Risk Assessment of Norovirus Illness from Consumption of Raw Oysters in the United States and in Canada.

Human norovirus (NoV) is the leading cause of foodborne illness in the United States and Canada. Bivalve molluscan shellfish is one commodity commonly identified as being a vector of NoV. Bivalve molluscan shellfish are grown in waters that may be affected by contamination events, tend to bioaccumulate viruses, and are frequently eaten raw. In an effort to better assess the elements that contribute to potential risk of NoV infection and illness from consumption of bivalve molluscan shellfish, the U.S. Department of Health and Human Services/Food and Drug Administration (FDA), Health Canada (HC), the Canadian Food Inspection Agency (CFIA), and Environment and Climate Change Canada (ECCC) collaborated to conduct a quantitative risk assessment for NoV in bivalve molluscan shellfish, notably oysters. This study describes the model and scenarios developed and results obtained to assess the risk of NoV infection and illness from consumption of raw oysters harvested from a quasi-steady-state situation. Among the many factors that influence the risk of NoV illness for raw oyster consumers, the concentrations of NoV in the influent (raw, untreated) and effluent (treated) of wastewater treatment plants (WWTP) were identified to be the most important. Thus, mitigation and control strategies that limit the influence from human waste (WWTP outfalls) in oyster growing areas have a major influence on the risk of illness from consumption of those oysters.

Outcomes from the Health Resources and Services Administration's Dental Faculty Development Program.

PURPOSE/OBJECTIVES: While the Commission on Dental Accreditation (CODA) requires programs to conduct faculty development, implementation of faculty development activities vary widely. Faculty development programs can enhance teaching, research, and leadership skills needed to transition from clinical practice to teaching. In 2012, the Health Resources and Services Administration (HRSA) funded 6 institutions to plan, develop, and operate programs for training oral healthcare providers who plan to teach in general, pediatric, public health dentistry, or dental hygiene. This performance study examines the results of the dental faculty development programs. METHODS: After the 5-year grant program (2012-2017), we used descriptive analysis to examine annual performance data including trainee demographics, faculty development activities, post-completion intentions, and course development activities. RESULTS: Nearly 300 trainees participated across 6 funded grantees; the majority were female, aged 30-49 years, and non-Hispanic White. For those who completed, 80% intended to teach. Common faculty development activities included community-based training, curriculum enhancements, Web-based training, and interprofessional education methods. Faculty development modalities included faculty seminars, Master's degrees, and mentoring. Pipeline activities, online resources, and continuing education supported dental students and providers moving into academics. CONCLUSIONS: Faculty development better prepares individuals to compete in academic environments and develop faculty. Community-based programs may utilize faculty development to recruit community preceptors and achieve calibration. HRSA investment in faculty development programs builds resources and infrastructure to promote continuing engagement in clinical education, research, and administrative skills. Future research is needed to establish the impact of faculty development initiatives on practice change and patient outcomes.

Academic Units for Primary Care Training and Enhancement: Improving Evidence and Training to Strengthen Primary Care.

The primary care workforce is an essential component of any high-functioning health care system. The Health Resources and Services Administration awarded six Academic Units for Primary Care Training and Enhancement grants in 2016. The overarching goal of the program is to improve primary care clinical teaching and research to strengthen the primary care workforce. Academic Units achieve this goal through 1) systems-level research to inform primary care training; 2) dissemination of best practices and resources; and 3) community of practice activities to promote the widespread enhancement of primary care training to produce a diverse, high-quality primary care workforce.

The Impact of Title VII Dental Workforce Programs on Dentists' Practice Location: A Difference-in-Differences Analysis.

