Cannabis Pharmacogenomics: A Path to Personalized Medicine.

Cannabis and related compounds have created significant research interest as a promising therapy in many disorders. However, the individual therapeutic effects of cannabinoids and the incidence of side effects are still difficult to determine. Pharmacogenomics may provide the answers to many questions and concerns regarding the cannabis/cannabinoid treatment and help us to understand the variability in individual responses and associated risks. Pharmacogenomics research has made meaningful progress in identifying genetic variations that play a critical role in interpatient variability in response to cannabis. This review classifies the current knowledge of pharmacogenomics associated with medical marijuana and related compounds and can assist in improving the outcomes of cannabinoid therapy and to minimize the adverse effects of cannabis use. Specific examples of pharmacogenomics informing pharmacotherapy as a path to personalized medicine are discussed.

Therapeutic Approaches for Chronic Obstructive Pulmonary Disease (COPD) Exacerbations.

Chronic Obstructive Pulmonary Disease (COPD) is a progressive pulmonary disorder underpinned by poorly reversible airflow resulting from chronic bronchitis or emphysema. The prevalence and mortality of COPD continue to increase. Pharmacotherapy for patients with COPD has included antibiotics, bronchodilators, and anti-inflammatory corticosteroids (but with little success). Oral diseases have long been established as clinical risk factors for developing respiratory diseases. The establishment of a very similar microbiome in the mouth and the lung confirms the oral-lung connection. The aspiration of pathogenic microbes from the oral cavity has been implicated in several respiratory diseases, including pneumonia and chronic obstructive pulmonary disease (COPD). This review focuses on current and future pharmacotherapeutic approaches for COPD exacerbation including antimicrobials, mucoregulators, the use of bronchodilators and anti-inflammatory drugs, modifying epigenetic marks, and modulating dysbiosis of the microbiome.

COVID-19 Pharmacotherapy: Drug Development, Repurposing of Drugs, and the Role of Pharmacogenomics.

The SARS-CoV-2 virus has been the subject of intense pharmacological research. Various pharmacotherapeutic approaches including antiviral and immunotherapy are being explored. A pandemic, however, cannot depend on the development of new drugs; the time required for conventional drug discovery and development is far too lengthy. As such, repurposing drugs is being used as a viable approach for identifying pharmacological agents for COVID-19 infections. Evaluation of repurposed drug candidates with pharmacogenomic analysis is being used to identify near-term pharmacological remedies for COVID-19.

Pharmacogenomics Informs Cardiovascular Pharmacotherapy.

Precision medicine exemplifies the emergence of personalized treatment options which may benefit specific patient populations based upon their genetic makeup. Application of pharmacogenomics requires an understanding of how genetic variations impact pharmacokinetic and pharmacodynamic properties. This particular approach in pharmacotherapy is helpful because it can assist in and improve clinical decisions. Application of pharmacogenomics to cardiovascular pharmacotherapy provides for the ability of the medical provider to gain critical knowledge on a patient's response to various treatment options and risk of side effects.

Pharmacogenomic Testing and Patient Perception Inform Pain Pharmacotherapy.

