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The dental gingivae are a unique part of the oral anatomy and an integral part of the periodontal tissues. Although the vast majority of abnormalities affecting the gingival tissues are due to a simple inflammatory reaction directly related to the presence of dental plaque, a range of non-plaque-related conditions also occur due to either local or systemic factors. Such factors include developmental abnormalities, the presence of malignancy and manifestations of underlying systemic conditions. Recognition and diagnosis of non-plaque-related gingival disease is essential for comprehensive dental health care. CPD/Clinical Relevance: This paper provides a review of the spectrum of non-plaque-related conditions that can affect the dental gingivae.

The dental gingivae are a unique part of the oral anatomy and an integral part of the periodontal tissues. Although the vast majority of abnormalities affecting the gingival tissues are due to a simple inflammatory reaction directly related to the presence of dental plaque, a range of non-plaque-related conditions also occur due to either local or systemic factors. Such factors include developmental abnormalities, the presence of malignancy and manifestations of underlying systemic conditions. Recognition and diagnosis of non-plaque-related gingival disease is essential for comprehensive dental health care. CPD/Clinical Relevance: This paper provides a review of the spectrum of non-plaque-related conditions that can affect the dental gingivae.

The incidence of mouth cancer in the UK has increased more than 30% during the past decade and the overall 5-year survival remains poor, at approximately 55%. A number of risk factors for mouth cancer has been identified, and all dental professionals should be aware of these, and, where possible, provide intervention. Some cases of mouth cancer arise in a pre-existing mucosal condition, known as an oral potentially malignant disorder (OPMD). Awareness of the presence of an OPMD, or any mucosal changes that fulfil the criteria for urgent suspected cancer (USC) in primary care, should lead to an appropriate referral to specialist services. CPD/Clinical Relevance: This paper provides a review of the risk factors for mouth cancer and potentially malignant disorders.

Objectives\ud \ud To determine whether phenotypic and genotypic differences amongst isolates ofEnterococcus faecalis relate to geographical and clinical origin.\ud \ud \ud Methods\ud \ud E. faecalis from primary endodontic infections in Brazilian patients (n = 20), oral infections in UK patients (n = 10), and non-oral infections in Japanese patients (n = 9) were studied. In addition, 20 environmental vancomycin resistant Enterococcus faecalis (VRE) isolates from a UK hospital were analysed. For all isolates, polymerase chain reaction (PCR) was used to detect genes associated with antibiotic resistance and virulence, whilst randomly amplified polymorphic DNA-PCR (RAPD-PCR) was used to produce molecular profiles.\ud \ud \ud Results\ud \ud Gelatinase gene (gelE) was prevalent amongst isolates (77–100%) and for oral isolates, genes of aggregation substances (agg), immune evasion protein (esp), cytolysin (cylB), tetracycline resistance (tetM; tetL) and erythromycin resistance (ermB) were detected to varying extent. Japanese non-oral isolates had a similar genetic profile to oral isolates, but with higher prevalence of ermB and cylB. All VRE isolates were positive for gelE, esp, agg, vanA, ermB and tetM, 95% were positive for cylB and 17% positive for tetL. All isolates were negative for ermA, asa373 vanB, vanC1 and vanC2/3. RAPD-PCR revealed clustering of VRE isolates.\ud \ud \ud Conclusions\ud \ud RAPD-PCR analysis revealed extensive genetic variability among the tested isolates. Oral isolates carried antibiotic resistance genes for tetracycline and whilst they possessed genes that could contribute to pathogenicity, these were detected at lower incidence compared with non-oral and VRE isolates. RAPD-PCR proved to be a useful approach to elucidate relatedness of disparate isolates.

The COVID-19 pandemic has drawn attention to microbial transmission risk via aerosols in dental practice. Demonstration electric toothbrushes are used intra-orally for education. The aim of this investigation was to measure the size of droplets emitted by the brush head of two demonstration oscillating-rotating electric toothbrushes. Measurement of droplet production and size was recorded in vitro using three methods: (1) Malvern Spraytec (LASER particle size measurement device with detectable particle size of 0.1–2500 µm) and brushes mounted on a 3D-printed, two-shell form-fit fixture with a supply of tap water, (2) a DustTrak aerosol measurement device and toothpaste slurry, with brushing simulated in the oral cavity of a phantom head, (3) high-speed visualization in a simulated-use situation in the oral cavity of a phantom head, with individual evaluation of tap water, water with detergent, 70% ethanol, glycerin and toothpaste slurry. Both brushes showed the size of emitted droplets was consistently between 200 and 1200 µm, categorized as splatter (dental aerosols are &lt, 50 µm diameter). No significant incremental aerosol-sized matter was detected during toothbrush operation. The high-speed video visualization confirmed only splatter-sized droplets during operation. These findings indicate that oscillating-rotating toothbrushes do not produce aerosol-sized particles during simulated use.

