Expanding the physician's role in addressing the oral health of adults.

Many disadvantaged adults visit physicians or hospital emergency departments to receive relief from dental pain. Physicians also see patients with general questions or concerns about their oral health. Unfortunately, because physicians generally have received little oral health training, patients often do not receive comprehensive emergency services or appropriate counseling. This situation has begun to change, as there has been a growing sentiment among the dental and medical communities that better integration and coordination between medicine and dentistry would be beneficial. Reports from the Institute of Medicine and professional associations and foundations reflect the need for better integration. I have outlined the rationale for and progress toward expanding the physician's role in addressing the oral health of adults.

Enhancing pharmacists' role as oral health advisors.

OBJECTIVE: To examine the expanded role of pharmacists as oral health advisors. SETTING: U.S. community pharmacies. PRACTICE DESCRIPTION: Counseling patients on issues related to oral health. PRACTICE INNOVATION: The traditional role of pharmacists (i.e., dispensing medications) has evolved to include a broader range of functions associated with primary health care. Pharmacists are important members of the health care team and have an important role in addressing oral health-related problems. The pharmacist role in addressing oral health issues in the United States should be expanded. CONCLUSION: Studies are needed to examine the extent of pharmacist training in oral health, the degree to which pharmacists who receive oral health training incorporate it into their practices, and pharmacist interest in relevant continuing education. Data gathered from such studies will be invaluable in developing appropriate training standards, model curricula, and clinical best practices.

Comparison of patient visits to emergency departments, physician offices, and dental offices for dental problems and injuries.

OBJECTIVES: Our understanding of the use of emergency departments (EDs) and physician offices for the management of dental problems is limited. We undertook this study to examine whether there are differences in their use by low-income White and minority adults as compared with higher-income adults. METHODS: Participantsincluded White, Black, and Hispanic adults who had experi enced a dental problem during the previous 12 months and who visited a physician, ED, or dentist for treatment. We selected a stratified random sample of 27,002 Maryland households with listed telephones to screen for eligibility. We identified 1,387 households with an eligible adult, selected 423 for interviews, and completed interviews with 401 (94.8%). RESULTS: To restore correct proportionality to the sample, and to adjust for nonresponse and the distribution of demographic characteristics, weights were created for use in the analyses. Only 7.1 percent of respondents contacted an ED, while 14.3 percent contacted a physician and 90.2 percent a dentist. The vast majority of respondents who contacted an ED (96.0%) or a physician (92.2%) also contacted a dentist. Lower-income respondents were more likely to seek care from an ED, while higher-income respondents were more likely to seek care from a dentist. Over whelmingly, respondents visiting EDs (89.4%) and physicians (51.7%) were instructed to see a dentist or given prescriptions/samples. Treatment provided by EDs, physicians, and dentists was not associated with the respondent's income or race/ethnicity. CONCLUSIONS: Respondents visiting EDs and physicians typically did not receive definitive care and subsequently visited a dentist for treatment.

Comparison of patient centeredness of visits to emergency departments, physicians, and dentists for dental problems and injuries.

BACKGROUND: Patient-centered care has a positive impact on patient health status. This report compares patient assessments of patient centeredness during treatment in hospital emergency departments (EDs) and physician and dentist offices for dental problems and injuries. RESEARCH DESIGN: Participants included low-income White, Black, and Hispanic adults who had experienced a dental problem or injury during the previous 12 months and who visited an emergency department, physician, or dentist for treatment. A stratified random sample of Maryland households participated in a cross-sectional telephone survey. Interviews were completed with 94.8% (401/423) of eligible individuals. Multivariable logistic regression analyses were performed. RESULTS: The measure of predictive power, the pseudo-R2s, calculated for the logistic regression models ranged from 12% to 18% for the analyses of responses to the measures of patient centeredness (satisfaction with treatment, careful listening, thorough explaining, spending enough time, and treated with courtesy and respect). EDs were less likely than dentists to treat patients with great courtesy and respect. CONCLUSIONS: Further research is needed to identify factors that support patient-centered care.

Targeted therapy of renal cell carcinoma: synergistic activity of cG250-TNF and IFNg.

