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A double-blind controlled trial initiated in 1944 has led to the common narrative that a 10-mg daily vitamin C intake is adequate to prevent and treat impaired wound healing, and by inference, other collagen-related diseases such as heart disease or stroke. The WHO relies on this narrative to set the recommended nutrient intake for vitamin C. This narrative, however, is based on what is known as the eyeball method of data assessment. The 1944 trial published individual participant data on scar strength providing an opportunity to statistically probe the validity of the 10-mg narrative, something which has not yet been done. The findings show that a vitamin C intake that averages to 10 mg/d over a mean follow-up of 11.5 mo was associated with a 42% weakened scar strength when compared with 80 mg vitamin C intake/d (P < 0.001). The observed dose-response curve between scar strength and vitamin C intake suggests that the daily vitamin C intake needed to prevent collagen-related pathologies is in the range recommended by the National Academy of Medicine and the European Food Safety Authority (75 to 110 mg/d), not the WHO recommendation (45 mg/d). The findings also show that a vitamin C intake that averages to 65 mg/d over a mean follow-up of 6.5 mo failed to restore the normal wound-healing capacity of vitamin C-depleted tissues; such tissues had a 49% weaker scar strength when compared with nondepleted tissues (P < 0.05). Thus, average daily vitamin C intakes ∼50% higher than the WHO recommends may fail to treat existing collagen-related pathologies. It is concluded that the prior lack of statistical analyses of a landmark trial may have led to a misleading narrative on the vitamin C needs for the prevention and treatment of collagen-related pathologies.

Ignoring evidence on causes of disease such as smoking can harm public health. This report explores how public health experts started to ignore evidence that pediatric vitamin D deficiencies are associated with dental caries. Historical analyses show that an organization of clinical specialists, the American Dental Association (ADA), initiated this view. The ADA was a world-leading organization and its governing bodies worked through political channels to make fluoride a global standard of care for a disease which at the time was viewed as an indicator of vitamin D deficiencies. The ADA scientific council was enlisted in this endeavor and authorized the statement saying that “claims for vitamin D as a factor in tooth decay are not acceptable”. This statement was ghost-written, the opposite of what the ADA scientific council had endorsed for 15 years, and the opposite of what the National Academy of Sciences concluded. Internal ADA documents are informative on the origin of this scientific conundrum; the ADA scientific council had ignored their scientific rules and was assisting ADA governing bodies in conflicts with the medical profession on advertising policies. The evidence presented here suggests that professional organizations of clinical specialists have the power to create standards of care which ignore key evidence and consequently can harm public health.

Fluoride has no tangible health benefits other than preventing dental caries and there is a small difference between its minimum effective dose and its minimum toxic dose. Leading global organizations currently recommend fluoride supplementation because they recommend high-carbohydrate diets which can cause dental caries. Low-carbohydrate diets prevent dental caries making such fluoride recommendations largely unnecessary. A dental organization was among the first to initiate the public health recommendations which started fluoride-supplemented high-carbohydrate nutritional guidelines. This start required expert panels at this dental organization to reverse on three key scientific points between 1942 and 1949: (1) that topical fluoride had potential harms, (2) that dental caries was a marker for micronutrient deficiencies, and (3) that low-carbohydrate diets are to be recommended for dental caries prevention. Internal documents show that private interests motivated the events which led these expert panels to engage in pivotal scientific reversals. These private interests biased scientific processes and these reversals occurred largely in an absence of supporting evidence. It is concluded that private interests played a significant role in the start of public health endorsements of fluoride-supplemented high-carbohydrate nutritional guidelines.

Goal The goal of this study was to estimate the impact of verification bias on the diagnostic accuracy of immunoglobulin A tissue transglutaminase (IgA tTG) in detecting celiac disease as reported by an authoritative meta-analysis, the 2016 Comparative Effectiveness Review (CER). Background Verification bias is introduced to diagnostic accuracy studies when screening test results impact the decision to verify disease status. Materials and methods We adjusted the sensitivity and specificity of IgA tTG reported by the 2016 CER with the proportion of IgA tTG positive and negative individuals who are referred for confirmatory small bowel biopsy. We performed a systematic review from January 1, 2007, to July 19, 2017, to determine these referral rates. Results The systematic review identified 793 articles of which 9 met inclusion criteria (n=36,477). Overall, 3.6% [95% confidence interval (CI): 1.1%-10.9%] of IgA tTG negative and 79.2.2% (95% CI: 65.0%-88.7%) of IgA tTG positive individuals were referred for biopsy. Adjusting for these referral rates the 2016 CER reported sensitivity of IgA tTG dropped from 92.6% (95% CI: 90.2%-94.5%) to 57.1% (95% CI: 35.4%-76.4%) and the specificity increased from 97.6% (95% CI: 96.3%-98.5%) to 99.6% (95% CI: 98.4%-99.9%). Conclusions The CER may have largely overestimated the sensitivity of IgA tTG due to a failure to account for verification bias. These findings suggest caution in the interpretation of a negative IgA tTG to rule out celiac disease in clinical practice. More broadly, they highlight the impact of verification bias on diagnostic accuracy estimates and suggest that studies at risk for this bias be excluded from systematic reviews.

Context The World Health Organization set the recommended daily vitamin C intake, henceforth referred to as ascorbic acid (AA), on the basis of scurvy prevention. Double-blind AA depletion-repletion studies suggest that this recommended AA dose may be too low to prevent microvascular fragility. Objectives (1) To conduct a systematic review and meta-analysis of controlled clinical trials on whether AA supplementation leads to a reduced gingival bleeding tendency, a manifestation of microvascular fragility; and (2) to relate AA plasma levels to retinal hemorrhaging, another manifestation of microvascular fragility. Data sources Data were reviewed from 15 trials conducted in 6 countries with 1140 predominantly healthy participants with measures of gingival bleeding tendency, and from the National Health and Nutrition Examination Survey (NHANES) III of 8210 US residents with measures of retinal hemorrhaging. Results In clinical trials, AA supplementation reduced gingival bleeding tendency when estimated baseline AA plasma levels were 48 μmol/L or unknown (respective standardized mean differences: −0.23, 95%CI, −0.45 to −0.01, P Conclusion Consistent evidence from controlled clinical trials indicates that setting human AA requirements based on scurvy prevention leads to AA plasma levels that may be too low to prevent an increased gingival bleeding tendency. Gingival bleeding tendency and retinal hemorrhaging coincide with low AA plasma levels and thus may be reflective of a systemic microvascular pathology that is reversible with an increased daily AA intake.