Candida is a fungus (yeast) that is generally regarded as a normal and harmless member of the oral microbiome in humans. Should host defences against these commensals be compromised in any way then Candida can cause clinical signs and symptoms, which manifest as distinct forms of oral candidosis (candidiasis). Candida albicans is the most frequently isolated candidal species from the oral cavity, although a range of non-C. albicans Candida species are being increasingly encountered. The basic principle of the management of candidosis is to identify and eliminate any underlying host predisposing factor. However, in many cases, antifungal therapy will also be required as part of initial management. This article will provide an overview of the isolation, identification and pathogenicity of Candida species encountered within the mouth and relate these to clinical management of oral candidosis.\ud Word count

The increasing emergence of antibiotic resistance is a major international public health problem. As a consequence, it is essential that steps are taken to conserve the effectiveness of existing antimicrobial agents. Consumption of antibiotics is the prime contributor to the development of resistance. General dental practitioners write almost 1 out of 10 prescriptions for antibiotics in primary care within the UK and therefore the prudent prescribing of antibiotics in dentistry has never been more vital. This paper outlines the impact of antimicrobial resistance on modern healthcare, describes the current use of antibiotics in general dental practice, and recommends pragmatic ways in which dental practitioners can evaluate and optimize their prescribing. CPD/Clinical Relevance: Dental professionals have a responsibility to both their patients and the wider community to prescribe antibiotics appropriately.

Histological, haematological and microbiological investigations are essential in the field of oral medicine and are a crucial adjunct to clinical findings, often being relied on to obtain a definitive diagnosis. Importantly, in some cases, these investigations can help exclude or confirm the presence of malignancy. This project highlighted some problems regarding labelling and recording of specimens in an oral medicine department and a lack of clear specimen management processes. It aimed to improve specimen management by reducing reported incidents surrounding diagnostic tests. Quality improvement methods such as process mapping were key to understanding the journey of specimens and the departments involved at each stage of the system. Initiatives included a recording log book, staff training, information signage around the clinic and delegation of responsibilities, all of which were implemented over multiple plan, do, study, act (PDSA) cycles. The project was extremely successful and since implementation there has been a clear and sustained reduction in reported incidents. The small number of incidents which did occur all involved transportation of specimens and none involved labelling or recording. One can conclude that the change in test management systems in terms of recording and labelling of specimens in the department has been sustained. Ongoing engagement with stakeholders and senior leaders is the priority to ensure further reduction in incidents in the future and that the improvements are maintained. This project demonstrates how simple, realistic, cost-effective, quality improvement initiatives can have a significant positive impact on patient care and hospital management systems.

Denture-associated stomatitis (DS) affects over two-thirds of denture-wearers. DS presents as erythema of the palatal mucosa in areas where denture-surface associated polymicrobial biofilms containing the fungus Candida albicans exist. The contribution of the oral bacterial microbiota toward the infection is unknown. Therefore, this study characterised the bacterial microbiota of sites within the oral cavity to identify potential associations with occurrence of DS. Denture-wearing patients were recruited (denture stomatitis (DS) n = 8; non-denture stomatitis (NoDS) n = 11) and the oral bacterial microbiota of the tongue, palate and denture-fitting surface was characterised using next-generation sequencing. Operational taxonomic units (OTUs) were identified to bacterial genera and species, and presence/absence and relative abundances were examined. A significant (P = 0.007) decrease in the number of OTUs and thus, diversity of the microbiota was observed in tongue samples of DS patients (vs non-DS). The microbiota of denture-fitting surfaces and palatal mucosae were similar. Large differences in the abundance of bacterial genera and species were observed at each sample site, and unique presence/absence of bacteria was noted. Presence/absence and relative abundance of specific bacteria associated with DS warrants further in vitro and in vivo evaluation, particularly as our previous work has shown C. albicans virulence factor modulation by oral bacteria.

The profile of the inflammatory cell infiltrate in chronic hyperplastic candidosis (CHC) was determined in oral mucosal biopsies by immunohistochemistry. One tonsillar tissue section was included as an immunohistochemistry control, whilst squamous papilloma (n = 4) with secondary Candida infection was used as Candida controls. Oral lichen planus tissues (n = 10) provided negative controls for Candida presence, as well as positive controls for inflammation. Immunohistochemistry employed antibodies specific for CD3+ (T lymphocytes), CD4+ (T helper cells), CD8+ (cytotoxic T cells), and CD20+ (B lymphocytes). Manual counting of stained cells from digitised images determined the proportion of each cell type relative to the total number of cells, and these were assessed in the mucosa, the epithelium, and the lamina propria. The mean proportion of CD3+ cells was significantly higher than CD20+ cells in all tissue types. For CHC, the mean proportion of CD3+ cells in entire tissues was 15.6%, with the highest proportion in the lamina propria (32.6%) compared with the epithelium (3.9%). CD20+ cells were in much lower proportions (1.8%) in CHC, with the highest proportion (3.6%) in the lamina propria. T lymphocytes were predominately CD4+ cells (9.0%) compared with CD8+ cells (4.4%). CD4+ cells were most prevalent in the lamina propria (23.1%) compared with the epithelium (mean = 3.2%). From these results, it was concluded that the immune response invoked by Candida in CHC is primarily driven by the T helper cells.