Immunotherapeutic targeting of G250/Carbonic anhydrase IX (CA-IX) represents a promising strategy for treatment of renal cell carcinoma (RCC). The well characterized human-mouse chimeric G250 (cG250) antibody has been shown in human studies to specifically enrich in CA-IX positive tumors and was chosen as a carrier for site specific delivery of TNF in form of our IgG-TNF-fusion protein (cG250-TNF) to RCC xenografts. Genetically engineered TNF constructs were designed as CH2/CH3 truncated cG250-TNF fusion proteins and eucariotic expression was optimized under serum-free conditions. In-vitro characterization of cG250-TNF comprised biochemical analysis and bioactivity assays, alone and in combination with Interferon-gamma (IFNgamma). Biodistribution data on radiolabeled [(125)J] cG250-TNF and antitumor activity of cG250-TNF, alone and in combination with IFNgamma, were measured on RCC xenografts in BALB/c nu/nu mice. Combined administration of cG250-TNF and IFNgamma caused synergistic biological effects that represent key mechanisms displaying antitumor responses. Biodistribution studies demonstrated specific accumulation and retention of cG250-TNF at CA-IX-positive RCC resulting in growth inhibition of RCC and improved progression free survival and overall survival. Antitumor activity induced by targeted TNF-based constructs could be enhanced by coadministration of low doses of nontargeted IFNgamma without significant increase in side effects. Administration of cG250-TNF and IFNgamma resulted in significant synergistic tumoricidal activity. Considering the poor outcome of renal cancer patients with advanced disease, cG250-TNF-based immunotherapeutic approaches warrant clinical evaluation.

Role of pharmacists in consulting with the underserved regarding toothache pain.

OBJECTIVE: To examine the pharmacist's role in managing toothache pain from the patient's perspective. DESIGN: Cross-sectional study. SETTING: Maryland during April and May 2006. PARTICIPANTS: 5,556 low-income white, black, and Hispanic households were screened to identify 398 households with at least one adult who had experienced a toothache during the previous 12 months. INTERVENTION: Telephone screening followed by telephone interview concerning treatment sought for most recent toothache. MAIN OUTCOME MEASURE: Whether a pharmacist was consulted for toothache pain. RESULTS: Interviews were completed for 68.3% of eligible households. One of five respondents consulted a pharmacist regarding toothache pain. No differences were noted among demographic groups other than differences related to age. No association was observed between respondents asking for advice from pharmacists and the number of toothaches they experienced during the previous 10 years or the pain level of their most recent toothache; however, an association was seen between the duration of the most recent toothache and the degree to which the toothache interfered with daily activities. Approximately 90% of respondents adhered to pharmacist advice, while 55.7% reported that the advice helped "a lot." CONCLUSION: Pharmacists have an important role to play in alleviating toothache pain, especially among lower-income individuals without ready access to traditional dental services.

Toothache pain: behavioral impact and self-care strategies.

A computer-assisted telephone interview in Maryland of adults who had low income and were Hispanic, Black, and White and who had experienced a toothache during the previous 12 months was conducted. Respondents reported a high prevalence of toothaches, with 44.3% having experienced more than five toothaches during the preceding 10 years. Pain intensity associated with the most recent toothache was high with 45.1% of the respondents reporting the highest pain possible. Pain interfered with many aspects of normal functioning. Self-care strategies generally took precedence over professional health services. Pain sufferers used a combination of self-care and formal care strategies. Initial strategies most often focused on nonprescription medicines(home remedies and prayer. The majority of respondents ultimately sought pain relief from a dentist. We identified a number of significant differences in the strategies used across racial/ethnic groups.

Low-income and minority patient satisfaction with visits to emergency departments and physician offices for dental problems.

