Development of a European consensus from dentists, dental hygienists and physicians on a standard for oral health care in care-dependent older people: An e-Delphi study.

OBJECTIVES: This study aimed to obtain a consensus on oral health policy, access to dental care, oral hygiene measures and training levels. BACKGROUND: Poor oral health is widespread in care-dependent older people, but no consensus for a minimum standard of oral health care exists yet. METHODS: The e-Delphi approach was applied to a selected panel of interdisciplinary experts. Data analysis was based on three measurements: (a) ≥70% of experts' opinion fall into category "agree or strongly agree," (b) median score on the 5-point Likert scale ≥4, (c) interquartile range ≤1. RESULTS: A total of 31 experts from 17 European countries participated in this survey. Agreement was achieved for a compulsory dental examination when an elder is admitted to a long-term care (LTC) facility. Older people should brush their teeth twice/day and regularly clean interproximal spaces and oral mucosa. Dentures should be rinsed after meals and cleaned twice/day. The use of denture cleansing tablets was considered necessary. Dentures should be removed before sleeping and stored dry. A 5000 ppm fluoride toothpaste should be applied daily in elder with high caries risk. A short report on the oral health status of the elder should be included in the geriatric assessment. All experts concluded that the knowledge and the training in oral health care for caregivers and family members of care-dependent older people were imperative. CONCLUSIONS: Using the e-Delphi method, multidisciplinary healthcare professionals from different countries agreed on certain cardinal recommendations for a standard oral health care for care-dependent older people.

Characterization of inter-crystallite peptides in human enamel rods reveals contribution by the Y allele of amelogenin.

Proteins of the inter-rod sheath and peptides within the narrow inter-crystallite space of the rod structure are considered largely responsible for visco-elastic and visco-plastic properties of enamel. The present study was designed to investigate putative peptides of the inter-crystallite space. Entities of 1-6 kDa extracted from enamel rods of erupted permanent teeth were analysed by mass spectrometry (MS) and shown to comprise N-terminal amelogenin (AMEL) peptides either containing or not containing exon 4 product. Other dominant entities consisted of an N-terminal peptide from ameloblastin (AMBN) and a series of the most hydrophobic peptides from serum albumin (ALBN). Amelogenin peptides encoded by the Y-chromosome allele were strongly detected in Enamel from male teeth. Location of N-terminal AMEL peptides as well as AMBN and ALBN, between apatite crystallites, was disclosed by immunogold scanning electron microscopy (SEM). Density plots confirmed the relative abundance of these products including exon 4+ AMEL peptides that have greater capacity for binding to hydroxyapatite. Hydrophilic X and Y peptides encoded in exon 4 differ only in substitution of non-polar isoleucine in Y for polar threonine in X with reduced disruption of the hydrophobic N-terminal structure in the Y form. Despite similarity of X and Y alleles of AMEL the non-coding region upstream from exon 4 shows significant variation with implications for segregation of processing of transcripts from exon 4. Detection of fragments from multiple additional proteins including keratins (KER), fetuin A (FETUA), proteinases and proteinase inhibitors, likely reflect biochemical events during enamel formation.

Effect of tooth bleaching agents on protein content and mechanical properties of dental enamel.

This study investigated the effect of two bleaching agents, 16% carbamide peroxide (CP) and 35% hydrogen peroxide (HP), on the mechanical properties and protein content of human enamel from freshly extracted teeth. The protein components of control and treated enamel were extracted and examined on sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). Marked reduction of the protein matrix and random fragmentation of the enamel proteins after bleaching treatments was found. The mechanical properties were analyzed with Vickers indentations to characterize fracture toughness, and nanoindentation to establish enamel hardness, elastic modulus and creep deformation. Results indicate that the hardness and elastic modulus of enamel were significantly reduced after treatment with CP and HP. After bleaching, the creep deformation at maximum load increased and the recovery upon unloading reduced. Crack lengths of CP and HP treated enamel were increased, while fracture toughness decreased. Additionally, the microstructures of fractured and indented samples were examined with field emission gun scanning electron microscopy (FEG-SEM) showing distinct differences in the fracture surface morphology between pre- and post-bleached enamel. In conclusion, tooth bleaching agents can produce detrimental effects on the mechanical properties of enamel, possibly as a consequence of damaging or denaturing of its protein components.

Structural analysis of reactionary dentin formed in response to polymicrobial invasion.

In response to microbial invasion of dentin odontoblasts secrete an altered calcified matrix termed reactionary dentin (Rd). 3D reconstruction of focused-ion-beam scanning electron microscopy (FIB-SEM) image slices revealed helical tubular structures in Rd that contrasted with regular cylindrical tubules characteristic of dentin from healthy teeth and affected so-called physiological dentin (Pd) lying exterior to Rd. This helical structure in Rd provided effective constriction of tubule lumen diameter that formed a barrier to bacterial advance towards the dental pulp. SEM of resin cast preparations revealed altered extension of odontoblast processes through Rd. The distribution of key mineral elements was studied by combination of 3D reconstruction of focused-ion-beam based X-ray microanalysis (FIB-EDS), laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) and diffuse reflectance infrared Fourier transform spectroscopy (DRIFTS). There was a marked redistribution of calcium and phosphorous in Rd together with an increase of diffusely deposited magnesium compatible with the mineral deposition phase of synthesis of this altered matrix. Changes in tubule structure and mineral content characteristic of Rd are consistent with reduced hardness and lower elastic modulus reported for this matrix. Findings provide insight into the unique structure of Rd synthesised as a primary response to infection.

Regulation of reactionary dentin formation by odontoblasts in response to polymicrobial invasion of dentin matrix.

Odontoblast synthesis of dentin proceeds through discrete but overlapping phases characterized by formation of a patterned organic matrix followed by remodelling and active mineralization. Microbial invasion of dentin in caries triggers an adaptive response by odontoblasts, culminating in formation of a structurally altered reactionary dentin, marked by biochemical and architectonic modifications including diminished tubularity. Scanning electron microscopy of the collagen framework in reactionary dentin revealed a radically modified yet highly organized meshwork as indicated by fractal and lacunarity analyses. Immuno-gold labelling demonstrated increased density and regular spatial distribution of dentin sialoprotein (DSP) in reactionary dentin. DSP contributes putative hydroxyapatite nucleation sites on the collagen scaffold. To further dissect the formation of this altered dentin matrix, the associated enzymatic machinery was investigated. Analysis of extracted dentin matrix indicated increased activity of matrix metalloproteinase-2 (MMP-2) in the reactionary zone referenced to physiologic dentin. Likewise, gene expression analysis of micro-dissected odontoblast layer revealed up-regulation of MMP-2. Parallel up-regulation of tissue inhibitor of metalloproteinase-2 (TIMP-2) and membrane type 1- matrix metalloproteinase (MT1-MMP) was observed in response to caries. Next, modulation of odontoblastic dentinogenic enzyme repertoire was addressed. In the odontoblast layer expression of Toll-like receptors was markedly altered in response to bacterial invasion. In carious teeth TLR-2 and the gene encoding the corresponding adaptor protein MyD88 were down-regulated whereas genes encoding TLR-4 and adaptor proteins TRAM and Mal/TIRAP were up-regulated. TLR-4 signalling mediated by binding of bacterial products has been linked to up-regulation of MMP-2. Further, increased expression of genes encoding components of the TGF-ß signalling pathway, namely SMAD-2 and SMAD-4, may explain the increased synthesis of collagen by odontoblasts in caries. These findings indicate a radical adaptive response of odontoblasts to microbial invasion of dentin with resultant synthesis of modified mineralized matrix.