Objectives Birth season has been inconsistently associated with anthropometrics, bone fractures, and malocclusion. Our aim was to assess the association between birth season and anthropometrics (height, weight, birth weight), bone fractures and dental malocclusion in the United States. Methods US surveys conducted between 1963-1973 assessed 16 152 6-to-21-year-old participants. Prevalence ratios and mean differences were estimated using linear models using fall as reference. Results Participants born in spring, when compared to fall, were of similar height (mean difference (MD) in height-adjusted Z score 0.03, 95% Confidence Interval (CI): -0.01 to 0.08; P-value = .17), weight (MD for weight-adjusted Z-score 0.00, 95% CI: -0.05 to 0.04; P-value =0.83), had similar rates of bone fractures (Prevalence Rate [PR] 1.07; 95% CI: 0.94 to 1.22; P-value = .28) and similar rates of dental malocclusion (MD of malocclusion index HLD -0.16; 95% confidence interval - 0.39 to 0.07; P = .18). Conclusion We did not find an impact of birth season on anthropometrics, bone fractures, and dental malocclusions.

The consensus of a leading scientific panel in 1930 was that oral hygiene products could not prevent dental caries. Their view was that dental caries prevention required the proper mineralisation of teeth and that vitamin D could achieve this goal. Over a hundred subsequent controlled trials, conducted over seven decades, largely confirmed that this scientific panel had made the right decisions. They had, in 1930, when it comes to dental caries, correctly endorsed vitamin D products as dental caries prophylactics and oral hygiene products as cosmetics. And yet, despite this consistent scientific evidence for close to a century, an opposing conventional wisdom emerged which thrives to this day: oral hygiene habits (without fluoride) protect the teeth from dental caries, and vitamin D plays no role in dental caries prevention. This historical analysis explores whether persistent advertising can deeply engrain memes on dental caries prevention which conflict with controlled trial results. The question is raised whether professional organisations, with a dependence on advertising revenues, can become complicit in amplifying advertised health claims which are inconsistent with the principles of evidence-based medicine.

Article Title and Bibliographic Information Relationship between periodontal disease and lung cancer: A systematic review and meta-analysis. Wang J, Yang X, Zou X, Zhang Y, Wang J, Wang Y. J Periodontal Res. 2020 Oct;55(5):581–593. doi: 10.1111/jre.12772 . Epub 2020 Jun 25. PMID: 32,583,879. Source of Funding National Natural Science Foundation of China and Scientific Research foundation of the Health Planning Committee of Sichuan. Type of Study/Design Systematic review with meta-analysis of cohort and case-control studies.

Objectives We investigated the relationship between early childhood malnutrition-related measures and subsequent enamel defects in the permanent dentition. Materials and Methods This cohort study included 349 Amerindian adolescents (10–17 years, 52% male) from the Bolivian Amazon. Exposures included: stunted growth (height-for-age z-scores), underweight (weight-for-age z-scores), anemia (hemoglobin), acute inflammation (C-reactive protein) and parasitic infection (hookworm). We measured the occurrence (no/yes) and extent ( 2/3) of enamel defects. We estimated associations between childhood exposures and enamel defect measures using log-binomial and multinomial logistic regression. Results The prevalence of an enamel defect characterized by an orange peel texture on a large central depression on the labial surface of the central maxillary incisors was 92.3%. During childhood (1–4 years), participants had a high prevalence of stunted growth (75.2%), anemia (56.9%), acute inflammation (39.1%), and hookworm infection (49.6%). We observed associations between childhood height-for-age (OR = 0.65; P = 0.028 for >2/3 extent vs. no EH) and gastrointestinal hookworm infection (OR = 3.43; P = 0.035 for >2/3 extent vs. no defects or

Periodontal diseases and dental caries are the most common diseases of humans and the main cause of tooth loss. Both diseases can lead to nutritional compromise and negative impacts upon self‐esteem and quality of life. As complex chronic diseases, they share common risk factors, such as a requirement for a pathogenic plaque biofilm, yet they exhibit distinct pathophysiologies. Multiple exposures contribute to their causal pathways, and susceptibility involves risk factors that are inherited (e.g. genetic variants), and those that are acquired (e.g. socio‐economic factors, biofilm load or composition, smoking, carbohydrate intake). Identification of these factors is crucial in the prevention of both diseases as well as in their management. Aim. To systematically appraise the scientific literature to identify potential risk factors for caries and periodontal diseases. Methods. One systematic review (genetic risk factors), one narrative review (role of diet and nutrition) and reference documentation for modifiable acquired risk factors common to both disease groups, formed the basis of the report. Results & Conclusions. There is moderately strong evidence for a genetic contribution to periodontal diseases and caries susceptibility, with an attributable risk estimated to be up to 50%. The genetics literature for periodontal disease is more substantial than for caries and genes associated with chronic periodontitis are the vitamin D receptor (VDR), Fc gamma receptor IIA (Fc‐γRIIA) and Interleukin 10 (IL10) genes. For caries, genes involved in enamel formation (AMELX, AMBN, ENAM, TUFT, MMP20, and KLK4), salivary characteristics (AQP5), immune regulation and dietary preferences had the largest impact. No common genetic variants were found. Fermentable carbohydrates (sugars and starches) were the most relevant common dietary risk factor for both diseases, but associated mechanisms differed. In caries, the fermentation process leads to acid production and the generation of biofilm components such as Glucans. In periodontitis, glycaemia drives oxidative stress and advanced glycation end‐products may also trigger a hyper inflammatory state. Micronutrient deficiencies, such as for vitamin C, vitamin D or vitamin B12, may be related to the onset and progression of both diseases. Functional foods or probiotics could be helpful in caries prevention and periodontal disease management, although evidence is limited and biological mechanisms not fully elucidated. Hyposalivation, rheumatoid arthritis, smoking/tobacco use, undiagnosed or sub‐optimally controlled diabetes and obesity are common acquired risk factors for both caries and periodontal diseases.