PURPOSE: To examine the potential impact of Health Resources and Services Administration (HRSA) funding (predoctoral [PD] and postdoctoral [PDD] programs) on dentists' practice location in the United States. METHOD: The authors linked 2011-2015 data from HRSA's Electronic Handbooks to 2015 data from the American Dental Association Masterfile, dental health professional shortage areas, and rural-urban commuting area codes. They examined the associations between PD and PDD funding and dentists' practice location between 2004 and 2015 using a difference-in-differences analysis and multiple logistic regressions, adjusting for covariates. RESULTS: From 2004 to 2015, 21.2% (1,588/7,506) of dentists graduated from institutions receiving PD funding and 26.8% (2,014/7,506) graduated from institutions receiving PDD funding. Among dentists graduating from institutions receiving PDD funding, after adjusting for covariates, those graduating between 2011 and 2015 were more likely to practice in a rural area than those graduating between 2004 and 2010 (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.04-3.76). The difference-in-differences approach showed that PD and PDD funding significantly increased the odds that a dentist would practice in a rural area (respectively, OR = 2.70; 95% CI = 1.31-5.79/OR = 2.84; 95% CI = 1.40-5.77). CONCLUSIONS: HRSA oral health training program funding had a positive effect on dentists choosing to practice in a rural area. By increasing the number of dentists practicing in rural communities, HRSA is improving access to, and the delivery of, oral health care services to underserved and vulnerable rural populations.

Oral Health Literacy and Measures of Periodontal Disease.

BACKGROUND: Existing evidence demonstrating a relationship between health literacy (HL) and periodontal health is insufficient to identify how providers can help patients manage periodontal disease. This study assesses associations between HL measures (word recognition, numeracy, and conceptual knowledge) and signs of periodontal disease. METHODS: This study included 325 new patients at a dental school clinic and employed an oral HL (OHL) survey, full-mouth radiographs, and clinical examination. Evaluations included the relationship between each HL measure versus number of teeth, bleeding score, plaque score, and periodontal severity with linear and ordinal logistic regression models before and after adjusting for covariates. RESULTS: Among HL measures, the Newest Vital Sign demonstrated a significant relationship with number of teeth and the Short Test of Functional Health Literacy in Adults showed a significant association with plaque score. The short Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALMD-20) showed participants who performed in the highest quartile had nearly two additional teeth, over 5.5% fewer bleeding sites, and nearly 9% fewer teeth with plaque after adjustment for demographic variables, smoking, and diabetes mellitus (DM). Participants who scored in the highest quartile of the Comprehensive Measure of Oral Health Knowledge (CMOHK) had nearly 9% less plaque. CONCLUSIONS: Two OHL instruments (REAMLD-20 and CMOHK) provided statistical associations with clinical measures of periodontal health at a level that could be considered of moderate clinical relevancy. Findings suggest dentists may wish to assess familiarity of their patients with dental terminology and knowledge of periodontal disease to provide education on oral hygiene, smoking, and DM.

Assessing health literacy and oral health: preliminary results of a multi-site investigation.

OBJECTIVES: To introduce a multi-site assessment of oral health literacy and to describe preliminary analyses of the relationships between health literacy and selected oral health outcomes within the context of a comprehensive conceptual model. METHODS: Data for this analysis came from the Multi-Site Oral Health Literacy Research Study (MOHLRS), a federally funded investigation of health literacy and oral health. MOHLRS consisted of a broad survey, including several health literacy assessments, and measures of attitudes, knowledge, and other factors. The survey was administered to 922 initial care-seeking adult patients presenting to university-based dental clinics in California and Maryland. For this descriptive analysis, confidence filling out forms, word recognition, and reading comprehension comprised the health literacy assessments. Dental visits, oral health functioning, and dental self-efficacy were the outcomes. RESULTS: Overall, up to 21% of participants reported having difficulties with practical health literacy tasks. After controlling for sociodemographic confounders, no health literacy assessment was associated with dental visits or dental caries self-efficacy. However, confidence filling out forms and word recognition were each associated with oral health functioning and periodontal disease self-efficacy. CONCLUSIONS: Our analysis showed that dental school patients exhibit a range of health literacy abilities. It also revealed that the relationship between health literacy and oral health is not straightforward, depending on patient characteristics and the unique circumstances of the encounter. We anticipate future analyses of MOHLRS data will answer questions about the role that health literacy and various mediating factors play in explaining oral health disparities.