Background Orofacial infections when treated by dental practitioners are not routinely sampled for culture and susceptibility testing. Consequently, antimicrobial resistant rates amongst the causative bacteria are unknown, hindering efforts to appropriately manage these infections and undertake surveillance of resistant rates. As part of the Cardiff health board leadership in patient safety quality improvement programme a multidisciplinary group was tasked with the aim of improving sampling practices. Methods Dental professionals' limited knowledge regarding the role of diagnostic support and an associated lack of confidence in sampling procedures was addressed by the creation and distribution of training aids. Sampling and transportation kits were developed and transport routes identified enabling dentists within the community setting to send samples to the specialist microbiology services based at Cardiff University Dental Hospital [UDH]. All significant anaerobes were identified and antibiotic susceptibility testing undertaken via agar dilution through referral of isolates to the UK Anaerobic Reference Unit. Results A 10% increase was seen in the proportion of pus aspirates being received in comparison to pus swabs. For the first time, pus aspirate samples have been received from community dental clinics. A vast diversity of anaerob species and susceptibility profiles have been identified. Increasing rates of resistance amongst Prevotella species to amoxicillin and clindamycin is of concern. Conclusion This project has shown that through educational interventions and support the barriers to the sampling of orofacial infections can be overcome. The ultimate aim is for all dentists in Wales to have access to diagnostic support.

Purpose In mechanically ventilated patients, the endotracheal tube is an essential interface between the patient and ventilator, but inadvertently, it also facilitates the development of ventilator-associated pneumonia (VAP) by subverting pulmonary host defenses. A number of investigations suggest that bacteria colonizing the oral cavity may be important in the etiology of VAP. The present study evaluated microbial changes that occurred in dental plaque and lower airways of 107 critically ill mechanically ventilated patients. Materials and Methods Dental plaque and lower airways fluid was collected during the course of mechanical ventilation, with additional samples of dental plaque obtained during the entirety of patients' hospital stay. Results A “microbial shift” occurred in dental plaque, with colonization by potential VAP pathogens, namely, Staphylococcus aureus and Pseudomonas aeruginosa in 35 patients. Post-extubation analyses revealed that 70% and 55% of patients whose dental plaque included S aureus and P aeruginosa, respectively, reverted back to having a predominantly normal oral microbiota. Respiratory pathogens were also isolated from the lower airways and within the endotracheal tube biofilms. Conclusions To the best of our knowledge, this is the largest study to date exploring oral microbial changes during both mechanical ventilation and after recovery from critical illness. Based on these findings, it was apparent that during mechanical ventilation, dental plaque represents a source of potential VAP pathogens.

Not surprisingly, a wide range of systemic medical condition can either have specific orofacial manifestations or influence oral health and delivery of dental care.

The prescribing of medicines is an integral part of dental primary care and it is essential that this aspect of healthcare is delivered appropriately and effectively.

A variety of special investigations are routinely used to aid clinical diagnosis. It is clearly not necessary to perform a large number of special investigations on every patient and tests should therefore be limited to those which are most appropriate.

In health salivary production alters during the day depending on the need for saliva in the mouth. For example, when at rest or asleep salivary production is low whilst during eating salivary production is stimulated and greatly increased. However, a number of conditions can have a sustained impact on salivary production which may be either reduced or increased.

A number of developmental, infective, inflammatory, acquired and neoplastic conditions of the oral mucosa may present as erythematous patches.

Mouth cancer can present as a variety of abnormalities and visible changes affecting the oral mucosa, including ulceration, swelling and areas of erythema. The five-year survival from mouth cancer is poor at approximately 50%. Detection of the cancer while less than 2 cm in diameter with no metastasis greatly improves the outcome for the patient. Although many cancers in the mouth develop from what was previously an apparently normal mucosa, some arise in pre-existing conditions that are therefore regarded as potentially malignant. Regular assessment of the soft tissues within the mouth and the neck for the presence of abnormalities is an essential component of primary dental care. Any persistent and unexplained abnormality requires referral for definitive diagnosis and specialist management.