This study aims to determine whether breastfeeding duration affects the prevalence of nonrighthandedness in later life. A systematic search for studies on this topic was completed in 2018, and risk of bias was assessed by means of the Newcastle-Ottawa scale. Seven national surveys in five countries with Individual Participant Data (IPD) were identified (

Background The authors sought to determine associations between serum vitamin D levels and dental caries in noninstitutionalized children aged 5 to 12 years in the United States. Methods The authors used National Health and Nutrition Examination Survey, 2005-2006, data to study childhood caries and vitamin D. Vitamin D deficiency and inadequacy were defined as serum 25-hydroxyvitamin D (25[OH]D) less than 30 nanomoles per liter and between 30 and 49 nmol/L, respectively. Associations between vitamin D and caries experience (a combined measure of untreated caries or restorations) were examined after adjustment for confounders using multivariate logistic regression at a critical value of 5%. Sample weights were used to generate nationally representative estimates. Results The overall prevalence of serum 25(OH)D less than 30 nmol/L and 25(OH)D between 30 and 49 nmol/L among 5- to 12-year-olds was 3% and 16%, respectively. Prevalence of 25(OH)D less than 30 nmol/L and 25(OH)D between 30 and 49 nmol/L among children with caries experience was 2% and 16%, respectively. Multivariate logistic regression analysis found no significant association between vitamin D and caries experience ( P = .78). Furthermore, this association was not significant after adjusting for age, sex, race and ethnicity, ratio of family income to poverty threshold, and sugar consumption ( P = .46). Conclusions The authors did not find a significant association between 25(OH)D status and caries experience in US children who participated in NHANES, 2005-2006. Practical Implications The authors’ findings do not support existing evidence of an association between caries and vitamin D.

The aim of this study was to assess the effectiveness of fluoride varnish (FV) in reducing dentine caries at the patient, tooth, and surface levels as well as caries-related hospitalizations in preschoolers. We performed a systematic review of clinical trials of FV, alone or associated with an oral health program, compared with placebo, usual care, or no intervention. Bibliographical search included electronic searches of seven databases, registers of ongoing trials, and meeting abstracts, as well as hand searching. We performed random-effects meta-analyses and calculated confidence and prediction intervals. The search yielded 2,441 records; 20 trials were included in the review and 17 in at least one meta-analysis. Only one study had low risk of bias in all domains. We found no study reporting on caries-related hospitalizations. At the individual level, the pooled relative risk was 0.88 (95% confidence interval [CI] 0.81, 0.95); this means that in a population of preschool children with 50% caries incidence, we need to apply fluoride varnish in 17 children to avoid new caries in one child. At the tooth level, the pooled weighted mean difference was –0.30 (95% CI –0.69, 0.09) and at the surface level –0.77 (95% CI –1.23, –0.31). Considering the prediction intervals, none of the pooled estimates were statistically significant. We conclude that FV showed a modest and uncertain anticaries effect in preschoolers. Cost-effectiveness analyses are needed to assess whether FV should be adopted or abandoned by dental services.

OBJECTIVE To conduct a systematic review of randomised trials assessing the association between personal oral hygiene and dental caries in the absence of the confounding effects of fluoride. BACKGROUND Dental caries continues to affect close to 100% of the global population. There is a century-old conflict on whether dental caries is caused by poor oral hygiene or poorly formed teeth (ie, teeth with dental defects). Resolving this conflict is of significant public health importance as these two hypotheses on dental caries aetiology can lead to different prevention strategies. METHODS A systematic search for randomised trials was conducted using predefined criteria in 3 databases. The impact of personal oral hygiene interventions on coronal dental caries incidence was evaluated using random-effects models. RESULTS Three randomised studies involving a total of 743 participants were included. Personal oral hygiene interventions failed to influence the incidence of dental caries (Δ Decayed, Missing and Filled Surfaces (DFMS) = -0.11; 95% confidence interval: (-0.91, 0.69; P-value

OBJECTIVES: Bioarchaeological findings have linked defective enamel formation in pre-adulthood with adult mortality. We investigated how defective enamel formation in infancy and childhood is associated with risk factors for adult morbidity and mortality in adolescents. METHODS: This cohort study of 349 Amerindian adolescents (10-17 years of age) related extent of enamel defects on the central maxillary incisors (none, less than 1/3, 1/3 to 2/3, more than 2/3) to adolescent anthropometrics (height, weight) and biomarkers (hemoglobin, glycated hemoglobin, white blood cell count, and blood pressure). Risk differences and 95% confidence intervals were estimated using multiple linear regression. Enamel defects and stunted growth were compared in their ability to predict adolescent health indicators using log-binomial regression and receiver operating characteristics (ROCs). RESULTS: Greater extent of defective enamel formation on the tooth surface was associated with shorter height (−1.35 cm, 95% CI: −2.17, −0.53), lower weight (−0.98 kg, 95% CI: −1.70, −0.26), lower hemoglobin (−0.36 g/dL, 95% CI: −0.59, −0.13), lower glycated hemoglobin (−0.04 %A(1c), 95% CI: −0.08, −0.00008), and higher white blood cell count (0.74 10(9)/L, 95% CI: 0.35, 1.14) in adolescence. Extent of enamel defects and stunted growth independently performed similarly as risk factors for adverse adolescent outcomes, including anemia, prediabetes/type II diabetes, elevated WBC count, pre-hypertension/hypertension, and metabolic health. CONCLUSIONS: Defective enamel formation in infancy and childhood predicted adolescent health outcomes and may be primarily associated with infection. Extent of enamel defects and stunted growth may be equally predictive of adverse adolescent health outcomes.