OBJECTIVES: Individuals lacking access to dentists may use hospital emergency departments (EDs) or physicians (MDs) for the management of their dental problems. This study examined visits by minority and low-income individuals to physicians and hospital emergency departments for the treatment of dental problems with the goal of exploring the nature of treatment provided and patient satisfaction with the care received. METHODS: Eight focus group sessions were conducted with 53 participants drawn from low-income White, Black, and Hispanic adults who had experienced a dental problem and who had sought MD/ED care at least once during the previous 12 months. RESULTS: Toothache pain or more generalized jaw/face pain was the most frequent oral problem resulting in MD/ED visits. Pain severity was the principle reason for seeking care from MDs/EDs, with financial barriers most often mentioned as the reason for not seeking care from dentists. Expectations of MD/ED visits were generally consistent with care received; most participants limited their expectations to the provision of antibiotics or pain medication. Nearly all of the participants thought they would eventually need to see a dentist for resolution of their dental problem. CONCLUSIONS: Poor/minority individuals seek relief from oral pain through MDs/ EDs while recognizing that such care is not definitive.

Toothache pain: a comparison of visits to physicians, emergency departments and dentists.

BACKGROUND: Researchers' understanding of the use of emergency departments (EDs) and physicians' offices for the treatment of toothaches is limited. The authors conducted a study to explore their use by low-income and minority adults in comparison with the use of traditional dental services. METHODS: Participants included low-income white, African-American and Hispanic adults who had experienced a toothache during the previous 12 months. A stratified random sample of 4,200 households in Maryland participated in a cross-sectional telephone survey. Trained survey staff completed interviews with someone in 272 (68.3 percent) of 398 eligible households. RESULTS: Only 8.7 percent of respondents contacted an ED for toothache pain relief, while 20.1 percent contacted physicians. The majority of respondents who contacted an ED (80.5 percent) or a physician (82.6 percent) also contacted a dentist. Contacts with a dentist were reported by 58.6 percent of respondents. The authors conducted tabular analyses using chi(2) tests of statistical significance (P < .05) and SUDAAN's multivariable logistic regression procedure (Research Triangle Institute, Research Triangle Park, N.C.) (P < .05). CONCLUSIONS: Respondents experiencing toothache pain ultimately sought definitive resolution of their pain from dentists while visiting EDs and physicians for temporary relief. Access to dentists' services was particularly problematic for Hispanics and was exacerbated by health literacy issues. CLINICAL IMPLICATIONS: The elimination of oral health disparities must involve consideration of cultural influences on minority populations, as well as the responsibilities of the dental profession.

Soy isoflavone intake and estrogen excretion patterns in young women: effect of probiotic administration.

BACKGROUND: Soy isoflavones may lower breast cancer risk through altered hepatic estrogen metabolism, leading to increased urinary excretion ratios of 2-hydroxyestrone (20HE1) to 16a-hydroxyestrone (16alphaOHE1). MATERIALS AND METHODS: Urinary excretion of 20HE1/16alphaOHE1 was measured in 36 healthy, pre-menstrual women before and after ingestion of a soy-protein formula containing 120 mg of isoflavone daily for one month. Since isoflavone absorption and metabolism depends on intestinal bacteria, effects of co-administration of Lactobacillus GG (2 x 10(12)) on estrogen ratios and isoflavone excretion were studied. Urinary isoflavone excretion measurements assessed compliance. RESULTS: Soy isoflavone ingestion induced quantitative differences in urinary excretion of estrogen metabolites and isoflavones but failed to alter 20HE1/16alphaOHE1 ratios. Co-administration of Lactobacillus GG with soy reduced excretion of total and individual isoflavones by 40% (p=0.08), without altering 2OHE1/16alphaOHE1 ratios. CONCLUSION: Isoflavone-rich soy protein administration alone, or with probiotic supplement, did not alter urinary excretion of estrogen metabolites in premenopausal women. However, adding concentrated probiotics may alter isoflavone bioavailability.

Coping with toothache pain: a qualitative study of low-income persons and minorities.