Detection and proportion of very early dental caries in independent living older adults.

BACKGROUND AND OBJECTIVES: Dental caries is an important healthcare challenge in adults over 65 years of age. Integration of oral health screening into non-dental primary care practice may improve access to preventive dental care for vulnerable populations such as the elderly. Such integration would require easy, fast, and accurate early caries detection tools. Primary goal of this study was to evaluate the diagnostic performance of optical coherence tomography (OCT) imaging for detecting very early caries in the elderly living in community-based settings. The International Caries Detection and Assessment System (ICDAS) served as gold standard. Secondary goal of this study was to provide baseline prevalence data of very early caries lesions in independent living adults aged 65+ years. MATERIALS AND METHODS: Seventy-two subjects were recruited from three sites in Southern California: a retirement community, a senior health fair, and a convalescent hospital. Clinical examination was performed using the ICDAS visual criteria and this was followed by OCT imaging. The two-dimensional OCT images (B-scan) were analyzed with simple software. Locations with a log of back-scattered light intensity (BSLI) below 2.9 were scored as sound, and areas equaling or exceeding 2.9 BSLI were considered carious. Diagnostic performance of OCT imaging was compared with ICDAS score. RESULTS: OCT-based diagnosis demonstrated very good sensitivity (95.1%) and good specificity (85.8%). 54.7% of dentate subjects had at least one tooth with very early coronal caries. CONCLUSIONS: Early coronal decay is prevalent in the unrestored pits and fissures of coronal surfaces of teeth in independent living adults aged 65+ years. Though OCT imaging coupled with a simple diagnostic algorithm can accurately detect areas of very early caries in community-based settings, existing devices are expensive and not well-suited for use by non-dental health care providers. Simple, inexpensive, fast, and accurate tools for early caries detection by field health care providers working in non-traditional settings are urgently needed to support inter-professional dental health management.

Meta-Analysis of the Reduction of Norovirus and Male-Specific Coliphage Concentrations in Wastewater Treatment Plants.

Human norovirus (NoV) is the leading cause of foodborne illness in the United States and Canada. Wastewater treatment plant (WWTP) effluents impacting bivalve mollusk-growing areas are potential sources of NoV contamination. We have developed a meta-analysis that evaluates WWTP influent concentrations and log10 reductions of NoV genotype I (NoV GI; in numbers of genome copies per liter [gc/liter]), NoV genotype II (NoV GII; in gc/liter), and male-specific coliphage (MSC; in number of PFU per liter), a proposed viral surrogate for NoV. The meta-analysis included relevant data (2,943 measurements) reported in the scientific literature through September 2013 and previously unpublished surveillance data from the United States and Canada. Model results indicated that the mean WWTP influent concentration of NoV GII (3.9 log10 gc/liter; 95% credible interval [CI], 3.5, 4.3 log10 gc/liter) is larger than the value for NoV GI (1.5 log10 gc/liter; 95% CI, 0.4, 2.4 log10 gc/liter), with large variations occurring from one WWTP to another. For WWTPs with mechanical systems and chlorine disinfection, mean log10 reductions were -2.4 log10 gc/liter (95% CI, -3.9, -1.1 log10 gc/liter) for NoV GI, -2.7 log10 gc/liter (95% CI, -3.6, -1.9 log10 gc/liter) for NoV GII, and -2.9 log10 PFU per liter (95% CI, -3.4, -2.4 log10 PFU per liter) for MSCs. Comparable values for WWTPs with lagoon systems and chlorine disinfection were -1.4 log10 gc/liter (95% CI, -3.3, 0.5 log10 gc/liter) for NoV GI, -1.7 log10 gc/liter (95% CI, -3.1, -0.3 log10 gc/liter) for NoV GII, and -3.6 log10 PFU per liter (95% CI, -4.8, -2.4 PFU per liter) for MSCs. Within WWTPs, correlations exist between mean NoV GI and NoV GII influent concentrations and between the mean log10 reduction in NoV GII and the mean log10 reduction in MSCs.