Teeth are mineralized organs composed of three unique hard tissues, enamel, dentin, and cementum, and attached by an unmineralized periodontal ligament to the surrounding alveolar bone that composes the tooth socket. Vitamin D deficiencies and hereditary defects in vitamin D metabolism have been associated with significant changes in dental-oral-craniofacial structures. The most relevant consequences from a public health perspective are the dental manifestations. This chapter reviews the effects of vitamin D on target cells and tissues in the dentoalveolar complex, describes dental disorders resulting from nutritional vitamin D deficiency and associated hereditary diseases, and summarizes what is known about vitamin D and oral health, including the susceptibility to dental caries and periodontal disease.

Background A panel of experts convened by the American Dental Association Council on Scientific Affairs presents an evidence-based clinical practice guideline on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts. Methods The authors developed this clinical practice guideline according to the American Dental Association's evidence-based guideline development methodology. This guideline is founded on a systematic review of the evidence that included 72 research articles providing clinical attachment level data on trials of at least 6 months' duration and published in English through July 2014. The strength of each recommendation ( strong , in favor , weak , expert opinion for , expert opinion against , and against ) is based on an assessment of the level of certainty in the evidence for the treatment's benefit in combination with an assessment of the balance between the magnitude of the benefit and the potential for adverse effects. Practical Implications and Conclusions For patients with chronic periodontitis, SRP showed a moderate benefit, and the benefits were judged to outweigh potential adverse effects. The authors voted in favor of SRP as the initial nonsurgical treatment for chronic periodontitis. Although systemic subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefits as adjunctive therapies to SRP, they were recommended at different strengths ( in favor for systemic subantimicrobial-dose doxycycline and weak for systemic antimicrobials) because of the higher potential for adverse effects with higher doses of antimicrobials. The strengths of 2 other recommendations are weak : chlorhexidine chips and photodynamic therapy with a diode laser. Recommendations for the other local antimicrobials (doxycycline hyclate gel and minocycline microspheres) were expert opinion for . Recommendations for the nonsurgical use of other lasers as SRP adjuncts were limited to expert opinion against because there was uncertainty regarding their clinical benefits and benefit-to-adverse effects balance. Note that expert opinion for does not imply endorsement but instead signifies that evidence is lacking and the level of certainty in the evidence is low.

Purpose To evaluate aged partially and fully edentulous patients who received dental implants and were maintained over time. Further, to determine how the partially and edentulous ageing populations (65 and above) with dental implants maintain bone levels, proper oral hygiene, and perceive benefits of dental implants. Materials and Methods Since 1995, patients receiving dental implants have been prospectively entered into an Access-based computerized program (Triton Tacking System). Patient demographics (age, sex), bone quality, quantity, implant location, and type of surgery have been continuously entered into the database. The database was queried for patients receiving implants (first stage) between 66 and 93 years of age. Thirty-one patients were within this age group. Twenty-five patients returned to the clinic for periodontal and dental implant evaluation. The Periodontal Index was used to evaluate selected teeth in terms of probing depth, bleeding on probing, plaque accumulation, and mobility. Using NIH Image J, radiographs taken at second stage and last examination were measured for changes in interproximal bone levels. Once identified, each patient anomalously filled out an abbreviated quality of health life form. Due to small sample size, descriptive statistics were used to compare clinical findings. Results Fifteen males ranging from 78 to 84 (mean age 84 years) years and 16 females from 66 to 93 (mean age 83 years) (age range 66–93) were contacted by phone or mail and asked to return to our office for a re-examination. For this group, the first dental implants were placed in 1996 (n = initial two implants) and continuously recorded through 2013 (n = last seven implants). Thirty-one patients received a total of 84 implants. Two patients were edentulous, and the remaining were partially edentulous. Four implants were lost. Between implant placement and 6- to 7-year interval, 13 patients with 40 implants had a cumulative survival rate of 94.6%. Of the original group (n = 33), three were deceased, two were in nursing homes, and three could not be located. Conclusions Aged patients receiving dental implants had excellent implant survival rates, low periodontal disease index scores with minimal changes in interproximal bone levels. Results from this study indicate that patients with advanced age, in reasonably good health, have excellent implant survival rates, excellent quality of life scores, and can be maintained in good oral health.

Background Numerous studies indicate implants placed immediately after extraction or with minimally invasive procedures have excellent long-term success and survival rates. There is general agreement that implants must be stable after implant placement. This study evaluated implant stability changes from the time of implant placement to second stage (prior to restoration). Resonance frequency analysis (RFA) was determined for two commercially available units (Osstell, Osstell USA, Columbia, MD and Penguin, Penguin Integration Diagnostics, Sweden). The unit of measurement was the implant stability quotient (ISQ). Materials and Methods Prior to treatment patients were given medical and dental evaluations. Periapical and panogram radiographs were taken Computerized tomography images were taken for sites where adequate bone volume or quality were uncertain. Thirty patients were enrolled in this study (13 females, 17 males, mean age 73.4 years, (maximum age 90, minimum 47 year total of 38 implants were placed. One implant was lost. Computerized implant planning (Nobel Clinician) Nobel Biocar United States (Nobel Biocare, Yorba Linda, CA) was performed for all patients. Implants were placed utilizing a surgical guide. Using Resonance Frequency anal this study compared two RFA systems for determining implant stability (ISQ; Osstell and Penguin). Measurement pegs were screwed into the implants, and RFA measurements were taken at mesial, distal, lingual, and buccal implant surfaces. Stability measurements were taken at implant placement and at second stage. Clinical data and RFA measurements were recorded on data sheets. The average interval between first and second stages was 144.1 days (range 21.3) Results Average interval between implant placement and second stage was 141.1 days. One implant was lost prior to second stage. The results are based on 30 patients with 38 implants. At second stage, the RFA measures were slightly higher than first stage with a mean increase of 1.15, SE = 0.3, P–.067. The Penguin RFA values were marginally higher than Osstell (mean increase 1.10, SE = 0.64, P