This study examined the influence of bacteria on the virulence and pathogenicity of candidal biofilms. Mature biofilms (Candida albicans-only, bacteria-only, C. albicans with bacteria) were generated on acrylic and either analysed directly, or used to infect a reconstituted human oral epithelium (RHOE). Analyses included Candida hyphae enumeration and assessment of Candida virulence gene expression. Lactate dehydrogenase (LDH) activity and Candida tissue invasion following biofilm infection of the RHOE were also measured. Candida hyphae were more prevalent (p < 0.05) in acrylic biofilms also containing bacteria, with genes encoding secreted aspartyl-proteinases (SAP4/SAP6) and hyphal-wall protein (HWP1) up-regulated (p < 0.05). Candida adhesin genes (ALS3/EPA1), SAP6 and HWP1 were up-regulated in mixed-species biofilm infections of RHOE. Multi-species infections exhibited higher hyphal proportions (p < 0.05), up-regulation of IL-18, higher LDH activity and tissue invasion. As the presence of bacteria in acrylic biofilms promoted Candida virulence, consideration should be given to the bacterial component when managing denture biofilm associated candidoses.

Purpose:\ud \ud Mechanically ventilated patients are at risk for developing ventilator-associated pneumonia, and it has been reported that dental plaque provides a reservoir of respiratory pathogens that may aspirate to the lungs and endotracheal tube (ETT) biofilms. For the first time, metataxonomics was used to simultaneously characterize the microbiome of dental plaque, ETTs, and non-directed bronchial lavages (NBLs) in mechanically ventilated patients to determine similarities in respective microbial communities and therefore likely associations.\ud \ud Material and methods:\ud \ud Bacterial 16S rRNA gene sequences from 34 samples of dental plaque, NBLs, and ETTs from 12 adult mechanically ventilated patients were analyzed.\ud \ud Results:\ud \ud No significant differences in the microbial communities of these samples were evident. Detected bacteria were primarily oral species (e.g., Fusobacterium nucleatum, Streptococcus salivarius, Prevotella melaninogenica) with respiratory pathogens (Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcuspneumoniae, and Haemophilus influenzae) also in high abundance.\ud \ud Conclusion:\ud \ud The high similarity between the microbiomes of dental plaque, NBLs, and ETTs suggests that the oral cavity is indeed an important site involved in microbial aspiration to the lower airway and ETT. As such, maintenance of good oral hygiene is likely to be highly important in limiting aspiration of bacteria in this vulnerable patient group.

In comparison to the range of antibiotics used in medicine, the spectrum of antifungal and antiviral drugs used in primary dental care is relatively limited. In practical terms, there are only three antifungal agents and two antiviral agents that have a role. This paper will describe the clinical presentation of orofacial candidal and viral infections and the use of antimicrobial drugs in their management.

a b s t r a c t Objectives: To determine the phenotypic and molecular characteristics of Enterococcus faecalis recovered from primary endodontic infections in Brazilian patients. Methods: Twenty isolates of E. faecalis recovered from 43 Brazilian patients with primary endodontic infections were identified by biochemical profiling (API20Strep) and 16S rDNA sequencing. Antimicrobial susceptibility was ascertained by agar dilution, using the recommended protocol of the Clinical and Laboratory Standards Institute (CLSI). PCR with validated primers was used to detect genes associated with antibiotic resistance and specific virulence factors. Results: All isolates were deemed susceptible to penicillin G, erythromycin and vancomycin. However, nine isolates had a minimum inhibitory concentration of 4 mg/mL to vancomycin (the resistance breakpoint). Fourteen isolates (70% of isolates) were also resistant to tetracycline with MICs of >64 mg/mL. PCR products for tetracycline resistance genes were detected in test isolates, while erythromycin and vancomycin resistance genes were not evident. Gelatinase, aggregation substance and enteroccocal surface protein genes were detected in 20, 18 and 12 isolates, respectively. Conclusions: Endodontic E. faecalis isolates exhibit high level of resistance to tetracycline, an antibiotic that has use in local treatment of dental infections. This opens up a much-needed debate on the role and efficacy of this antibiotic for oral infections. Furthermore, these isolates were shown to possess genes that could contribute to pathogenicity in the pulp cavity.

Human infections involving yeast of the genusCandidaoften occur in the presence of bacteria, and, as such, it is important to understand how these bacteria influence innate host immunity towardsCandida. Dectin-1 is a cell receptor of macrophages forCandida albicansrecognition. The aim of this study was to examine dectin-1 expression by monocytes after stimulation with bacterial lipopolysaccharide (LPS), followed by heat-killedC. albicans(HKC). Freshly isolated human peripheral blood monocytes (PBMCs) and human monocytes cell line (THP-1) cells expressed low levels of dectin-1. Stimulation with LPS and GM-CSF/IL-4 was found to increase dectin-1 expression in both CD14+human PBMC and THP-1 cells. Enhanced dectin-1 expression resulted in increased phagocytosis ofCandida. When THP-1 cells were challenged only with HKC, detectable levels of IL-23 were not evident. However, challenge by LPS followed by varying concentrations of HKC resulted in increased IL-23 expression by THP-1 cells in HKC dose-dependent manner. Increased expression of IL-17 by PBMC also occurred after stimulation withCandidaand LPS. In conclusion, bacterial LPS induces an enhanced immune response toCandidaby immune cells, and this occurs through increasing dectin-1 expression.