(1) Background: Chronic pain is one of the most common reasons for individuals to seek medications. Historically, opioids have been the mainstay of chronic pain management. However, in some patient populations, opioids fail to demonstrate therapeutic efficacy, whereas in other populations, opioids may cause toxic effects, even at lower doses. Response to pain medication is affected by many factors, including an individual's genetic variations. Pharmacogenomic testing has been designed to help achieve optimal treatment outcomes. This study aimed at assessing the impact of CYP2D6 pharmacogenomic testing on physicians' choice in prescribing chronic pain medications and patient pain control. (2) Methods: This retrospective study reviewed 107 patient charts from a single site pain management center. All 107 patients received pharmacogenomic testing. The outcomes of interest were confirmation that the optimal pain medication is being administered or a change in the chronic pain medication is warranted as a result of the pharmacogenomic testing. The main independent variable was the pharmacogenomic test result. Other independent variables included patient gender, race, and comorbidities. The retrospective study was reviewed and approved by the Touro College and University System IRB, HSIRB1653E. (3) Results: Patients self-reported pain intensity on a scale of 1-10 before and after pharmacogenomic testing. Then, 100% of patients in the retrospective study were tested for their pain pharmacogenomic profile. Of the 107 patients participating in the study, more than 50% had their medications altered as a result of the pharmacogenomic testing. The percentage of patients with intense pain were decreased post-pharmacogenomic testing (5.6%) as compared to pre-pharmacogenomic testing (10.5%). Patients with intense, moderate, and mild pain categories were more likely to receive changes in pain medications. In contrast, patients with severe pain were less likely to receive a change in pain medication. Hispanic ethnicity was associated with a statistically significantly decrease in a pain scale category. Illegal drug abuse was associated with a decrease in pain scale category. Change in medication dose was associated with a decrease in pain scale category. (4) Conclusion: In this retrospective study, implementation of pharmacogenomic testing demonstrated significant benefits to patients with intense pain undergoing treatment.

Anti-Inflammatory Effects of Vitamin E in Response to Candida albicans.

Oral mucositis, inflammation, and ulceration that occur in the oral cavity can manifest in significant pain. A formulation was designed to investigate the potential of vitamin E to ameliorate inflammation resulting from Candida albicans in cell-based systems. Human gingival fibroblasts and THP1 cells were stimulated with heat killed C. albicans and Porphyromonas gingivalis LPS (agonists). Unstimulated cells were included as controls. Cells were also simultaneously treated with a novel denture adhesive formulation that contains vitamin E (antagonist). The experimental conditions included cells exposed to the experimental formulation or the vehicle for 2 h for mRNA extraction and analysis, and cells left for 24 h under those experimental conditions for analysis of protein expression by ELISA. ssAffymetrix expression microarray pathway analyses demonstrated that the tested formulation exhibited a statistically significant (p < 0.05) inhibition of the following key inflammatory pathways: TLR 6, IL-1 signaling (IRAK, A20), NF-kappaB, IL-6 signaling (gp130, JK2 and GRB2), TNF signaling (TNF receptor) and Arachidonic acid metabolism (PLA2). Quantitative PCR array analysis confirmed the downregulation of key inflammatory genes when cells under adhesive treatment were challenged with heat killed C. albicans. PGE2 secretion was inhibited by the tested formulation only on THP1 cells after 24 h stimulation with C. albicans. These results suggest that the active formulation containing vitamin E acetate can modulate inflammatory responses, through anti-inflammatory actions as indicated by in vitro experimental conditions.

Studying the factors that impact the dissolution characteristic of complex drug product.

This article summarizes the critical factors involved in product development of a single dosage form formulated by compacting ethyl cellulose (EC) coated controlled release pellets into a tablet. The greatest challenge associated with this type of complex system is to minimize the effect of compression on the drug release. The effects of compression on the drug release were optimized with combination of the following factors (1) particle size of the core pellets, (2) the selection of the coating polymer's viscosity grade, and (3) emergence of cushioning agents. The optimization of these factors provided superior protection for the controlled release coated pellets; therefore, the desired drug release from the tablet was successfully achieved as designed. However, the drug release rates from the coated pellets before and after the compression were minimized and exhibited only a slight difference.

Differential Mucosal Gene Expression Patterns in Candida-Associated, Chronic Oral Denture Stomatitis.