Lower face variability in modern humans has been associated with a series of phenotypic characteristics including body architecture and handedness. The aim of this study was to provide a systematic review of lower face variability and handedness in national health surveys conducted in the United States. Three informative surveys with a total of 13,663 participants were identified. Lower face variability was described as one of six facial phenotypes and related to handedness using logistic regression models while adjusting for sex, ancestry, geography, and income. The results on 13,536 participants with complete information showed that bilateral retrognathism-a marker for a lower face phenotype characterized by a convex facial profile and slender jaws-was associated with a 25% increased odds for non-right-handedness (odds ratio, 1.250; 95% confidence interval: 1.076-1.453, p-value .004). This association between non-right-handedness and a convex facial profile may unexpectedly find its origin in the genetic polymorphisms which determine tuberculosis susceptibility.

Aim To provide a narrative review of the role of macro- and micronutrients in relation to dental caries, gingival bleeding and destructive periodontal disease. Materials & Methods This review is based on systematic reviews (when available) and comparative human studies. Results Dental caries cannot develop without the presence of dietary fermentable carbohydrates, in particular sugar. The susceptibility to develop caries in the presence of carbohydrates may be influenced by genetics and micronutrients such as vitamin D. Gingival bleeding and destructive periodontal disease are sensitive markers to both abnormalities in macronutrient content (excessive carbohydrates or poly-unsaturated fat intake, deficient protein intake) and micronutrient intake (e.g. vitamin C and B12). Conclusion Dental caries and periodontal diseases are a sensitive alarm bell for an unhealthy diet, which predicts the future onset of the diseases of civilizations.

We investigated the relationship between early childhood malnutrition-related measures and subsequent enamel defects in the permanent dentition.This cohort study included 349 Amerindian adolescents (10-17 years, 52% male) from the Bolivian Amazon. Exposures included: stunted growth (height-for-age z-scores), underweight (weight-for-age z-scores), anemia (hemoglobin), acute inflammation (C-reactive protein) and parasitic infection (hookworm). We measured the occurrence (no/yes) and extent (1/3, 1/3-2/3,2/3) of enamel defects. We estimated associations between childhood exposures and enamel defect measures using log-binomial and multinomial logistic regression.The prevalence of an enamel defect characterized by an orange peel texture on a large central depression on the labial surface of the central maxillary incisors was 92.3%. During childhood (1-4 years), participants had a high prevalence of stunted growth (75.2%), anemia (56.9%), acute inflammation (39.1%), and hookworm infection (49.6%). We observed associations between childhood height-for-age (OR = 0.65; P = 0.028 for2/3 extent vs. no EH) and gastrointestinal hookworm infection (OR = 3.43; P = 0.035 for2/3 extent vs. no defects or1/3 extent) with enamel defects.The study describes a possibly novel form of enamel hypoplasia and provides evidence for associations of malnutrition-related measures in early childhood, including stunted growth and parasitic helminth infection, with the observed enamel defects.

Background A panel of experts convened by the American Dental Association (ADA) Council on Scientific Affairs presents evidence-based clinical recommendations regarding professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention. These recommendations are an update of the 2006 ADA recommendations regarding professionally applied topical fluoride and were developed by using a new process that includes conducting a systematic review of primary studies.

Reports of osteonecrosis of the jaw (ONJ) have associated this lesion to treatment with bisphosphonates (BPs) and dental procedures. In this study, we investigated the association of specific dental diagnoses and procedures with ONJ among patients with past BP use.Dentists from three practice-based research networks provided ONJ cases and controls (1:3). Data gathered from patients and dental offices with two respective standard questionnaires included demographic, medical, pharmaceutical, and dental information. Diagnoses and procedures up to 3 years prior to ONJ (prior to interview for controls) were analyzed within risk strata, defined by BP use and cancer status, using interaction terms within conditional logistic regression models.We enrolled 191 ONJ cases and 573 controls from 119 dental offices. Among participants who had used only oral BP, extraction was the only dental risk factor for ONJ (odds ratio (OR) = 12, p = 0.01). Suppuration was also more prevalent in cases (18 %) than in controls (9 %), but not statistically significant (OR = 9, p = 0.06). Among participants who had not used either oral or IV BP (a majority of whom received radiation therapy to the head and neck), suppuration was the only dental risk factor for ONJ (prevalence = 34 % for cases and 8 % for controls; OR = 7, p = 0.01). The prevalence of extractions in this group was also higher, but not statistically significant (44 vs 10 %; OR = 3). Limited power precludes definitive findings among participants exposed to IV BP.Among patients taking oral BP, extraction was the only dental procedure associated with subsequent ONJ developmentResults of this study suggest that routine dental procedures are not associated with development of ONJ in patients exposed to BPs.

Fluctuating asymmetries in the craniofacial skeleton have been shown to be predictive for mortality from degenerative diseases. We investigate whether lower face asymmetries are a potential marker for the developmental origins of health and disease.The lower face of a representative sample of 6654 12- to 17-year old United States (US) adolescents (1966-1970, National Health Examination Survey III) was classified as asymmetric when the mandibular teeth occluded prognathically (forward) or retrognathically (backward) on one side of the face only. It was investigated whether these lower face asymmetries were directional (preferentially to the left or the right) or fluctuating (random left-right distribution) in the US population.Lower face asymmetries affected 1 in 4 of the US adolescents. Unilateral retrognathic dental occlusions were fluctuating asymmetries, had a US prevalence of 17.0% (95% confidence interval: 15.5-18.4) and were associated with race/ethnicity (P .0001), not with handedness (P .7607). Unilateral prognathic dental occlusions were directional asymmetries (P .0001), had a US prevalence of 7.6% (95% confidence interval: 6.4-8.7) and were associated with large household size (P .001) and handedness (P .0223). Lower face asymmetries were not associated with distinct heritable traits such as color blindness.The findings suggest that lower face asymmetries are a marker for environmental stress and cerebral lateralization during early development.