OBJECTIVES: This study examined the behavioral impact of toothache pain as well as self-care strategies for pain relief among minority and low-income individuals. METHODS: Eight focus group sessions were conducted with 66 participants drawn from low-income non-Hispanic White, non-Hispanic Black, and Hispanic adults over the age of 20 who had experienced a toothache during the previous 12-month period and who had utilized self-care or care from a nondentist. RESULTS: Toothache pain was described as intense, throbbing, miserable, or unbearable. Focus group participants indicated that toothache pain affected their ability to perform normal activities, such as their job, housework, social activities, sleeping, talking, and eating, as well as making them depressed and affecting their social interactions. Numerous prescription and nonprescription medications as well as home remedies and self-care strategies were used for pain relief, although these were generally of limited and uncertain benefit. While receiving care at a dental office was the most preferable option for care, most participants reported multiple barriers, including the cost of dental care that resulted in long delays in seeking dental care. The main reason for eventually seeking dental care was the severity of the pain. CONCLUSIONS: Although removing financial barriers alone may not lead to preventive dental visits, it would facilitate more timely visits to dentists to treat toothache pain.

Glycoprotein A34, a novel target for antibody-based cancer immunotherapy.

To identify novel, tissue-restricted cell surface proteins in cancer which can serve as targets for antibody-based diagnostics and therapeutics, a translated version of the expressed sequence tag database (tblastn) was mined for transcripts with similarity to the glycoprotein A33 (GPA33) colon cancer antigen. A novel human transcript, termed A34, was identified which encoded a putative cell surface protein, GPA34, which is approximately 30% identical to GPA33 and other members of the junctional adhesion molecule (JAM) family. Conventional end-point and quantitative real-time RT-PCR showed that A34 mRNA expression is highly tissue-restricted, as it is expressed predominantly in stomach and testis. A34 mRNA was also detected in 6/19 (31%) gastric cancers, 8/16 (50%) esophageal carcinomas, and 4/17 (23%) ovarian cancers, but not in lung, breast or colon carcinomas. A murine monoclonal antibody (mAb A34) was generated to the extracellular domain of the A34 protein and used to biochemically and immunohistochemically characterize the A34 antigenic system. The mAb A34 specifically recognized glycoproteins ranging in apparent size from 55-70 kDa, present in normal gastric mucosa and in COS-7 cells transfected with A34 cDNA. Of 31 different normal tissues examined by immunohistochemistry, GPA34 protein expression was detected primarily in normal stomach mucosa and testicular germ cells, and in the tumor cells of 5/17 (29%) gastric cancers, 7/11 (63%) esophageal cancers, and 2/21 (9%) ovarian cancers, in agreement with gene expression results. The A34 antigen and monoclonal antibody may be of considerable value for immunotherapy of different types of cancer.

Visits to non-dentist health care providers for dental problems.

BACKGROUND AND OBJECTIVES: Although poor and minority adults experience greater levels of dental disease, they frequently face cost and other system-level barriers to obtaining dental care. These individuals may be forced to use physicians or hospital emergency rooms for the treatment of dental problems. This study was conducted to gain a better understanding of the role that non-dentist health care providers play in providing access to oral health care services. METHODS: Dental conditions and dental condition-related visits to non-dentist health care providers during 2001 for the US civilian noninstitutionalized population were analyzed using data from the Household Component of the Medical Expenditure Panel Survey. RESULTS: During 2001, approximately 3.1% of the US population experienced at least one dental problem reported outside of the traditional office-based dental delivery system. Of these, approximately 2.7% received care in a hospital emergency room setting while 7.0% received care in other medical settings. A majority (68.1%) had contact with the formal health care system via a prescription associated with their identified dental problem. Approximately 22.5% did not seek any formal treatment for their problem. Overall, low-income individuals were more likely not to seek formal care than were middle/high-income individuals (32.5% versus 19.7%). CONCLUSIONS: Individuals not using traditional sources of dental care appear to have greater access to physician offices and other medical settings than to hospital emergency rooms for the treatment of dental problems.

Adult patient visits to physicians for dental problems.

BACKGROUND AND OBJECTIVES: Most physicians lack substantive training in dentistry and are usually not capable of providing definitive dental care. Therefore, physician offices are generally not the most appropriate site for the management of most dental problems. This study was conducted to examine the rate with which patients visit physician offices for the treatment of dental problems and their satisfaction with the treatment received. METHODS: Data on dental related problems were collected through a random telephone survey of English-speaking Maryland residents over the age of 20. A random digit dial methodology was used to generate the sampling frame. A total of 811 interviews were conducted. The overall survey has a margin of error of +/- 3.44% at the 95% confidence level. RESULTS: 5.6% of respondents reported seeing a physician for a dental problem during the prior year. Almost 80% reported being satisfied with the treatment received, while 36.4% reported needing follow-up care with a dentist for treatment of the same problem. Respondents expressing greater satisfaction with their visit to the physician were less likely to report needing to see a dentist for follow-up care (p < .05). CONCLUSIONS: Additional studies are needed to assess the quality and appropriateness of physician management of dental problems.