PURPOSE: Denture stomatitis is a common condition manifested by inflammation of the oral mucous membrane beneath a denture. The objective of this study was to compare the transcriptome of human palatal mucosa with chronic oral stomatitis-associated Candida albicans infection to that of healthy oral mucosa. MATERIALS AND METHODS: Oral palatal biopsies were obtained from 17 healthy and 15 C. albicans-infected stomatitis subjects for whole transcriptome analyses. The presence of C. albicans was confirmed by cytology and cultivable methods. The clinical severity of the stomatitis was evaluated by the Newton Classification (Class II or III). For transcriptome analyses a false discovery rate (FDR) of <0.05 was used, and the effects of age, race, and gender were evaluated by principle component analysis (PCA). Specific differentially expressed genes identified by mRNA array data were confirmed by measurements of salivary protein expression using multiplex analyses. RESULTS: Microarray analysis of mRNA expression indicated that in C. albicans stomatitis there were 3034 genes-in-play that were differentially expressed and met the FDR < 0.05 criteria. Two hundred thirty five (235) genes were up-regulated >2-fold, and 71 genes were down-regulated >2-fold. Five of the 6 most significant gene ontology pathways involve inflammation and activation of the immune response with CD28 and CTLA signaling of T cells. There was strong up-regulation of TLR2, CD14, MYD88, IKKA, and NFKB as the dominant toll-like receptor-signaling pathway. The expression of several extracellularly expressed inflammatory protein genes was up-regulated in candidiasis, and 2 were confirmed as up-regulated within the saliva using protein multiplexing analyses. CONCLUSIONS: Neutrophil recruitment and activation, epithelial suppression, and T-cell activation appear as major pathways in chronic oral candidiasis. Tissue up-regulation of TLR2 pathways, as well as potential C. albicans binding proteins, was observed, whereas keratin and adhesion molecule synthesis were down-regulated. Several candidate biomarkers to potentially identify the presence of oral candidiasis were differentially expressed in tissues and saliva.

A cohort study of the impact of tooth loss and periodontal disease on respiratory events among COPD subjects: modulatory role of systemic biomarkers of inflammation.

BACKGROUND: In COPD patients, fatal and non-fatal respiratory-related events are influenced by age, severity of respiratory disease, and comorbidities. OBJECTIVES: Analyze the effects of edentulism, periodontal disease and systemic biomarkers of inflammation on the occurrence of serious fatal and non-fatal respiratory-related events among subjects with COPD. METHODS: Cases were identified from Dental Atherosclerosis Risk in Communities study. Edentulism was defined as study participants without any natural teeth or implants. Participants with one or more natural teeth (comprising 11,378 subjects) were studied as dentate subjects. Periodontal disease status among dentate individuals was determined using the consensus definitions published by the joint Center for Disease Control/American Association of Periodontology working group). Adjusted Hazard Models are developed to evaluate the relationship between edentulism/periodontal disease and COPD Related Events. Models were then stratified by GOLD Stage I, II and III/IV. Serum biomarkers were also evaluated to explore the effect of systemic inflammation. RESULTS: A statistically significant association was found between oral health status and COPD-related events, even adjusting for conditions such as hypertension, smoking and diabetes. Edentulous individuals who had been diagnosed with COPD had a higher incidence and were at greater risk of having a COPD related event (hospitalization and death) than individuals who had teeth and whose mouths had healthy periodontal status. However, being edentulous did not convey excess risk for COPD-related events for those study participants who were classified as GOLD III/IV at baseline. Finally, we showed that individuals who had levels of serum IL-6 in the highest two quartiles were at even higher risk for COPD-related events. CONCLUSIONS: These findings suggest that the risk for COPD-related events after adjusting for potential confounders may be attributable to both edentulism and elevated serum IL-6 levels.

Development of a new model system to study microbial colonization on dentures.