Introduction Most of the published literature on the management of overbite with the Invisalign appliance (Align Technology, Santa Clara, Calif) consists of case reports and case series. Methods In this retrospective study of 120 patients, we sought to assess the nature of overbite changes with the Invisalign appliance. Records were collected from 3 practitioners, all experienced with the Invisalign technique. The patients were consecutively treated adults (>18 years old) who underwent orthodontic treatment only with the Invisalign appliance. Patients with major transverse or anteroposterior changes or extraction treatment plans were excluded. The study sample included 68 patients with normal overbites, 40 with deepbites, and 12 with open bites. Their median age was 33 years, and 70% of the patients were women. Results Cephalometric analyses indicated that the deepbite patients had a median overbite opening of 1.5 mm, whereas the open bite patients had a median deepening of 1.5 mm. The median change for the normal overbite patients was 0.3 mm. Changes in incisor position were responsible for most of the improvements in the deepbite and open bite groups. Minimal changes in molar vertical position and mandibular plane angle were noted. Conclusions The Invisalign appliance appears to manage the vertical dimension relatively well, and the primary mechanism is via incisor movements.

Vitamin D has been used to prevent and treat dental caries. The objective of this study was to conduct a systematic review of controlled clinical trials (CCTs) assessing the impact of vitamin D on dental caries prevention. Random-effects and meta-regression models were used to evaluate overall and subgroup-specific relative-rate estimates. Twenty-four CCTs encompassing 2,827 children met the inclusion criteria. Twenty-two of the 24 CCTs predated modern clinical trial design, some of which nonetheless reported characteristics such as pseudo-randomization (n = 2), blinding (n = 4), or use of placebos (n = 8). The relative-rate estimates of the 24 CCTs exhibited significant heterogeneity (P0.0001), and there was evidence of significant publication bias (P0.001). The pooled relative-rate estimate of supplemental vitamin D was 0.53 (95% CI, 0.43-0.65). No robust differences were identified between the caries-preventive effects of vitamin D(2) , vitamin D(3) , and ultraviolet radiation (ProbF = 0.22). The analysis of CCT data identified vitamin D as a promising caries-preventive agent, leading to a low-certainty conclusion that vitamin D may reduce the incidence of caries.

Our understanding of the causes of periodontal disease have two major competing paradigms: one that focuses on ‘local’ etiologic factors and one that focuses on remote ‘host-level’ factors. We provide a historical overview of local and remote cause hypotheses and discuss some key reasons why the local cause hypothesis has become dominant.

The availability of automated administrative databases in medical and dental healthcare, combined with modern computing power, allows sophisticated multi-layered analyses of the causes and consequences of care delivered to large populations. These automated databases are now also commonly linked to data extracted from electronic medical records, and are used to measure health system performance, adjust payments, assess providers for quality improvement purposes, and inform policy decisions. Use of health insurance databases can be particularly powerful when linked through common unique identifiers to allow examination of the influences of dental care on medical outcomes and costs, and vice versa. This review describes the growing use of these databases for epidemiological and health services research, their advantages and limitations, and presents a case study in which dental claims data are used to identify persons with periodontitis in order to enable critical assessment of the relationship between periodontal interventions and systemic health outcomes/medical costs.

The distribution of branded drug samples in an educational setting may obscure the line between an evidence-based and a marketing-based education. The aim of this study was to evaluate the impact of branded drug samples on clinical recommenda- tions in a dental education setting. Survey respondents exposed (n=95) and unexposed (n=80) to a specific branded drug sample program containing non-patented ingredients responded to a brief questionnare on recommendations for dentinal hypersensitivity. The results showed that an exposure to the branded drug sample was associated with twelve-fold increased odds for recommend- ing the brand name (95 percent confidence interval (CI): 5.8-24.5; p

To determine the long-term safety and benefit of a new intraoral bone conduction device (SoundBite Hearing System by Sonitus Medical) for single-sided deafness (SSD).A multi-center, controlled, nonrandomized, prospective unblinded study of SSD patients wearing the device over a 6-month period.Ambulatory care centers typical of those where SSD patients are diagnosed and treated.Adults (N = 22) with acquired, permanent SSD and no current use of any other SSD device.Continual daily wear of the new device for 6 months.Comprehensive medical, audiologic, and dental measures; aided thresholds; Abbreviated Profile of Hearing Aid Benefit scores, and an SSD questionnaire.There were no related adverse events or changes in the medical or audiologic findings at the end of the trial compared with the beginning. There were no significant changes in the mean aided thresholds (p0.01) or the mean dental measures (p0.05) at 3 or 6 months compared with pretrial measures. The mean Abbreviated Profile of Hearing Aid Benefit benefit scores showed improvement (p0.01) for the Background Noise, Reverberation, and Ease of Communication subscales and the Global scale at 3 and 6 months. The results of the SSD questionnaire indicated that the vast majority (90%) of the subjects reported satisfaction and improvement in a variety of areas after wearing the device long term.The SoundBite system is safe and continues to provide substantial benefit for SSD patients with continual daily use over a 6-month period.

