[The Intensified Dental Preventive Programme in Rhineland-Palatinate: Investigations on first-grade school-children in 2013/2014]. / Die zahnärztliche selektive Intensivprophylaxe in Rheinland-Pfalz: Untersuchungen an Erstklässlern im Schuljahr 2013/2014.

Aim: For children and adolescents at increased risk of caries, the "Selective Intensive Prophylaxis" (SIP) programme was established in Rhineland-Palatinate in 2004, as well as in the most other German states. This study compares the results of the school dentists' evaluations of first grade school children in 2013/2014 participating in the "Selective Intensive Prophylaxis" (SIP) programme or the "Standard Programme" (SP). Methods: The d3mft/D3MFT index was recorded by school dentists according to the WHO criteria; caries was diagnosed if dentin was affected; no radiography or fiber-optic transillumination was used. The examinations were performed once under the SP and twice under the SIP. Children and parents were informed in case of a need for treatment and reminded if the did not see the family dentist. Out of the evaluated d3mft/D3MFT values, the Significant Caries Index (SiC) was calculated. Statistical computing was performed using SPSS 22.00. Results: Of all first graders, n=25 020 were evaluable for d3mft/D3MFT. Altogether n=1 164 first graders were included into the SIP in the 2013/2014 term; for n=1 002 of those, the results for both examinations were available. The caries experience of those pupils participating in the SIP was clearly higher than in the SP (41.8% naturally healthy vs. 61.7%, p<0.0001). There was significant difference between the first and second examination in the SIP, especially with respect to individual (16.0 vs. 23.0%, p<0.0001) and tooth-related (43.2 vs. 54.2%, p<0.0001) level of restoration. Conclusion: The results show that the SIP in Rhineland-Palatinate is conducted in a population with high caries experience. The significant difference concerning the dental restoration level, both individual- and teeth-related - leads to the conclusion that children frequently sought dental treatment if a need for treatment was diagnosed by the school dentist.

Effectiveness of a miswak extract-containing toothpaste on gingival inflammation: a randomized clinical trial.

OBJECTIVES: In this study, the efficacy of a miswak extract-containing toothpaste (Salvadora persica) on gingival inflammation was compared with that of a herbal and a conventional toothpaste. METHODS: Non-smoking outpatients with sulcus bleeding index (SBI) ≥25% and with periodontal pocket depths ≤3 mm were randomly selected and divided into three groups: M-group, miswak extract-containing toothpaste; P-group, herbal toothpaste; and C-group, conventional toothpaste. After instructing the patients to brush their teeth twice a day for 3 weeks with the assigned toothpaste using a flat-trimmed manual toothbrush, a thorough oral examination was performed by a calibrated examiner (EH). The primary outcome was the SBI after 21 days. Furthermore, the amount of plaque was measured by approximal plaque index (API). RESULTS: Sixty-six patients with a mean age of 57.8 ± 10.2 years were recruited and enrolled. After 3 weeks of brushing, all three patient groups showed a significant reduction in SBI. The P-group (SBI reduction: 17.1% ± 9.1) and the M-group (14.5% ± 8.1) showed the strongest effect followed by the C-group (9.4% ± 7.8). All three groups showed a significant reduction in API without significant differences between the groups. CONCLUSIONS: The use of each of the three tested toothpastes caused a significant reduction in gingival inflammation and amount of plaque. The miswak extract-containing toothpaste showed a similar effect as the herbal toothpaste and can be safely used for domestic oral hygiene in patients with gingivitis.

Braces versus Invisalign®: gingival parameters and patients' satisfaction during treatment: a cross-sectional study.

