Influence of salivary conditioning and sucrose concentration on biofilm-mediated enamel demineralization

The acquired pellicle formation is the first step in dental biofilm formation. It distinguishes dental biofilms from other biofilm types. Objective: To explore the influence of salivary pellicle formation before biofilm formation on enamel demineralization. Methodology: Saliva collection was approved by Indiana University IRB. Three donors provided wax–stimulated saliva as the microcosm bacterial inoculum source. Acquired pellicle was formed on bovine enamel samples. Two groups (0.5% and 1% sucrose–supplemented growth media) with three subgroups (surface conditioning using filtered/pasteurized saliva; filtered saliva; and deionized water (DIW)) were included (n=9/subgroup). Biofilm was then allowed to grow for 48 h using Brain Heart Infusion media supplemented with 5 g/l yeast extract, 1 mM CaCl2.2H2O, 5% vitamin K and hemin (v/v), and sucrose. Enamel samples were analyzed for Vickers surface microhardness change (VHNchange), and transverse microradiography measuring lesion depth (L) and mineral loss (∆Z). Data were analyzed using two-way ANOVA. Results: The two-way interaction of sucrose concentration × surface conditioning was not significant for VHNchange (p=0.872), ∆Z (p=0.662) or L (p=0.436). Surface conditioning affected VHNchange (p=0.0079), while sucrose concentration impacted ∆Z (p<0.0001) and L (p<0.0001). Surface conditioning with filtered/pasteurized saliva resulted in the lowest VHNchange values for both sucrose concentrations. The differences between filtered/pasteurized subgroups and the two other surface conditionings were significant (filtered saliva p=0.006; DIW p=0.0075). Growing the biofilm in 1% sucrose resulted in lesions with higher ∆Z and L values when compared with 0.5% sucrose. The differences in ∆Z and L between sucrose concentration subgroups was significant, regardless of surface conditioning (both p<0.0001). Conclusion: Within the study limitations, surface conditioning using human saliva does not influence biofilm–mediated enamel caries lesion formation as measured by transverse microradiography, while differences were observed using surface microhardness, indicating a complex interaction between pellicle proteins and biofilm–mediated demineralization of the enamel surface

The Use of Fluorescence Technology Versus Visual and Tactile Examination in the Detection of Oral Lesions: A Pilot Study

PURPOSE: This study compared the effectiveness of the VELscope(R) Vx versus visual and tactile intraoral examination in detecting oral lesions in an adult, high risk population. METHODS: The pilot study compared the intra oral findings between 2 examination types. The sample was comprised of 30 participants who were addicted to either cigarettes or a dual addiction (cigarettes plus hookah). High risk population was defined as males who were current cigarette smokers or had a dual addiction. Two trained and experienced licensed dental hygienists conducted all examinations. Throughout the study, all visual and tactile intraoral examinations were conducted first by one dental hygienist first, followed by the VELscope(R) Vx fluorescence examinations by the second dental hygienist. All subjects received an inspection of the lips, labial and buccal mucosa, floor of the mouth, dorsal, ventral and lateral sides of the tongue, hard and soft palate, and visual inspection of the oropharynx and uvula. Both evaluations took place in 1 visit in the Dental Hygiene Research Center at Old Dominion University and external sites. All participants received oral cancer screening information, recommendations, referrals for tobacco cessation programs and brochures on the 2 types of examinations conducted. RESULTS: Participants were considered high risk based on demographics (current smokers and mostly males). Neither visual and tactile intraoral examination nor the VELscope(R) Vx examination showed positive lesions. No lesions were detected; therefore, no referrals were made. Data indicated the duration of tobacco use was significantly higher in cigarette smokers (14.1 years) than dual addiction smokers (5 years) (p\u3e0.005). The average numbers of cigarettes smoked per day were 13.5 compared to 14.2 cigarettes for dual addiction smokers. CONCLUSION: Results from this study suggest the visual and tactile intraoral examination produced comparative results to the VELscope(R) Vx examination. Findings from this study support that the VELscope(R) Vx is still considered an adjunct technology and cannot be used exclusively for oral cancer screening