The association of patients' oral health literacy and dental school communication tools: a pilot study.

The aim of this pilot study was to assess adult patients' ability to read and understand two communication tools at the University of California, Los Angeles, School of Dentistry: the dental school clinic website and a patient education brochure pertaining to sedation in children that was written by dental school personnel. A convenience sample of 100 adults seeking treatment at the school's general dental clinic during 2012-13 completed a health literacy screening instrument. They were then asked to read clinic educational and informational materials and complete a survey. Analyses were conducted to determine the association between the subjects' oral health literacy and sociodemographics and their ability to locate and interpret information in written oral health information materials. SMOG and Flesch-Kincade formulas were used to assess the readability level of the electronic and written communication tools. The results demonstrated an association between these adults' oral health literacy and their dental knowledge and ability to navigate health information website resources and understand health education materials. Health literacy was not associated with age or gender, but was associated with education and race/ethnicity. The SMOG Readability Index determined that the website and the sedation form were written at a ninth grade reading level. These results suggest that dental schools and other health care organizations should incorporate a health-literate approach for their digital and written materials to enhance patients' ability to navigate and understand health information, regardless of their health literacy.

Assessment of early occlusal caries pre- and post-sealant application--an imaging approach.

BACKGROUND AND OBJECTIVE: Clinicians have difficulty assessing and monitoring early occlusal caries. Traditional clinical exam and radiographs are unable to detect the subtle alterations in enamel indicative of de- or re-mineralization, particularly under dental sealants. Although clinicians have used laser fluorescence (LF) to address this gap, this modality has demonstrated weak correlation with histology. The International Caries Detection and Assessment System (ICDAS-II) has demonstrated high sensitivity and specificity for caries detection, but since it is based on visual assessment, it is of no use in areas beneath the most commonly used dental sealants which are opaque. Optical coherence tomography (OCT) is an emergent assessment tool which has demonstrated great promise in detecting and quantifying caries, including areas beneath commonly used dental sealants and composites. However, OCT has not yet been widely integrated into clinical dental practice, perhaps because OCT imaging does not provide an easily accessible diagnostic outcome for clinicians. The objective of this ex vivo study was to use OCT-images of sound and carious occlusal surfaces in combination with a simple algorithm to compare the caries detection ability of OCT with tools clinicians may be more familiar with (LF and radiography), and with an established valid and reliable clinical assessment tool (ICDAS-II). STUDY DESIGN/MATERIALS AND METHODS: One hundred twenty extracted teeth with sound or naturally carious occlusal surfaces were imaged with OCT, LF, radiography, and examined clinically with the ICDAS-II. Teeth were randomized to one of two dental sealants recommended for use with LF. A novel simple algorithm was used to interpret OCT-based images. The accuracy of caries severity assessments of the OCT-based diagnosis, LF, ICDAS-II, and digital radiography were compared to the 4-point histological analysis gold standard. RESULTS: OCT and ICDAS-II caries severity assessments demonstrated high sensitivity (94.0%; 92.3%) and specificity (85.0%; 83.3%), LF demonstrated low sensitivity (65.2%) but high specificity (97.6%), and digital radiography demonstrated low sensitivity (67.1%) with moderate specificity (79.5%) on unsealed occlusal surfaces. OCT-based caries severity assessments of sealed teeth demonstrated high specificity (97.6%), sensitivity (89.9%), excellent positive predictive value (98.6%), and negative predictive value (83.3%). Despite our use of LF recommended dental sealants, in the presence of sealants, LF assessment of caries severity demonstrated high sensitivity (95.1%), but extremely low specificity (10.3%), positive predictive value (68.8%), and negative predictive value (50.0%). CONCLUSION: This study found that OCT-based imaging combined with a simple diagnostic algorithm accurately assessed the severity of natural early caries on occlusal surfaces in extracted teeth both in the absence and presence of dental sealant. The findings of this study support the clinical use of OCT imaging for assessment and monitoring progression of early non-cavitated caries lesions on occlusal surfaces including areas under dental sealants.