Introduction Anterior open-bite (AOB) treatment is considered challenging because of difficulties in determining and addressing etiologic factors and the potential for relapse in the vertical dimension after treatment. In this review, we compiled evidence on the long-term stability of the major therapeutic interventions for correcting AOB. Our objective was to review and compile evidence for the stability of surgical and nonsurgical therapies for AOB malocclusion. Our data sources were PubMed, EMBASE, Cochrane Library, limited gray literature search, and hand searching. Methods A search was performed of the electronic health literature on the stability of AOB after treatment. Hand searching of major orthodontic journals and limited gray literature searching was also performed, and all pertinent abstracts were reviewed for inclusion. Full articles were retrieved for abstracts or titles that met the initial inclusion criteria or lacked sufficient detail for immediate exclusion. Studies accepted for analysis were reviewed and their relevant data retrieved for pooling. The long-term stability estimates were pooled into nonsurgical and surgical groups, and summary statistics were generated. Results One hundred five abstracts met the initial search criteria, and 21 articles were included in final analyses. Rejected articles failed to exhibit follow-up times of 12 months or more, did not include measurements of overbite (OB), or did not meet inclusion criteria. All included articles were divided into a surgical group (SX) with a mean age of 23.3 years and a nonsurgical group (NSX) with a mean age of 16.4 years. All studies were case series. Random-effects statistical models were used to pool the mean OB measures before and after treatment and also at the long-term follow-up. The pretreatment adjusted means of OB were –2.8 mm for the SX and –2.5 mm for the NSX. AOB closures up to +1.6 mm (SX) and +1.4 mm (NSX) were achieved. Relapse in the SX group during the mean 3.5 years of follow-up reduced the OB to +1.3 mm; the NSX group relapsed to +0.8 mm in the mean 3.2 years of follow-up. Pooled results indicated reasonable stability of both the SX (82%) and NSX (75%) treatments of AOB measured by positive OB at 12 or more months after the treatment interventions. Conclusions In the included case series publications, success of both the SX and NSX treatments of AOB appeared to be greater than 75%. Because the SX and the NSX were examined in different studies and applied to different clinical populations, no direct assessment of comparative effectiveness was possible. The pooled results should be viewed with caution because of the lack of within-study control groups and the variability among studies.

Background This article presents evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question: Is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition? Types of Studies Reviewed A panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question. Results CEBD staff identified one systematic review and two clinical studies. The panel reviewed this evidence to develop recommendations. Clinical Implications The panel suggested that when dentists advise parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition, they can suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risks of enamel fluorosis development. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences.

OBJECTIVE Compare GHb among people with diabetes who have and have not received periodontal care. RESEARCH DESIGN AND METHODS This cross-sectional study linked 5 years of electronic medical record and dental insurance data for dually insured patients with diabetes, ages 40–70 years (n = 5,103). We assessed the association between annual mean GHb (%) and periodontal care (a proxy for periodontitis) defined using claim codes. Among patients who received periodontal care, we assessed the association between GHb and periodontal treatment intensity. We determined associations using linear regression adjusted for potential confounders and tested for effect modification by age, sex, insulin use, diabetes severity, BMI, and smoking. RESULTS Mean GHb was 7.66%; 38% of participants received periodontal care during the 5 years. After multivariate adjustment, patients who received periodontal care had a GHb level 0.08 percentage points higher than patients who did not (P = 0.02). In stratified analyses, the association was present for women (0.18 percentage points higher GHb with periodontal care, P < 0.001) but not significant for men (0.008 percentage points lower, P = 0.86). In patients who received periodontal care, those with one, and with two or more, surgical treatments had GHb 0.25 (P = 0.04) and 0.36 (P = 0.002) percentage points lower, respectively, than patients without periodontal surgeries. CONCLUSIONS This population-based cross-sectional study showed small associations between periodontal care (a proxy for periodontitis) and higher GHb. Well-controlled longitudinal studies or clinical trials are needed to evaluate causality and temporal trends. Sub-analyses suggest that further investigation of this association among women, and by intensity of periodontal treatment, may be of interest.

Background Researchers have considered infant formula consumption a potential risk factor for enamel fluorosis in the U.S. population. The authors conducted a systematic review of controlled studies regarding the risk of developing enamel fluorosis associated with use of infant formula. Methods One reviewer independently conducted systematic searches in eight databases. The authors then abstracted information, assessed study quality and combined odds ratios (ORs), when obtainable, by using a random-effects model. Results After evaluating 969 potentially eligible published studies, the reviewers found that the authors of 41 studies had evaluated the effect of infant formula on enamel fluorosis risk. Authors of 14 of the 41 studies did not report their findings in their results. The authors of the remaining 27 published studies reported the findings of 19 observational studies; authors of 17 of these 19 studies reported ORs and, among these, infant formula consumption was associated with a higher prevalence of enamel fluorosis in the permanent dentition (summary OR 1.8, 95 percent confidence interval [CI] 1.4–2.3). There was significant heterogeneity among studies (I 2 66 percent) and evidence of publication bias ( P = .002). A metaregression analysis indicated that the ORs associating infant formula with enamel fluorosis increased by 5 percent for each 0.1–part-per-million increase in the reported levels of fluoride in the water supply (OR 1.05, 95 percent CI 1.02–1.09). Clinical Implications Infant formula consumption may be associated with an increased risk of developing at least some detectable level of enamel fluorosis, which depends on the level of fluoride in the water supply. The evidence that the fluoride in the infant formula caused enamel fluorosis was weak, as other mechanisms could explain the observed association.

Background: The placement of implants using a minimally invasive flapless approach has the potential to reduce operative bleeding and postoperative discomfort and minimize crestal bone loss. This article presents follow-up data on a prospective clinical study of implants placed using a flapless procedure. Methods: The original study reported on 57 patients (33 female patients with an age range of 24 to 86 years; 24 male patients with an age range of 27 to 81 years) recruited from three clinical centers (Tucson, Arizona; Gothenburg, Sweden; and Tel Aviv, Israel) who received 79 implants. After an average of 3 years and 8 months, the patients were contacted and invited to return to their respective clinics for reexamination. Thirty-seven patients with 52 implants returned for a follow-up examination; the remaining 20 patients (27 implants) were not available for reexamination and were considered study drop-outs. Results: The cumulative survival rate at the 3- to 4-year follow-up examination remains at 98.7%, reflecting the loss of one implant. The mean probing depth at abutment connection was 2.2 mm, as reported in the initial study (examination 2 at ;2 years postplacement); it was 2.4 mm at the 3- to 4-year second follow-up examination. This change was not clinically or statistically significant. Bleeding score changes also were not significant between the two intervals. The average crestal bone level was -0.7 mm at examination 2 and -0.8 mm at examination 3, a change that approached significance (P