In the winter of 2007-08 a new public-facing antimicrobial campaign was agreed by the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infection (ARHAI) Education sub-Group (later divided into subgroups for professional and public education): it comprised posters with a positive message on how the public could help themselves when they had a cold. However, the poster campaign, used in isolation in England, did not improve antibiotic use; therefore, the Public Education sub-Group took forward educational approaches to change the behaviour of the public and health professionals. Professionals have been encouraged to give patients clear information about the likely duration of symptoms, self-care, and benefits and harms of antibiotics, reinforcing the public poster campaigns in surgeries, hospitals and pharmacies. Since 2008, campaigns have been launched in England to coincide with European Antibiotic Awareness Day (EAAD) on 18 November, using Department of Health and EAAD materials. Professional education has been facilitated by the 2008 National Institute for Health and Clinical Excellence respiratory tract infection delayed prescribing guidance for general practitioners. A toolkit of materials for medicines management teams, to facilitate good antimicrobial stewardship in primary care (ASPIC), is being taken forward by the Public Education sub-Group and professional societies. After advice from ARHAI, in 2009 the General Medical Council requested that all postgraduate deans and Royal Colleges ensure infection prevention and control and antimicrobial prescribing become standard practice implemented in all clinical settings, and that they are emphasized strongly in undergraduate and postgraduate medical training. ARHAI has also taken a keen interest in reviewing, advising and leading on a number of European Union initiatives dealing with professional education.

Aim: To evaluate a disinfection and decontamination dental postgraduate course run by the Wales Dental Postgraduate Deanery between 2008 and 2010. Methods: Pre- and post-course multiple choice questionnaires were completed by 1177 course attendees. Mean scores before and after participation on the training course were compared and analysed. Results: Mean pre-course score was 45.3%, rising to 87.0% in the post-course assessment, reflecting an improvement of 41.8%. Prior to training, 30.7% achieved a satisfactory score of 13/20 (65%) compared to 98.3% on completion of training. Dental technicians were found to score significantly lower than other occupation groups both before and after course attendance. Decade of graduation had no effect on results. Theoretical microbiology was the question area which showed least improvement. Conclusion: Attending the disinfection and decontamination course significantly improved participants’ knowledge. Theoretical microbiology, as a topic area, may be targeted for improvements in future courses to improve results further.

Candida albicansis an opportunistic fungal pathogen that normally exists as a harmless commensal in humans. In instances where host debilitation occurs,Candidacan cause a range of clinical infections, and whilst these are primarily superficial, effecting mucosal membranes, systemic infections can develop in severely immunocompromised individuals. The mechanism of host immunity during commensal carriage ofC. albicanshas been intensively studied. In this paper, we present the most recent information concerning host recognition ofC. albicansleading to cytokine production and the subsequent T-cell responses generated in response toC. albicans. Particular focus is given to the role of the IL-12 cytokine family including IL-12, IL-23, IL-27, and IL-35, in host immunity toCandida. T-cells are considered crucial in the regulation of immunity and inflammation. In this regard, the role of Th1/2, helper cells, together with the recently identified Th17 and Treg cells in candidosis will be discussed. Understanding the detailed mechanisms that underlie host immunity toCandidanot only will be of benefit in terms of the infections caused by this organism but could also be exploited in the development of therapeutic interventions for other diseases.

Background X-linked inhibitor of apoptosis protein (XIAP) is a member of the inhibitor of apoptosis proteins family of caspase inhibitors. Expression of XIAP in various neoplasms has been associated with aggressive behavior. The biological progression from pleomorphic adenoma (PA) to carcinoma ex pleomorphic adenoma (CXPA) has been poorly understood. We studied XIAP expression by immunohistochemistry in PA and CXPA. Materials and methods Formalin-fixed, paraffin-embedded representative sections of 14 cases of PA and seven cases of CXPA (four invasive and three intracapsular) were stained with anti-XIAP (# 610763; BD Biosciences, San Jose, CA, USA) following citrate-based antigen retrieval. Granular cytoplasmic staining was considered positive and intensity was assessed from weak (1+) to strong (3+). PAs were morphologically evaluated for cellularity, cytological atypia and mitotic activity. Results Of the seven PAs composed mostly of myxohyaline stroma with scattered ductal elements, two tumors showed no staining and five showed rare ( Conclusion Increased expression of XIAP from PA to cellular PA to CXPA and in atypical cells within cellular areas of PA adds to our growing understanding of defective apoptotic pathways in malignant transformation in this group of salivary gland tumors and suggests an adenoma to adenocarcinoma model of progression. Further correlation with other oncogene expression may provide insight into the multiple molecular pathways that are affected in these tumors. Targeted therapy of XIAP may play a future role in the management of CXPA.