In-Vitro Model of Scardovia wiggsiae Biofilm Formation and Effect of Nicotine

Recently, Scardovia wiggsiae has been reported to be strongly associated with caries formation. This study aimed to establish an in vitro model of S. wiggsiae biofilm and to investigate the effect of nicotine on S. wiggsiae colony-forming units (CFUs) growth. S. wiggsiae biofilm was grown overnight using brain-heart infusion (BHI) broth supplemented with 5 g of yeast extract/L (BHI-YE). The overnight culture was used as an inoculum to grow S. wiggsiae biofilm on standardized enamel and dentin samples. Samples were incubated with different nicotine concentrations (0, 0.5, 1, 2, 4, 8, 16 and 32 mg/mL) for 3 days. The dissociated biofilms were diluted, spiral plated on blood agar plates, and incubated for 24 h. CFUs/mL were quantified using an automated colony counter. A two-way ANOVA was used to compare the effect of different nicotine concentrations on S. wiggsiae CFUs. This study demonstrated that S. wiggsiae biofilm could be initiated and formed in vitro. Increased CFUs was observed through 0.5-4 mg/mL and 0.5-8 mg/mL of nicotine using enamel and dentin substrates, respectively. 16 and 32 mg/mL of nicotine were determined as the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC), respectively. S. wiggsiae formed greater biofilm on enamel than dentin specimens in response to the nicotine stimulus. This study demonstrated the negative effect of smoking on increasing S. wiggsiae biofilm. Establishing S. wiggsiae biofilm in vitro may allow researchers in the future to have a better understanding of caries pathogenesis and bacterial interaction

The influence of biofilm maturation on fluoride’s anticaries efficacy

Objectives (1) To explore the influence of biofilm maturation and timing of exposure on fluoride anticaries efficacy and (2) to explore biofilm recovery post-treatment. Methods Bovine enamel specimens were utilized in a pH cycling model (28 subgroups [n = 18]). Each subgroup received different treatments [exposure]: sodium fluoride [NaF]; stannous fluoride [SnF2]; amine fluoride [AmF]; and de-ionized water [DIW], at a specific period: early: days 1–4; middle: days 3–6; and late: days 7–10. During non-exposure periods, pH cycling included DIW instead of fluorides. Objective 1: part 1 (cycling for 4, 6, or 10 days). Part 2 (cycling for 10 days). Objective 2: early exposure: three sample collection time points (immediate, 3 days, and 6 days post-treatment); middle exposure: two sample collection time points (immediate, 4 days post-treatment). The enamel and biofilm were analyzed ([surface microhardness; mineral loss; lesion depth]; [lactate dehydrogenase enzyme activity; exopolysaccharide amount; viability]). Data were analyzed using ANOVA (p = 0.05). Results Objective 1: Early exposure to fluorides produced protective effects against lesion progression in surface microhardness and mineral loss, but not for lesion depth. Objective 2: Early exposure slowed the demineralization process. SnF2 and AmF were superior to NaF in reducing LDH and EPS values, regardless of exposure time. They also prevented biofilm recovery. Conclusion Earlier exposure to SnF2 and AmF may result in less tolerant biofilm. Early fluoride treatment may produce a protective effect against demineralization. SnF2 and AmF may be the choice to treat older biofilm and prevent biofilm recovery. Clinical relevance The study provides an understanding of biofilm-fluoride interaction with mature biofilm (e.g., hard-to-reach areas, orthodontic patients) and fluoride’s sustainable effect hours/days after brushing

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

In-Vitro Model of Scardovia wiggsiae Biofilm Formation and Effect of Nicotine

Recently, Scardovia wiggsiae has been reported to be strongly associated with caries formation. This study aimed to establish an in vitro model of S. wiggsiae biofilm and to investigate the effect of nicotine on S. wiggsiae colony-forming units (CFUs) growth. S. wiggsiae biofilm was grown overnight using brain-heart infusion (BHI) broth supplemented with 5 g of yeast extract/L (BHI-YE). The overnight culture was used as an inoculum to grow S. wiggsiae biofilm on standardized enamel and dentin samples. Samples were incubated with different nicotine concentrations (0, 0.5, 1, 2, 4, 8, 16 and 32 mg/mL) for 3 days. The dissociated biofilms were diluted, spiral plated on blood agar plates, and incubated for 24 h. CFUs/mL were quantified using an automated colony counter. A two-way ANOVA was used to compare the effect of different nicotine concentrations on S. wiggsiae CFUs. This study demonstrated that S. wiggsiae biofilm could be initiated and formed in vitro. Increased CFUs was observed through 0.5-4 mg/mL and 0.5-8 mg/mL of nicotine using enamel and dentin substrates, respectively. 16 and 32 mg/mL of nicotine were determined as the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC), respectively. S. wiggsiae formed greater biofilm on enamel than dentin specimens in response to the nicotine stimulus. This study demonstrated the negative effect of smoking on increasing S. wiggsiae biofilm. Establishing S. wiggsiae biofilm in vitro may allow researchers in the future to have a better understanding of caries pathogenesis and bacterial interaction