PURPOSE: Dentures are often colonized with a variety of microorganisms, including Candida albicans, that contribute to denture stomatitis. Several in vitro models have been previously established to study denture-related microbial colonization and evaluate treatment efficacy of denture cleansers; however, those models typically fail to appreciate the complex topology and heterogeneity of denture surfaces and lack effective ways to accurately measure microbial colonization. The purpose of this study was to study microbial colonization with a new model system based on real dentures, to more realistically mimic in vivo conditions. MATERIALS AND METHODS: Scanning electron microscopy was used to observe topological structures among surfaces from different parts of the denture. Employing C. albicans as a model microorganism, we established microbial colonization on different denture surfaces. Moreover, we applied a modified MTT (3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyl tetrazolium bromide) colorimetric assay to quantify C. albicans colonization on dentures without the necessity of biofilm removal and to evaluate treatment efficacy of denture cleansers. RESULTS: There were significant variations in topological structures among surfaces from different parts of the denture, with the unpolished side having the highest amounts of indentations and pores. The distinct denture surfaces support microbial colonization differently, with the unpolished side containing the highest level of microbial colonization and biofilm formation. Furthermore, the modified MTT colorimetric assay proved to be an accurate assay to measure biofilm formation on dentures and evaluate treatment efficacy of denture cleansers. CONCLUSION: This new denture model system in conjunction with the MTT colorimetric assay is a valuable tool to study denture-related microbiology and treatment approaches.

Clinical and histological findings of denture stomatitis as related to intraoral colonization patterns of Candida albicans, salivary flow, and dry mouth.

PURPOSE: Multifactorial etiological factors contribute to denture stomatitis (DS), a type of oral candidiasis; however, unlike other oral candidiasis, DS can occur in a healthy person wearing a denture. In this study, we therefore attempt to explore the association between candida, denture, and mucosal tissue using (1) exfoliative cytology, (2) the candidal levels present in saliva, on mucosal tissues and on denture surfaces, and (3) the salivary flow rate and xerostomic symptoms. MATERIALS AND METHODS: A cross-sectional study enrolled 32 edentulous participants, 17 without DS as controls and 15 with DS (Newton's classification type II and III). Participants with systemic or other known oral conditions were excluded. Participants completed a xerostomia questionnaire, and salivary flow rates were measured. Samples of unstimulated whole saliva (UWS) and stimulated whole saliva (SWS) were collected. UWS was used for fungal culturing. Periodic acid-Schiff (PAS) stain and quantitative exfoliative cytology were performed on samples from affected and unaffected mucosa from each participant. Levels of Candida species (albicans and non-albicans) were determined in salivary samples (expressed as colony-forming units, CFU), as well as from swab samples obtained from denture fitting surfaces, in addition to affected and unaffected mucosa. RESULTS: There were no significant differences in salivary flow rates, mucosal wetness, or frequency of reported dry mouth comparing participants with and without DS. Exfoliative cytology of mucosal smears demonstrated significantly higher (p= 0.02) inflammatory cell counts in DS patients, as compared with smears of healthy denture-wearers. Candida albicans was significantly more prevalent in saliva (p= 0.03) and on denture surfaces (p= 0.002) of DS participants, whereas mucosal candidal counts and the presence of cytological hyphae did not show significant difference comparing DS to healthy participants. CONCLUSIONS: In this investigation, we presented a unique group of healthy edentulous patients. This population may reflect the general DS population without systemic or other oral diseases. The prominent etiological factor for DS in this population is the presence of candida in denture and saliva. We found that other factors such as saliva flow/xerostomia, fitting of the denture, and the presence of candida in the mucosa, are less important in this population. Therefore, DS treatments in healthy patients should first focus on sanitization of an existing denture and/or fabrication of a new denture.

Obstructive airway disease and edentulism in the atherosclerosis risk in communities (ARIC) study.