Aim To determine the susceptibility of strains of the Streptococcus milleri group (SMG) to commercially available antimicrobial peptides. Methodology Thirty strains of SMG from a range of sources were assessed for their susceptibility to 10 antimicrobial peptides of either human, animal or insect origin, using a double layer diffusion assay. Results The majority of the test strains were sensitive to the amidated peptides, mastoparan (100%; n = 30), magainin 2 amide (95%; n = 21) and indolicin (91%; n = 23). Some strains were susceptible to cecropin B (30%; n = 30) and histatin (10%; n = 30), whilst no activity was observed for the defensins HNP-1 and HNP-2, histatin 8, cecropin P1 and magainin 2. Conclusions The majority of strains were resistant to the human derived peptides. The ability to resist such peptides may be a factor in the colonisation of the oral cavity and the survival and initiation of infection in the pulp and root canal environment. Interestingly, the present study indicated that amidated and alpha helical peptides exhibit antimicrobial activity against SMG. Structural modification of these peptides may allow a targeted approach for the development of these substances as preventative or therapeutic agents.

A number of methods of sampling the oral cavity for the presence of candida have been developed. Such techniques play an important role in the diagnosis and management of oral candidosis. In the past, identification of candida isolated from the oral cavity has usually been limited to the genus Candida or to the species C. albicans. However, with the recognition that Candida species differ in the production of putative virulence factors and sensitivity to antifungal agents, greater emphasis has been placed on identification of isolates to species level. As a result a range of commercially available systems for yeast identification can now be used in conjunction with traditional identification procedures.

Self-inflicted trauma is found in several patient groups including those with learning and developmental delay, the very young and those suffering from psychiatric disturbance. The diagnosis of artefactual disease can only be made when all possible organic disease has been excluded by specific investigations. The case presented is that of a 15-year-old girl complaining of persistent bleeding and crusting of her lips. Investigations provided no real information as to the cause of the allegedly spontaneous bleeding. The diagnosis of artefactual disease was finally decided upon and a referral to a child and adolescent psychiatrist made.Patients with unusual clinical signs may be examined regularly by their GDP. This case clearly illustrates the importance of considering a psychological disorder and referral in the differential diagnosis of conditions appearing with unusual clinical signs.

Whilst Candida albicans occurs in peri-implant biofilms, its role in peri-implantitis remains unclear. This study therefore examined the virulence of C. albicans in mixed-species biofilms on titanium surfaces. Biofilms of C. albicans (Ca), C. albicans with streptococci (Streptococcus sanguinis, S. mutans) (Ca-Ss-Sm) and those incorporating Porphyromonas gingivalis (Ca-Pg and Ca-Ss-Sm-Pg) were developed. Expression of C. albicans genes associated with adhesion (ALS1, ALS3, HWP1) and hydrolytic enzymes (SAP2, SAP4, SAP6, PLD1) was measured and hyphal production by C. albicans quantified. Compared with Ca biofilms, significant (p

There are conflicting reports on the agreement between the Clinical and Laboratory Standards Institute disk diffusion (M44-A) and reference broth microdilution (M27-A) methods for determination of antifungal susceptibility of yeasts. The antifungal susceptibility of 541 yeasts, the majority of which were from the oral cavity, was determined using these two methods and the accuracy of the disk diffusion method assessed for clinical testing of various Candida species. Of the strains tested, Candida albicans predominated (390 out of 541). The classification of susceptibility determined by the disk diffusion method was largely in concordance with that obtained using the broth dilution method, regardless of species within Candida genus. The overall observed agreement between these two methods was 94.7% for fluconazole and 96.7% for voriconazole was with a 'very major' discrepancy level of 1.5% and 1.7% respectively. This study demonstrates a strong agreement of the simple disk diffusion method with the more labour intensive 'gold standard' broth microdilution method. These findings would support the use of the disk diffusion method in a routine mycology service.

Objectives Role substitution between primary care dentists (PCDs) and dental hygienists and therapists is increasingly being used in a number of different countries. Opponents to this development argue that it is unsafe and frequently cite the potential for missing oral malignancy as an inherent danger. The aim of the present study was to determine the comparative diagnostic test accuracy of different members of the dental team when differentiating between standardised photographs of mouth cancer, potentially malignant disorders and benign oral lesions. Methods A total of 192 dental professionals, comprising 96 PCDs, 63 DH-Ts, nine hospital-based dental staff and 24 other dental professionals were sampled purposively. Following orientation, participants were asked to score 90 clinical photographs that depicted cases of oral squamous cell carcinoma, potentially malignant disorders and non-malignant lesions of the oral mucosa. For each photograph participants were asked to determine whether they felt the lesion was representative of carcinoma, a potentially malignant disorder (test positive), or whether the lesion was benign (test negative). They were also asked to record their confidence in their decision on a 0–10 scale. Judgement decisions were compared against the known histopathological diagnosis of each lesion. Sensitivity and specificity were calculated for each participant and clinical group. Results The diagnostic test accuracy of PCDs and DH-Ts was similar. There was a median sensitivity of 81% Interquartile range (IQR) 19%) for PCDs and 77% (IQR 19%) for DH-T, with specificity of 73% (IQR 16%) and 69% (IQR 17%) respectively. DH-Ts missed fewer frank malignant lesions compared to PCDs. Conclusion The performance of PCDs and DH-Ts when differentiating between mouth cancer, potentially malignant disorders and benign lesions is comparable. DH-Ts should be regarded as being as competent as PCDs as front-line healthcare workers with regard to detection of mouth cancer. However, considerable heterogeneity in detection was found within both clinical groups, suggesting that training remains paramount.