BACKGROUND: Fixed orthodontic appliances (FOA) temporarily interfere with periodontal health of patients, as the appliance complicates oral hygiene. The use of aligners in orthodontic therapy increased strongly during the last decade. In the literature, the reports about effects of aligner treatment on oral hygiene and gingival conditions are scarce. This cross-sectional study evaluated oral hygiene and patient's satisfaction during orthodontic treatment of patients with FOA or Invisalign®. METHODS: 100 patients (FOA = 50, Invisalign® = 50) were included who underwent orthodontic treatment for more than 6 months. Clinical examinations were performed to evaluate patients' periodontal condition and were compared with clinical data at the beginning of the orthodontic treatment. Oral hygiene, patients' satisfaction and dietary habits were documented by a detailed questionnaire. For statistical analysis, the Mann-Whitney U-Test and Fisher's Exact Test were used; as multiple testing was applied, a Bonferroni correction was performed. RESULTS: At the time of clinical examinations, patients with FOA were in orthodontic therapy for 12.9 ± 7.2 months, whereas patients with Invisalign® were in orthodontic therapy for 12.6 ± 7.4 months. Significantly better gingival health conditions were recorded in Invisalign® patients (GI: 0.54 ± 0.50 for FOA versus 0.35 ± 0.34 for Invisalign®; SBI: 15.2 ± 7.6 for FOA versus 7.6 ± 4.1 for Invisalign®), whereas the amount of dental plaque was also less but not significantly different (API: 37.7 % ± 21.9 for FOA versus 27.8 % ± 24.6 for Invisalign®). The evaluation of the questionnaire showed greater patients' satisfaction in patients treated with Invisalign® than with FOA. CONCLUSION: Patients treated with Invisalign® have a better periodontal health and greater satisfaction during orthodontic treatment than patients treated with FOA.

High-density versus low-density mapping in ablation of atypical atrial flutter.

PURPOSE: Ablation of atypical atrial flutter (AAFL) can be challenging. High-density (HD) mapping of ablation targets may potentially increase procedural success and freedom from recurrent AAFL. The objective of the present study was to explore whether employing HD mapping leads to a more favorable outcome in ablation of AAFL. METHODS: We compared baseline and procedural characteristics, procedural success, safety and outcome of mapping and ablation of atypical flutter in three groups. (1) HD Grid catheter + the high-density electroanatomical mapping (EAM) system EnSite Precision; (2) standard 10-pole circular mapping catheter (CMC) + EnSite Precision; (3) CMC + the low-density EnSite Velocity EAM. Voltage and propagation maps were constructed. RESULTS: Mapping of 142 AAFL in 82 patients was performed. Acute ablation success was 78%, 68%, and 51% in groups 1, 2, and 3 (p = 0.037 between group 1 and 3, non-significant between groups otherwise). Moreover, 8%, 27%, and 36% of flutters were unmappable in groups 1, 2, and 3, respectively (p < 0.05 between group 1 and both groups 2 and 3). AAFL recurrence at 1-year FU was 26%, 36%, and 62% in groups 1, 2, and 3 (p = 0.007 between groups 1 and 3, p = 0.05 between groups 2 and 3). AAFL-free survival was significantly higher in patients mapped with Precision than with Velocity (p = 0.011). No strokes or mortality occurred within 30 days. CONCLUSIONS: Acute procedural success of ablation of atypical atrial flutter is higher and the number of unmappable flutters is lower using the HD Grid mapping catheter in combination with the high-density EnSite Precision system, as compared to a decapolar circular mapping catheter and the low-density EnSite Velocity EAM system. This may lead to increased freedom from recurrent AAFL at 1 year. HD mapping is safe.

Mechanisms and mitigating factors for venous thromboembolism in chronic kidney disease: the REGARDS study.

