols using 50 ppm activated chlorine dioxide solution were tested. Each caused a short-term (<48 h) decline in total viable counts but did not provide potable quality water. Intermittent use of chloride dioxide is thus not suitable for long-term decontamination of dental unit waterlines. Units should be redesigned to discourage biofilm formation, and more research into practical methods of achieving potable water is required in the interim.

A clinical evaluation of glove washing and re-use in dental practice.

This study has assessed the durability of four brands of latex gloves, Ansell Medical 'Medi-Grip', Regent 'Biogel D', Surgikos 'Microtouch' and the London Rubber Company 'Supreme', under conditions of repeated washing and re-use in a clinical dental setting. The microbiological effectiveness of 'Hibiscrub' as a decontaminating washing agent was examined simultaneously. Examination by an electrical test for micropunctures in 200 unused gloves of each brand revealed such defects in 6(3%) of Ansell 'Medi-Grip', 3(1.5%) of 'Biogel D', 14(7%) of Surgikos 'Microtouch' and 2(1%) of LRC 'Supreme' gloves. Following repeated clinical use, micropunctures were detected in 18% of Ansell 'Medi-Grip', 10% of 'Biogel D', 75% of Surgikos 'Microtouch' and 56% of LRC 'Supreme'. Microorganisms were isolated from the glove surfaces after 45% of the occasions on which the gloves were washed for 1 min in 'Hibiscrub' (ICI Dental). Eighty-five per cent of these isolates were environmental organisms, but oral streptococci were isolated from 8.4% of the pairs of gloves examined. The high rate of micropuncture development following repeated washing and re-use of latex gloves indicates that they cannot effectively perform their barrier function under such conditions. The microbiological data have also revealed the potential for cross-infection between patients through inadequate decontamination of glove surfaces. For operative dental surgery, the results suggest that heavier, surgical type gloves are to be preferred, and that multiple use of any glove type should be discouraged.

Hepatitis C infection among dental personnel in the West of Scotland, UK.

Hepatitis C virus (HCV) is considered a serious occupational hazard for healthcare workers, particularly those performing exposure-prone procedures. In the UK, the majority of dental procedures are classified as exposure prone. In order to gauge the prevalence and determinants of infection among dental healthcare workers, a voluntary anonymous survey of HCV infection among primary care dental workers employed in the West of Scotland was undertaken, in which occupational and personal risk data were collected in parallel with a blood specimen. The overall prevalence of HCV antibodies was 0.1% (1/880, 95% CI 0-0.6); this is no greater than the estimated prevalence of HCV infection in the local population. Personal risk data collected suggested that the single infection identified was acquired through a non-occupational route. These results suggest that HCV infection is not a major occupational risk for dental healthcare workers.

Prions and the oral cavity.

Prion diseases have recently emerged as a significant challenge to health-care workers, including those involved in dentistry. Abnormal prion proteins are resistant to complete inactivation by conventional sterilization techniques. In the last decade, a new form of prion disease emerged in the UK, termed "variant CJD", thought to be acquired by consumption of bovine spongiform encephalopathy-contaminated food products. At present, CJD is an invariably fatal disease with no immediate prospect of treatment or vaccination. Of concern with the variant form of CJD, unlike the more classic forms of the disease, is the appearance of significant levels of infectivity outside the central nervous system. This raises concerns for the potential transmission of prion proteins via surgical procedures from individuals in the asymptomatic stage of the disease. This article reviews the existing knowledge base on the nature of prions, their distribution in oral tissues, and the implications for dental treatment.

Oral disease in terminally ill cancer patients with xerostomia.

Xerostomia is common among patients with advanced cancer and is likely to contribute to oral disease. This study determined the prevalence of oral signs and symptoms among a group of 70 terminally ill cancer patients [25 male, 45 female; age range 42-88 (mean 66) years] complaining of oral dryness, and examined the associated oral microflora. Imprint cultures for yeasts, coliforms and staphylococci were collected from the tongue and, in denture wearers, from the plate and denture fitting surface. A swab was collected for culture of herpes simplex virus. 68 patients (97%) complained of oral dryness during the day and 59 patients (84%) complained of oral dryness at night. Oral soreness was reported by 22 patients (31%). 46 patients (66%) had difficulty talking and 36 (51%) reported difficulty eating. Of the 56 denture wearers, 40% complained of denture problems. On examination, 63 (90%) of the patients had clinically dry mouths. Oral mucosal abnormalities were detected in 45 patients (65%), most commonly erythema (20%), coated tongue (20%), atrophic glossitis (17%), angular cheilitis (11%) and pseudomembraneous candidosis (9%). 47 (67%) of the patients carried yeasts, 18 (26%) were carriers of Staphylococcus aureus and 13 (19%) carried coliforms. Herpes simplex virus was isolated from 5 patients, of whom 2 had herpetic stomatitis. Oral complications and abnormalities of the oral microflora can be detected among significant numbers of terminally ill cancer patients with xerostomia.