OBJECTIVE: To assess the effect of educational outreach visits on antibiotic prescribing for acute dental pain in primary care. STUDY DESIGN: RCT. SETTING: General dental practices in four health authority areas in Wales. SUBJECTS AND METHODS: General dental practitioners were recruited to the study and randomly allocated to one of the three study groups (control group, guideline group or intervention group). Following the intervention, practitioners completed a standardised questionnaire for each patient that presented with acute dental pain. INTERVENTIONS: The control group received no intervention. The guideline group received educational material by post. The intervention group received educational material by post and an academic detailing visit by a trained pharmacist. The educational material included evidence-based guidelines on prescribing for acute dental pain and patient information leaflets. MAIN OUTCOME MEASURES: The number of antibiotic prescriptions issued to patients presenting with dental pain and the number of 'inappropriate' antibiotic prescriptions. Antibiotics were considered to be inappropriate if the patient did not have symptoms indicative of spreading infection. RESULTS: A total of 1,497 completed questionnaires were received from 23, 20 and 27 general dental practitioners in the control, guideline and intervention group respectively. Patients in the intervention group received significantly fewer antibiotic prescriptions than patients in the control group (OR (95% CI) 0.63 (0.41, 0.95)) and significantly fewer inappropriate antibiotic prescriptions (OR (95% CI) 0.33 (0.21, 0.54)). However, antibiotic and inappropriate antibiotic prescribing were not significantly different in the guideline group compared to the control group (OR (95% CI) 0.83 (0.55, 1.21) and OR (95% CI) 0.82 (0.53, 1.29) respectively).CONCLUSIONS: Strategies based upon educational outreach visits may be successfully employed to rationalise antibiotic prescribing by dental practitioners.

Clindamycin is a broad-spectrum antibiotic with activity against aerobic, anaerobic, and beta-lactamase-producing pathogens. This antibiotic has been used for many years as prophylactic treatment during dental procedures to prevent endocarditis. However, the spectrum and susceptibility of the bacteria species involved in dental infections indicate that clindamycin would also be an effective treatment option for these conditions. In addition to its antiinfective properties, clindamycin has high oral absorption, significant tissue penetration, including penetration into bone, and stimulatory effects on the host immune system. This review discusses the microbiologic and clinical evidence supporting the efficacy and safety of clindamycin for the successful management of dental infections.

Silicone rubber is widely used in the construction of medical devices that can provide an essential role in the treatment of human illness. However, subsequent microbial colonization of silicone rubber can result in clinical infection or device failure. The objective of this study was to determine the effectiveness of a novel silane-treated silicone rubber in inhibiting microbial adherence and material penetration. Test material was prepared by a combination of argon plasma discharge treatment and fluorinated silane coupling. Chemicophysical changes were then confirmed by X-ray photoelectron spectroscopy, contact-angle measurement, and atomic force microscopy. Two separate adherence assays and a material penetration assay assessed the performance of the new material against four strains of Candida species. Results showed a significant reduction (p < 0.01) of Candida albicans GDH 2346 adherence to silane-treated silicone compared with untreated controls. This reduction was still evident after the incorporation of saliva into the assay. Adherence inhibition also occurred with Candida tropicalis MMU and Candida krusei NCYC, although this was assay dependent. Reduced penetration of silane-treated silicone by Candida was evident when compared to untreated controls, plaster-processed silicone, and acrylic-processed silicone. To summarize, a novel silicone rubber material is described that inhibits both candidal adherence and material penetration. The clinical benefit and performance of this material remains to be determined.

There have been few reports describing the occurrence of pemphigus vulgaris (PV) during pregnancy. The patient described in this case report is interesting because the PV that developed during her pregnancy was confined to her mouth. It has been suggested that prompt treatment with systemic steroids prevents development of PV in cutaneous tissues. In this case, early control of the condition is believed to have eliminated the need for high dose steroids throughout the remainder of the pregnancy. In addition, this therapeutic approach could have contributed to the birth of a baby free of PV. Resolution of the presenting oral symptoms allowed the mother to resume a normal diet, allaying her anxiety about the possible effects of poor nutritional intake on foetal development. Aspects of clinical management considered in this report include the choice of immunospuppressive therapy and the multidisciplinary care involving both dental and obstetric specialists.