Essentials Chronic kidney disease (CKD) is associated with procoagulant and inflammatory biomarkers. We studied the association of CKD and venous thromboembolism (VTE) in a case-cohort study. Factor VIII, D-dimer and C-reactive protein appeared to explain the association of CKD and VTE. Statin use was protective against VTE in those with and without CKD. SUMMARY: Background Chronic kidney disease (CKD) is associated with venous thromboembolism (VTE) risk via unknown mechanisms. Whether factors associated with reduced VTE risk in the general population might also be associated with reduced VTE risk in CKD patients is unknown. Objectives To determine whether thrombosis biomarkers attenuate VTE risk, and whether factors associated with reduced VTE risk are similarly effective in CKD patients. Methods Baseline biomarkers were measured in a cohort (294 VTE cases; 939 non-cases) from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a nationwide prospective cohort study of 30 239 persons aged ≥45 years with 4.3 years of follow-up. The hazard ratio (HR) of VTE per 10 mL min-1 1.73 m-2 decrease in estimated glomerular filtration rate (eGFR), and the percentage attenuation of this HR by each biomarker, were calculated. Associations of protective factors (physical activity, lower body mass index [BMI], and aspirin, warfarin and statin use) with VTE were estimated in those with and without CKD. Results The HR for VTE with lower eGFR was 1.13 (95% confidence interval [CI] 1.02-1.25), and VTE risk was attenuated by 23% (95% CI 5-100) by D-dimer, by 100% (95% CI 50-100) by factor VIII, and by 15% (95% CI 2-84) by C-reactive protein. Normal BMI was associated with lower VTE risk in those without CKD (HR 0.47, 95% CI 0.32-0.70), but not in those with CKD (HR 1.07, 95% CI 0.51-2.22). Statin use, physical activity and warfarin use were associated with lower VTE risk in both groups. Conclusions Procoagulant and inflammatory biomarkers mediated the association of eGFR with VTE. Higher physical activity, statin use and warfarin use mitigated VTE risk in those with CKD and those without CKD, but normal BMI did not mitigate VTE risk in CKD patients.

Insulin resistance and risk of venous thromboembolism: results of a population-based cohort study.

BACKGROUND: Obesity is an established risk factor for venous thromboembolism (VTE), but it is uncertain how this is mediated. Insulin resistance has a central role in the pathophysiology of the metabolic effects of obesity. OBJECTIVE: We aimed to investigate whether insulin resistance is a risk factor for VTE. METHODS: For this analysis we used the PREVEND prospective community-based observational cohort study. Insulin resistance was measured as HOMA-IR (homeostasis model assessment of insulin resistance) and fasting insulin. VTE was assessed using databases of the national registries of hospital discharge diagnoses, death certificates and the regional anticoagulation clinic. RESULTS: Out of 7393 subjects, 114 developed VTE during a median follow-up of 10.5 years. High HOMA-IR was associated with increased risk of VTE after adjustment for traditional cardiovascular risk factors, CRP and markers of endothelial dysfunction (hazard ratio [HR], 1.38; 95% confidence interval [95% CI], 1.09-1.75; P=0.007). When body mass index (BMI) was added to the model, BMI was a strong risk predictor for VTE (HR, 1.53; 95% CI, 1.24-1.88; P<0.001) whereas HOMA-IR no longer showed such an association (HR, 1.11; 95% CI, 0.85-1.43; P=0.45). Results were similar for fasting insulin. CONCLUSION: Our population-based cohort study shows an increased risk of VTE in subjects with increasing insulin resistance but not independently of BMI.

The impact of antiproteinuric therapy on the prothrombotic state in patients with overt proteinuria.

BACKGROUND: Overt proteinuria is a strong risk factor for thromboembolism, owing to changes in the levels of various coagulation proteins and urinary antithrombin loss. The described coagulation disturbances in these patients are based on outdated studies conducted primarily in the 1970s and 1980s. Whether these coagulation disturbances resolve with antiproteinuric therapy has yet to be studied. METHODS: A total of 32 patients with overt proteinuria (median, 3.7 g day(-1) ; interquartile range, 1.5-5.6) were enrolled in this intervention crossover trial designed to assess optimal antiproteinuric therapy with sodium restriction, losartan, and diuretics. Levels of various procoagulant and anticoagulant proteins, and parameters of two thrombin generation assays (calibrated automated thrombogram [CAT] and prothrombin fragment 1 + 2) were compared between the placebo period and the maximum antiproteinuric treatment period. As a secondary analysis, coagulation measurements of the placebo period in these patients were compared with those of 32 age-matched and sex-matched healthy controls. RESULTS: Median proteinuria was significantly lower during the maximum treatment period (median, 0.9 g day(-1) ; interquartile range, 0.6-1.4; P < 0.001) than during the placebo period. Similarly, levels of various liver-synthesized procoagulant and anticoagulant proteins, activated protein C resistance and prothrombin fragment 1 + 2 levels were significantly lower during the maximum treatment period than during the placebo period. However, von Willebrand factor and factor VIII levels were similar. On the basis of the higher levels of procoagulant proteins (fibrinogen, FV, FVIII, and von Willebrand factor) and both thrombin generation assays, patients were substantially more prothrombotic than healthy controls (P < 0.004). CONCLUSIONS: Antiproteinuric therapy ameliorates the prothrombotic state. Proteinuric patients are in a more prothrombotic state than healthy controls.