Phase I study of anticolon cancer humanized antibody A33.

PURPOSE: Humanized A33 (huA33; IgG1) monoclonal antibody detects a determinant expressed by 95% of colorectal cancers and can activate immune cytolytic mechanisms. The present study was designed to (a) define the toxicities and maximum tolerated dose of huA33 and (b) determine huA33 immunogenicity. EXPERIMENTAL DESIGN: Patients (n = 11) with advanced chemotherapy-resistant colorectal cancer received 4-week cycles of huA33 at 10, 25, or 50 mg/m(2)/week. Serum samples were analyzed using biosensor technology for evidence of human antihuman antibody (HAHA) response. RESULTS: Eight of 11 patients developed a HAHA response. Significant toxicity was limited to four patients who developed high HAHA titers. In two of these cases, infusion-related reactions such as fevers, rigors, facial flushing, and changes in blood pressure were observed, whereas in the other two cases, toxicity consisted of skin rash, fever, or myalgia. Of three patients who remained HAHA negative, one achieved a radiographic partial response, with reduction of serum carcinoembryonic antigen from 80 to 3 ng/ml. Four patients had radiographic evidence of stable disease (2, 4, 6, and 12 months), with significant reductions (>25%) in serum carcinoembryonic antigen levels in two cases. CONCLUSIONS: The complementarity-determining region-grafted huA33 antibody is immunogenic in the majority of colon cancer patients (73%). HAHA activity can be measured reproducibly and quantitatively by BIACORE analysis. Whereas the huA33 construct tested here may be too immunogenic for further clinical development, the antitumor effects observed in the absence of antibody-mediated toxicity and in this heavily pretreated patient population warrant clinical testing of other IgG1 humanized versions of A33 antibody.

Preliminary report of a phase I study of combination chemotherapy and humanized A33 antibody immunotherapy in patients with advanced colorectal cancer.

PURPOSE: In previous studies, humanized A33 (huA33) demonstrated modest antitumor activity in chemotherapy-resistant colorectal cancer patients. In addition, unexpected major tumor responses were observed in patients treated with a specific chemotherapy regimen [carmustine, vincristine, fluorouracil, and streptozocin (BOF-Strep)] administered after huA33 protocols. We designed the present Phase I, open label, cohort, dose-escalation study of huA33 and a fixed dose of BOF-Strep to (a) determine the maximum tolerated dose of huA33 immunotherapy administered with chemotherapy, (b) determine whether chemotherapy modifies huA33 immunogenicity, and (c) develop preliminary information regarding antitumor activity. EXPERIMENTAL DESIGN: Stage IV fluorouracil/leucovorin and irinotecan-refractory colorectal cancer patients (n = 16) received escalating weekly doses of huA33 (5-40 mg/m(2)) with BOF-Strep chemotherapy. RESULTS: Four patients requiring radiotherapy or surgery were removed early. Of 12 evaluable patients, grade 3 and 4 neutropenia (n = 2) and grade 3 thrombocytopenia (n = 1) were observed. Seven of 12 (58.3%) patients developed anti-huA33 activity. Three patients had radiographic partial responses for 7.5, 5.5, and 14 months with greater than 85% decline in serum carcinoembryonic antigen levels. One mixed response (4.5 months with a serum carcinoembryonic antigen decline of 38%) was also observed. CONCLUSIONS: huA33 can be safely combined with BOF-Strep chemotherapy. The present report provides compelling evidence supporting our previous observations of major antitumor activity with the combination of huA33 and BOF-Strep chemotherapy. huA33 is still immunogenic when administered with chemotherapy. Future studies to evaluate the immunogenicity of new huA33 antibodies and identify which drugs in the BOF-Strep regimen are critical for enhanced antitumor efficacy are planned.