Comparison of Human and Bovine Enamel in a Microbial Caries Model at Different Biofilm Maturations

Objectives To compare human versus bovine enamel when used in microbial caries models; and to evaluate the use of nylon mesh to support biofilm growth over enamel. Methods Twenty-four sub-subgroups were included (time factor: 4, 8, and 12 days; substrate factor: human/bovine; mesh factor: yes/no; treatment factor: 18.4 mM NaF (350 ppm F), de-ionized water [DIW]; n = 9/sub-subgroup). Microcosm biofilm from human saliva (IRB approval #1,406,440,799) was grown on enamel specimens for 24-h (Brain Heart Infusion media; 0.2 % sucrose), using active attachment model. Then, pH-cycling took place. At the end of each pH-cycling period, enamel specimens were analyzed: surface microhardness (VHNchange); transverse microradiography (integrated mineral loss [ΔZ], lesion depth [L]). Biofilm was analyzed: lactic acid production (LDH activity); exopolysaccharide (EPS) amount; and viability (12-day sub-groups). Data were analyzed using ANOVA at a 5 % level of significance. Results The three-way interaction between pH-cycling duration, substrate type, and treatment type was significant for (VHNchange [p < 0.0005], ΔZ [p = 0.0027], and L [p < 0.0001]). VHNchange exhibited increased lesion severity as pH-cycling time increases, in both treatments. VHNchange data indicated a treatment effect in all timepoints. ΔZ and L exhibited higher values with more mature biofilms. ANOVA analyses for LDH and EPS indicated a significance between variables (LDH p = 0.0100; EPS p < 0.0001). Mesh-covered specimens resulted in lower LDH and EPS values in all maturations. ANOVA analyses of viability (12 days) between variables was significant. Conclusion within the study’s limitations, human or bovine enamel can be used in microbial in vitro caries models to study biofilm's maturation and anticaries agents. Clinical Significance: This study demonstrated how a known cariostatic effect of a fluoride concentration in toothpastes can be modulated by the maturation stage of oral biofilm. This can represent hard to reach areas in the oral cavity (e.g. in orthodontic patients or patients with intermaxillary fixation following oral and maxillofacial surgeries)

Comparison of Human and Bovine Enamel in a Microbial Caries Model at Different Biofilm Maturations

Objectives To compare human versus bovine enamel when used in microbial caries models; and to evaluate the use of nylon mesh to support biofilm growth over enamel. Methods Twenty-four sub-subgroups were included (time factor: 4, 8, and 12 days; substrate factor: human/bovine; mesh factor: yes/no; treatment factor: 18.4 mM NaF (350 ppm F), de-ionized water [DIW]; n = 9/sub-subgroup). Microcosm biofilm from human saliva (IRB approval #1,406,440,799) was grown on enamel specimens for 24-h (Brain Heart Infusion media; 0.2 % sucrose), using active attachment model. Then, pH-cycling took place. At the end of each pH-cycling period, enamel specimens were analyzed: surface microhardness (VHNchange); transverse microradiography (integrated mineral loss [ΔZ], lesion depth [L]). Biofilm was analyzed: lactic acid production (LDH activity); exopolysaccharide (EPS) amount; and viability (12-day sub-groups). Data were analyzed using ANOVA at a 5 % level of significance. Results The three-way interaction between pH-cycling duration, substrate type, and treatment type was significant for (VHNchange [p < 0.0005], ΔZ [p = 0.0027], and L [p < 0.0001]). VHNchange exhibited increased lesion severity as pH-cycling time increases, in both treatments. VHNchange data indicated a treatment effect in all timepoints. ΔZ and L exhibited higher values with more mature biofilms. ANOVA analyses for LDH and EPS indicated a significance between variables (LDH p = 0.0100; EPS p < 0.0001). Mesh-covered specimens resulted in lower LDH and EPS values in all maturations. ANOVA analyses of viability (12 days) between variables was significant. Conclusion within the study’s limitations, human or bovine enamel can be used in microbial in vitro caries models to study biofilm's maturation and anticaries agents. Clinical Significance: This study demonstrated how a known cariostatic effect of a fluoride concentration in toothpastes can be modulated by the maturation stage of oral biofilm. This can represent hard to reach areas in the oral cavity (e.g. in orthodontic patients or patients with intermaxillary fixation following oral and maxillofacial surgeries)