The association between oral health literacy and failed appointments in adults attending a university-based general dental clinic.

OBJECTIVES: The purpose of this study is to determine the association between personal characteristics, a person's oral health literacy, and failing to show for dental appointments at a university dental clinic. METHODS: A secondary data analysis was conducted on data collected from 200 adults at a university dental clinic between January 2005 and December 2006. In the original study, an oral health literacy instrument, the Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D), was administered, sociodemographic and health information seeking behavior was gathered, and electronic records were reviewed. RESULTS: Descriptive and bivariate analyses and a classification and regression tree (CART) analysis were conducted. Seeking health information through fewer sources vs. multiple sources was the strongest predictor of failing to show. The subjects' oral health literacy, as measured by the REALM-D List 3 score, was the next most significant variable. Classification and regression tree analyses also selected gender, chief complaint, age, and payment type as predictor variables. CONCLUSIONS: Multiple factors contribute to failing to show for dental appointments. However, individuals who use fewer sources of oral health information, a subset of health literacy skills, are more likely to fail to show for dental appointments.

A brief 20-item dental/medical health literacy screen (REALMD-20).

OBJECTIVES: Few health literacy instruments are available to clinicians to help understand the implications of patient difficulty understanding health information. Those that do exist are lengthy and would not be conducive to use in a busy clinical setting. Long-term dental and medical outcomes may improve if health care providers can identify individuals with low health literacy levels who may benefit from tailored communication, yet few instruments are available for clinical use. The purpose of this study is to introduce a brief 20-item screener for limited dental/medical health literacy among adult dental patients. METHODS: Two-hundred adult patients seeking treatment at a dental clinic in a large medical complex completed a health literacy screening instrument and survey. Steps in the development of the 20-item instrument are described. Comparison of the 20-item dental/medical instrument with other health literacy measures are calculated using mean health literacy scores, tests of reliability and readability, and correlation coefficients. RESULTS: Scores on the brief 20-item measure varied significantly by race, education level, language use, needing help with medical/health materials forms. Those with lower dental/medical health literacy, as measured by the REALMD-20 were less likely to receive regular follow-up care than those with higher literacy. CONCLUSIONS: The REALMD-20 is a quick screening instrument that can be used by clinicians to detect limited dental/medical health literacy among adult patients seeking treatment in dental/medical clinic settings.

Ability of optical coherence tomography to detect caries beneath commonly used dental sealants.

BACKGROUND AND OBJECTIVE: The onset and progression of early tooth decay is often preventable with dental sealants. However, occasionally decay progresses underneath the sealant. Current technology does not permit monitoring of potential lesion progression or arrest. Dental sealants themselves mask the visual cues that identify early tooth decay, and radiographs are not sufficiently sensitive. Therefore, clinicians can be reluctant to use dental sealant. The objective of this ex vivo study was to evaluate the ability of dentists to detect decay beneath commonly used dental sealants using optical coherence tomography (OCT) imaging. STUDY DESIGNS/MATERIALS/METHODS: Forty extracted teeth were divided into equal groups of carious and non-carious teeth, as determined by visual inspection. After radiographs and OCT imaging, teeth were randomly assigned for sealant placement with one of four commonly purchased dental sealants: Clinpro™, Fuji Triage™, Embrace Wet Bond™, and Delton™.Following sealant placement, teeth were radiographed, imaged with OCT, sectioned, examined histologically, and scored as healthy/not healthy. OCT and radiographic images were scored separately. The gold standard was histopathological diagnosis from the serial sections.Cohen's kappa, sensitivity, negative predictive value, and positive predictive value were computed for all measures. RESULTS: After 90 minutes training, pre-standardized dentists were able to detect tooth decay more accurately using OCT than with visual or radiographic examination. Detection using OCT was somewhat better prior to sealant placement than afterwards. This effect varied in size depending on the type of sealant used. Radiographic diagnosis was also less accurate after sealant placement. Of the four dental sealants, Delton provided excellent positive predictive value and the best post-sealant negative predictive values. CONCLUSION: In this ex vivo study, dentists were able to detect tooth decay beneath four commonly used dental sealants based on OCT images. Clinical investigations are now underway to determine the usefulness of this approach in vivo.