Chronic kidney disease stages 1-3 increase the risk of venous thrombosis.

BACKGROUND: End-stage renal disease has been associated with venous thrombosis (VT). However, the risk of VT in the early stages of chronic kidney disease (CKD) has not yet been investigated. The aim of this study was to investigate whether CKD patients with stage 1-3 disease are at increased risk of VT. METHODS: Eight thousand four hundred and ninety-five subjects were included in a prospective cohort study, in which renal function and albuminuria were assessed, starting in 1997-1998, and were followed for the occurrence of VT until 1 June 2007. CKD patients were staged according to the Kidney Disease Outcomes Quality Initiative guidelines, on the basis of 24-h urine albumin excretion and estimated glomerular filtration rates. Objectively verified symptomatic VT was considered to be the endpoint. RESULTS: Of the 8495 subjects, 243 had CKD stage 1, 856 CKD stage 2, and 491 CKD stage 3. During a median follow-up period of 9.2 years, 128 individuals developed VT. The hazard ratios (HRs) for CKD stages 1, 2 and 3 were, respectively, 2.2 [95% confidence interval (CI) 0.9-5.1], 1.9 (95% CI 1.1-3.1) and 1.6 (95% CI 0.9-2.8) relative to those without CKD after adjustment for age, sex, body mass index, hypertension, diabetes, malignancy, and high-sensitivity C-reactive protein. Subjects with CKD stage 3 and albuminuria (≥ 30 mg d(-1)) had an adjusted HR of 3.0, and subjects with CKD stage 3 without albuminuria had an adjusted HR of 1.0. CONCLUSIONS: CKD stages 1 and 2, and CKD stage 3 in the presence of albuminuria, are risk factors for VT. The risk of VT is more related to albuminuria than to impaired glomerular filtration rate.

A prospective cohort study on the absolute risks of venous thromboembolism and predictive value of screening asymptomatic relatives of patients with hereditary deficiencies of protein S, protein C or antithrombin.

BACKGROUND: Absolute risks of venous thromboembolism (VTE) in protein S-, protein C-, or antithrombin-deficient subjects are mainly based on retrospective data. Screening asymptomatic relatives of these patients is disputed, though studies addressing this issue have yet to be conducted. METHODS: We prospectively followed 382 relatives of 84 probands. Participants were assessed for other thrombophilic defects and occurrence of exogenous risk factors (i.e. surgery/trauma/immobilization, malignancies, use of systemic estrogens, and pregnancy/puerperium). After screening, deficient subjects were advised to use thromboprophylaxis during exogenous risk factors; use of oral contraceptives was discouraged. RESULTS: Overall annual incidence of VTE was 1.53% (95% CI, 1.00-2.34) in deficient vs. 0.29% (0.13-0.64) in non-deficient relatives; adjusted hazard ratio, 7.0 (95% CI, 2.7-18.0). Annual incidence of unprovoked VTE was 0.95% in deficient vs. 0.05% in non-deficient subjects; age-adjusted hazard ratio, 22.3 (P = 0.003). In contrast, annual incidence of provoked VTE was 0.58% vs. 0.24%; age-adjusted hazard ratio, 2.8 (P = 0.08). Fifty-five (37%) deficient and 80 (34%) non-deficient subjects experienced 91 and 143 exogenous risk factors, respectively, during which six vs. five VTEs (6.6% vs 3.5% per risk-period) occurred, despite the higher compliance with recommended thromboprophylaxis use in deficient (51%) vs. non-deficient (22%) subjects. In deficient subjects all provoked VTEs occurred when thromboprophylaxis was not used. CONCLUSIONS: Protein S, protein C or antithrombin deficiencies confer high absolute risk of VTE. Screening and subsequent augmentation of thromboprophylaxis use may result in reduction of provoked VTE, whereas risk of unprovoked VTE could not be affected by screening.