Silicone rubber, which is a widely used biomaterial, is often used to make soft liners for permanent denture. Colonization of denture soft lining materials by Candida albicans can result in clinical problems. The aim of this study was to chemically modify the surface of an experimental silicone rubber in order to produce a silicone that was less susceptible to candidal colonization. Surface modification was carried out with the use of argon-plasma bombardment followed by silane treatment, which caused the incorporation of either hydrophilic or hydrophobic functional groups onto the surface. Changes in water contact angles and chemical analysis of the materials with scanning ion mass spectroscopy confirmed surface changes. In vitro assays were carried out using C. albicans to measure levels of adherence to the surface-modified silicone after 1 h. C. albicans exhibited very low adherence to all silane-treated surfaces, whether hydrophobic or hydrophilic. This led to the conclusion that incorporated long-chain functional groups were inhibiting the adherence of the yeast, possibly by the formation of a barrier between the surface of the material and the yeast. In conclusion, silane surface treatment of an experimental silicone rubber has been successful in reducing candidal adherence.

Waterpipes are used to smoke tobacco by more than 100 million people worldwide. Use is not restricted to any single racial, ethnic, or cultural group, and dentists are almost certain to encounter waterpipe users amongst their patients. This article describes what the practice involves and seeks to inform members of the dental team of the significantly detrimental impacts of waterpipe smoking on both general and oral health and how ‘hubble-bubble really can lead to trouble’. Advising patients on ceasing waterpipe use is also discussed. Clinical Relevance: This paper explains what smoking a waterpipe involves, the associated misconceptions of safety amongst users and the dangers to health.

Objectives: The aim of this study was to assess persistence and tissue invasion of Candida albicans strains isolated from a 65 year-old patient with chronic hyperplastic candidosis (CHC), that subsequently developed into squamous cell carcinoma (SCC). Materials and Methods: C. albicans (n=7) were recovered from the oral cavity of the patient over seven years. Confirmation of CHC and SCC in this patient was achieved by histopathological examination of incisional biopsy tissue. DNA fingerprinting was performed on the seven isolates from the CHC patient together with a further eight isolates from patients with normal oral mucosa (n=2), chronic atrophic candidosis (n=1), SCC (n=1) and CHC (n=4). Genotyping involved the use of inter-repeat PCR using the eukaryotic repeat primer 1251. Characterisation of the tissue invasive abilities of the isolates was achieved by infecting a commercially available reconstituted human oral epithelium (RHE; SkinEthic, Nice, France). After 24 h. C. albicans tissue invasion was assessed by histopathological examination. Results: DNA fingerprinting demonstrated strain persistence of C. albicans in the CHC patient over a seven year period despite provision of systemic antifungal therapy. The strain of C. albicans isolated from this patient was categorised as a high invader within the RHE compared to other isolates. Conclusions: Candidal strain persistence was evident in a patient with CHC over seven years. This persistence may be due to incomplete eradication from the oral cavity following antifungal therapy or subsequent recolonisation from other body sites or separate exogenous sources. The demonstration of enhanced in vitro tissue invasion by this particular strain may, in part, explain the progression to carcinoma.

The pattern of candidal colonisation was studied in a group of terminally ill patients receiving antifungal treatment for oral candidosis. A total of 43 isolates of C. albicans was collected pre- and post-antifungal treatment from patients up to a maximum period of 4 weeks. Isolates were analysed by electrophoretic karyotyping (EK) and by inter-repeat polymerase chain reaction (IR-PCR). Fifteen electrophoretic karyotypes and 17 IR-PCR profiles were identified. Sequential isolates from 10 patients yielded identical profiles in both EKs and IR-PCR analyses. In the case of four patients, minor differences in the profiles were obtained by either EK or IR-PCR. The findings suggest that antifungal treatment in this patient group fails to eradicate the original C. albicans strain, thereby allowing recolonisation of the oral cavity. The present study has also shown that either EK or IR-PCR is a useful typing approach in such epidemiological investigations.

The phenotypes of 35 Candida albicans isolates from 19 patients with chronic hyperplastic candidosis (CHC) and 35 isolates from 30 patients with non-CHC infections were compared. Typing was based on carbohydrate assimilation, chemical sensitivity and serology. Eight carbohydrate assimilation profiles were evident with the API-20C system and a single profile predominated for isolates from CHC (17 of 19 patients; 89%) and non-CHC (18 of 30 patients; 63%). Chemical sensitivity tests revealed four profiles with no significant difference between CHC and non-CHC isolates. Serotype A predominated for isolates from both CHC (15 of 19 patients; 79%) and non-CHC (25 of 30 patients; 83%) infections. Boric acid resistance was more prevalent in CHC isolates, although a significant difference was not apparent. In summary, there was no overall difference in the phenotypes of isolates from CHC and non-CHC patients, and clonal restriction of CHC isolates was not demonstrated.