OBJECTIVES: We examined the potential association between prior chronic obstructive pulmonary disease (COPD) and edentulism, and whether the association varied by COPD severity using data from the Dental Atherosclerosis Risk in Communities Study. DESIGN: Cross-sectional. SETTING: Community dwelling subjects from four US communities. PARTICIPANTS AND MEASUREMENTS: Cases were identified as edentulous (without teeth) and subjects with one or more natural teeth were identified as dentate. COPD cases were defined by spirometry measurements that showed the ratio of forced expiratory volume (1 s) to vital capacity to be less than 0.7. The severity of COPD cases was also determined using a modified Global Initiative for Chronic Obstructive Lung Disease classification criteria (GOLD stage I-IV). Multiple logistic regression was used to examine the association between COPD and edentulism, while adjusting for age, gender, centre/race, ethnicity, education level, income, diabetes, hypertension, coronary heart disease and congestive heart failure, body mass index, smoking, smokeless tobacco use and alcohol consumption. RESULTS: 13 465 participants were included in this analysis (2087 edentulous; 11 378 dentate). Approximately 28.3% of edentulous participants had prior COPD compared with 19.6% among dentate participants (p<0.0001). After adjustment for potential confounders, we observed a 1.3 (1.08 to 1.62) and 2.5 (1.68 to 3.63) fold increased risk of edentulism among GOLD II and GOLD III/IV COPD, respectively, as compared with the non-COPD/dentate referent. Given the short period of time between the measurements of COPD (visit 2) and dentate status (visit 4) relative to the natural history of both diseases, neither temporality nor insight as to the directionality of the association can be ascertained. CONCLUSIONS: We found a statistically significant association between prior COPD and edentulism, with evidence of a positive incremental effect seen with increasing GOLD classification.

A comparative in vitro study of two denture cleaning techniques as an effective strategy for inhibiting Candida albicans biofilms on denture surfaces and reducing inflammation.

PURPOSE: Candida albicans is the predominant oral yeast associated with denture-induced stomatitis, and with an increasing population of denture wearers its incidence is increasing. Maintaining good oral and denture hygiene, through chemical and/or mechanical intervention, is essential to reducing this disease. The aim of this study, using a robust adherent C. albicans cell model system, was to evaluate and compare the efficacy of a novel denture cleanser to the efficacy of a commonly used dentifrice coupled with brushing. MATERIALS AND METHODS: Four C. albicans strains isolated from individuals diagnosed as having denture-induced stomatitis, were adhered to denture acrylic resin sections (1 cm(2) by 1 mm thickness) and after 4 hours of growth, challenged daily sequentially for 4 days with a denture cleanser (Polident) or intermittently with denture cleanser (day 1), then dentifrice (Colgate Cavity Protection Toothpaste) and brushing (days 2 and 3) and denture cleanser (day 4). Colony forming units were evaluated for each treatment, as were the levels of regrowth. Scanning electron microscopy (SEM) was also performed. Microbial susceptibility testing and time-kill studies were performed on biofilms. A coculture model was also used to assess interleukin-8 (IL-8) production from treated biofilms. RESULTS: It was shown that sequential treatment with the denture cleanser killed and inhibited regrowth each day. Intermittent treatment showed that viable C. albicans biofilms were only retained rather than being dispersed, which could be visualized by SEM. Time-kill studies demonstrated that the novel denture cleanser was highly active and killed quickly, unlike the dentifrice. IL-8 was expressed in greater levels in 24-hour biofilms than in 4-hour biofilms, but treatment with denture cleanser reduced IL-8 output. CONCLUSIONS: The data indicate that maintaining good oral health for denture wearers requires daily use of a denture cleanser rather than an alternating regimen. The inability of the denture cleanser to sterilize during intermittent treatments demonstrates the difficulty in controlling established biofilm. Moreover, the presence of mature biofilm may result in high levels of inflammation, but this can be controlled through denture cleansing.

Evaluation of cleansing methods for previously worn prostheses.