Translating basic science evidence into clinical trials is particularly challenging. The term translationist can refer to an individual who translates evidence into clinical action or an individual who has to choose the most promising intervention among alternatives and move it forward toward definitive randomized clinical trials. With respect to the first type of translationist, translating evidence into clinical action is most promising when there is unequivocal evidence that an intervention provides tangible patient benefits, preferably from rigorously designed randomized trials based on true end points. In the absence of such evidence, translation is challenging and can cause more harm than good, as has been illustrated by the rise and fall of treatments such as hormone replacement therapy, antioxidants, and temporomandibular joint implants. With respect to the second type of translationist, picking a most promising scientific finding and moving it toward clinical trials can be challenging; the future is inherently unpredictable and the value of major innovations—including medical innovations—often remains unrecognized at the time of discovery. Sound epidemiology, mechanistic studies on methods of action, and a comprehensive series of exploratory trials may help in improving the translation of promising findings to unequivocal evidence. Whether such suggestions on identifying promising treatments will lead to a larger success rate in successful translation remains to be determined. TRANSLATING EVIDENCE INTO PRACTICE

Knowledge of typical medication use among patients with chronic periodontitis or destructive periodontal disease is limited. The aim of this study was to associate periodontitis severity with the use of different classes of medications.Patients (N=12,631) who had medical, dental, and pharmaceutical coverage with a health maintenance organization and whose severity of destructive periodontal disease was diagnosed by a dentist or specialist were included in the study. The rate of drug use over 7 years was related to the severity of destructive periodontal disease by means of Poisson regression models.Individuals with moderate to advanced periodontitis had significantly lower fill rates for the respiratory agents (antihistamines: -23%, 95% confidence interval [CI]: -10% to -34%; decongestants: -24%, 95% CI: -13% to -34%; and cough/cold medications: -12%, 95% CI: -3% to -21%) and anti-infective agents (antibiotics: -12%, 95% confidence interval: -6% to -18%; urinary anti-infectives: -36%, 95% CI: -6% to -56%; and topical antibiotics: -18%, 95% CI: -5% to -29%).More severe periodontitis was a marker for reduced medication use for allergies and infections. The associations between destructive periodontal disease, infections, allergies, and the hygiene hypothesis need further exploration.

Background Orthodontic therapy has been suggested to lead to an improved periodontal status through mechanisms such as increased ease of plaque removal and reduced occlusal trauma. The objective of the authors' systematic review was to compare contemporary orthodontic treatment with no intervention, by means of evaluating periodontal outcomes measured after end of treatment. Methods The authors completed electronic searches in eight databases (1980–2006) and hand searches in six dental journals (1980–2006). They extracted data using standardized forms and calculated weighted mean differences. Results Weak evidence from one randomized study and 11 nonrandomized studies suggested that orthodontic therapy was associated with 0.03 millimeters of gingival recession (95 percent confidence interval [CI], 0.01–0.04), 0.13 mm of alveolar bone loss (95 percent CI, 0.07–0.20) and 0.23 mm of increased pocket depth (95 percent CI, 0.15–0.30) when compared with no treatment. The effects of orthodontic therapy on gingivitis and attachment loss were inconsistent across studies. Conclusions This systematic review identified an absence of reliable evidence describing positive effects of orthodontic treatment on periodontal health. The existing evidence suggests that orthodontic therapy results in small detrimental effects to the periodontium.

Introduction: The high prevalence of orthodontic treatment in young people makes the associated radiation to the head and neck of potential public-health significance. In this study, we estimated secular changes (1963-2003) in age-specific organ doses associated with orthodontic care and collective organ doses in the United States in 1999. Methods: A survey of radiographic records at 1 university clinic was combined with published estimates to provide organ-specific radiation doses. Collective organ doses were estimated from the 1999 US Nationwide Evaluation of X-ray Trends and published orthodontic utilization surveys. Results: Before 1992, orthodontic care in a university setting was associated with mean doses of 7.0 milligrays (mGy) to the thyroid, 0.8 mGy to the red bone marrow, 2.7 mGy to the brain, 13.2 mGy to the salivary glands, and 5.1 mGy to the bone. After 1992, the doses decreased to 2.8 mGy to the thyroid, 0.3 mGy to the red bone marrow, 0.7 mGy to the brain, 6.2 mGy to the saliva glands, and 2.4 mGy to the bone. Around 1999, the collective doses associated with orthodontic care in the United States in patients less than 19 years of age were 400 Gy to the red bone marrow and 3800 Gy to the thyroid. Conclusions: Orthodontic care, in part due to its high prevalence, potentially contributes significantly to the diagnostic radiation burden in those less than 19 years old in the United States.

Background and Objective: The purpose of this study was to assess the oral health-related quality of life of patients presenting to a periodontal specialist by means of six questions, and to assess the perceived oral health by means of one question. Self-assessments of oral health were associated with clinical characteristics. Material and Methods: Logistic regression models were used to associate self-assessments with clinical characteristics in a cross-sectional study. Results: On the six-item questionnaire, close to 20% (295/1480) of the patients reported that teeth, gums or dentures had an impact fairly often or very often on one or more items (eating, relaxing, avoiding going out, feeling self-conscious, pain or discomfort). On the single question requesting a self-assessment of oral health, 42% (628/1468) rated their oral health as fair or poor. Both common oral health-related quality of life problems and worse perceived oral health were associated with having more than eight teeth with >5 mm periodontal pockets (odds ratio = 1.45, 95% confidence interval = 1.01–2.08; and odds ratio = 2.83, 95% confidence interval = 2.08–3.84, respectively), compared with patients who had fewer than three teeth with >5 mm periodontal pockets. Conclusion: Oral health-related problems in patients presenting to a periodontal specialist office negatively affect their quality of life. If some of the findings of this study can be confirmed in other studies, it could change the perception of chronic periodontitis as a silent disease.