A Phase I dose-escalation study of sibrotuzumab in patients with advanced or metastatic fibroblast activation protein-positive cancer.

PURPOSE: The purpose of this research was to determine the safety, immunogenicity, pharmacokinetics, biodistribution, and tumor uptake of repeat infusions of a complementarity-determining region grafted humanized antibody (sibrotuzumab) directed against human fibroblast activation protein (FAP). EXPERIMENTAL DESIGN: A Phase I open-label dose escalation study was conducted in patients with cancers epidemiologically known to be FAP positive. Patients were entered into one of four dosage tiers of 5, 10, 25, or 50 mg/m(2) sibrotuzumab, administered weekly for 12 weeks, with trace labeling with 8-10 mCi of (131)I in weeks 1, 5, and 9. RESULTS: A total of 26 patients were entered into the trial (15 males and 11 females; mean age, 59.9 years; age range, 41-81 years). Twenty patients had colorectal carcinoma, and 6 patients had non-small cell lung cancer. A total of 218 infusions of sibrotuzumab were administered during the first 12 weeks of the study, with 24 patients being evaluable. One patient received an additional 96 infusions on continued-use phase for a total of 108 infusions over a 2-year period, and 1 patient received an additional 6 infusions on continued use. There were no objective tumor responses. Only one episode of dose-limiting toxicity was observed. Therefore, a maximum tolerated dose was not reached. Treatment-related adverse events were observed in 6 patients during the infusional monitoring period. Four of the 6 patients, 3 of whom had associated positive serum human antihuman antibody, were removed from the study because of clinical immune responses. Gamma camera images of [(131)I]sibrotuzumab demonstrated no normal organ uptake of sibrotuzumab, with tumor uptake evident within 24-48 h after infusion. Analysis of pharmacokinetics demonstrated a similar mean terminal t(1/2) of 1.4-2.6 days at the 5, 10, and 25 mg/m(2) dose levels, and with a longer mean t(1/2) of 4.9 days at the 50 mg/m(2) dose level. CONCLUSION: Repeat infusions of the humanized anti-FAP antibody sibrotuzumab can be administered safely to patients with advanced FAP-positive cancer.

Attitudes of dental hygiene students toward individuals with AIDS.

This study was undertaken to gain a better understanding of dental hygiene students' attitudes toward AIDS and homosexuals. Each respondent received a 500-word patient case vignette and two scales for recording impressions of the person described in the vignette. There were four vignettes, identical except that the portrayed individual's illness was identified as either AIDS or leukemia, and sexual preference as either homosexual or heterosexual. No differences in overall ratings on either scale were noted based on the patient's disease status or sexual preference or the interaction between sexual preferences with disease type. Similarly, neither scale displayed significant differences on any of the individual items based on the patient's sexual preference. There were, however, significant differences for several individual items on both scales based on the patient's disease type; students responded more negatively to individuals with AIDS. It appears, therefore, that the hygiene students displayed no bias toward homosexuals and only very minimal bias toward individuals with AIDS.

Attitudes of advanced dental education students toward individuals with AIDS.

The number of patients with HIV/AIDS who receive dental care is increasing. This study was undertaken to gain a better understanding of the attitudes of dentists enrolled in postgraduate training toward AIDS and homosexuals. Each respondent received a 500-word patient case vignette and two scales for recording impressions of the person described in the vignette. There were four vignettes, identical except that the portrayed individual's illness was identified as either AIDS or leukemia and sexual preference as either homosexual or heterosexual. Two-way analyses of variance and t tests (p<.05) revealed a bias toward individuals with AIDS and toward homosexuals. Respondents reacted more negatively to both groups on the Social Interaction Scale as seen in total scale scores as well as to individual scale items. In addition, although overall Prejudicial Evaluation Scale scores displayed no evidence of bias, several individual scale items did. It is important to ensure that dentists' attitudes toward patients with AIDS and homosexuals are not a barrier to these patients receiving the best possible care. Therefore, dental education programs at all levels should give consideration to interventions to address provider attitudes and potential biases.