STATEMENT OF PROBLEM: Although there are many product claims that address the issue of denture sanitization, controlled scientific studies on previously worn dentures have not been performed. PURPOSE: The purpose of this study was to evaluate procedures directed at sanitizing previously worn contaminated dentures from two regions of the United States. MATERIALS AND METHODS: This study examined 51 previously worn dentures from two regions. An established method of denture retrieval, sectioning, and culturing was used, including isolation of anaerobes. Evaluation of microbial contamination posttreatment was used to determine the effects of soaking dentures in Polident (US and European formulations) for varying periods of times/temperatures, microwaving dentures with varying temperatures, sonicating dentures, and immersing the dentures while using a vacuum. A combination of analysis of variance (ANOVA) and general linear model (GLM) of the SPSS was used to analyze the data with P < .05 being considered statistically significant when using a two-tailed test. RESULTS: While all Polident treatments were found to significantly reduce microorganism loads in dentures, extended soaking (8 hours) and 65 degrees C (5 minutes) were the most effective. Microwaving was slightly more effective than either sonication or vacuum. Regardless the treatment, dentures underwent sanitization rather than sterilization. CONCLUSIONS: Denture-borne microorganisms can be significantly reduced by using a Polident solution for 8 hours at room temperature or for 5 minutes at 65 degrees C. Microwaving, sonication, and use of a vacuum were less effective. ClLINICAL IMPLICATIONS The importance of daily use of Polident solution for 8 hours or for 5 minutes at 65 degrees C to sanitize worn prostheses must be stressed.

Epidemiology and etiology of denture stomatitis.

Denture stomatitis, a common disorder affecting denture wearers, is characterized as inflammation and erythema of the oral mucosal areas covered by the denture. Despite its commonality, the etiology of denture stomatitis is not completely understood. A search of the literature was conducted in the PubMed electronic database (through November 2009) to identify relevant articles for inclusion in a review updating information on the epidemiology and etiology of denture stomatitis and the potential role of denture materials in this disorder. Epidemiological studies report prevalence of denture stomatitis among denture wearers to range from 15% to over 70%. Studies have been conducted among various population samples, and this appears to influence prevalence rates. In general, where reported, incidence of denture stomatitis is higher among elderly denture users and among women. Etiological factors include poor denture hygiene, continual and nighttime wearing of removable dentures, accumulation of denture plaque, and bacterial and yeast contamination of denture surface. In addition, poor-fitting dentures can increase mucosal trauma. All of these factors appear to increase the ability of Candida albicans to colonize both the denture and oral mucosal surfaces, where it acts as an opportunistic pathogen. Antifungal treatment can eradicate C. albicans contamination and relieve stomatitis symptoms, but unless dentures are decontaminated and their cleanliness maintained, stomatitis will recur when antifungal therapy is discontinued. New developments related to denture materials are focusing on means to reduce development of adherent biofilms. These may have value in reducing bacterial and yeast colonization, and could lead to reductions in denture stomatitis with appropriate denture hygiene.

Evaluation of microbial flora found in previously worn prostheses from the Northeast and Southwest regions of the United States.

STATEMENT OF PROBLEM: Denture-induced stomatitis is a recognized clinical challenge. The responsible microorganisms have not been delineated and may differ among regions of the United States. PURPOSE: The purpose of this study was to identify the microorganisms found in dentures from 2 geographic regions. MATERIAL AND METHODS: Previously worn dentures from 51 available subjects living in the Southwest (41) and Northeast (10) were aseptically retrieved in sterile plastic bags. A posterior piece of the mandibular denture was removed and sampled on appropriate media under anaerobic conditions. The remaining denture material was divided into 7 equal pieces. Each piece was touched to appropriate aerobic media and incubated at 37 degrees C. Bacteria and yeasts were identified using standard clinical laboratory procedures. Data were analyzed by using descriptive statistics. Denture fragments were further analyzed by scanning electron microscopy (SEM). RESULTS: A total of 916 isolates were carried to final speciation. Of these, 711 were aerobic bacteria, 67 were anaerobic bacteria, 125 were yeasts, and 13 were amoebae. Microorganisms were found on the denture surfaces and interstices (denture pores). Most subjects wore their dentures for extended periods without sanitization. SEM analyses confirmed substantial porosity of the denture material with microbial penetration and biofilm formation within the pores. CONCLUSIONS: A wide range of potentially pathogenic microorganisms was found in dentures. There were also regional differences in the microbial flora.