Impact of community-based oral health experiences on dental students' attitudes towards caring for the underserved.

Dental students' attitudes towards access to dental care for the underserved may be impacted by participation in community oral health promotion programs that target individuals in underserved communities. At the University of Southern California School of Dentistry, freshman dental students provide classroom oral health promotion and preventive dental care programs to underserved elementary school children. One hundred forty-four freshman dental students were surveyed three times during their freshman year-before, during, and after participation in these programs. The students' attitudes about societal expectations, health professionals' responsibility, access to care, and students' personal efficacy to positively impact the need for expanded oral health care services for segments of the population were measured. Students reported positive attitudes in all categories throughout the study period. The students' attitudes about societal expectations to care for the oral health of the underserved remained stable over the study period, but they became more uncertain of who should be responsible for fulfilling that obligation, who should receive that care, and their capability to provide this care while in dental school. These changes in attitude may reflect the students' greater understanding of the complexity of the determinants of oral health as a consequence of their community education experiences.

Miniature protein ligands for EVH1 domains: interplay between affinity, specificity, and cell motility.

Dynamic rearrangements of the actin cytoskeleton power cell motility in contexts ranging from intracellular microbial pathogenesis to axon guidance. The Ena/VASP family proteins-Mena, VASP, and Evl-are believed to control cell motility by serving as a direct link between signaling events and the actin cytoskeleton. It has previously been reported that a novel miniature protein, pGolemi, binds with high affinity to the EVH1 domain of Mena (Mena1-112) but not to those of VASP (VASP1-115) or Evl (Evl1-115) and also causes an unusual defect in actin-driven Listeria monocytogenes motility. Here, scanning mutagenesis was used to examine the effects of single amino acid changes within pGolemi on EVH1 domain affinity and specificity, miniature protein secondary structure, and L. monocytogenes motility. The data suggest that pGolemi contains the expected aPP-like fold and binds Mena1-112 in a manner highly analogous to the proline-rich repeat region of L. monocytogenes ActA protein. Residues throughout pGolemi contribute to both EVH1 domain affinity and paralog specificity. Moreover, the affinities of pGolemi variants for Mena1-112 correlate with selectivity against the EVH1 domains of VASP and Evl. In L. monocytogenes motility assays, speed and speed variability correlate strongly with EVH1 paralog specificity, suggesting that the Ena/VASP paralogs do not play equivalent roles in the process of L. monocytogenes actin tail maturation.

High affinity, paralog-specific recognition of the Mena EVH1 domain by a miniature protein.

Many protein domains involved in cell signaling contain or interact with proline-rich sequences, and the design of molecules that perturb signaling pathways represents a foremost goal of chemical biology. Previously we described a protein design strategy in which the well-folded alpha-helix in avian pancreatic polypeptide (aPP) presents short alpha-helical recognition epitopes. The miniature proteins designed in this way recognize even shallow protein clefts with high affinity and specificity. Here we show that the well-folded type-II polyproline helix in aPP can present the short PPII-helical recognition epitope within the ActA protein of Listeria monocytogenes. Like miniature proteins that use an alpha-helix for protein recognition, the miniature protein designed in this way displays high affinity for a natural ActA target, the EVH1 domain Mena1-112, and achieves the elusive goal of paralog specificity, discriminating well between EVH1 domains Mena1-112, VASP1-115, and Evl1-112. Most importantly, the miniature protein competed with ActA in Xenopus laevis egg cytoplasmic extracts, decreasing actin-dependent motility of L. monocytogenes and causing extreme speed variations and discontinuous tail formation. Our results suggest that miniature proteins based on aPP may represent an excellent framework for the design of ligands that differentiate the roles of EVH1 domains in vitro and in vivo.