Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study.

OBJECTIVES: To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework. DESIGN: Qualitative correlational study to evaluate a national intervention programme. SETTING: Primary healthcare in two care homes in rural Germany. PARTICIPANTS: Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists. INTERVENTIONS: Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF. RESULTS: 860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health. PRIMARY OUTCOME: A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents. SECONDARY OUTCOMES: Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants. CONCLUSIONS: Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Oral health improvement for nursing home residents through delegated remotivation and reinstruction (MundZaRR Study): study protocol of a cluster-randomised controlled trial.

INTRODUCTION: Oral health and oral health-related quality of life (OHrQL) of residents in German long-term residential care (LRC) are poor. We will develop an evidence-based catalogue of interventions ('Oral Health Toolbox') and provide care-accompanying reinstruction and remotivation of nursing staff by dental assistants (DA). We hypothesise that such intervention will significantly improve OHrQL, daily oral hygiene/care behaviour and is cost-effective. METHODS AND ANALYSIS: A scoping review will be used to identify possible intervention components. Mixed methods will be used to identify barriers and enablers of oral hygiene and care in German LRC. The result will be the 'Oral Health Toolbox', a two-phased instrument supporting both initial intervention allocation to improve oral health/hygiene and reinstruction/remotivation. A two-arm clustered, randomised controlled trial (ratio of 1:1 via block randomisation) will be performed in LRC in Rhineland-Palatinate, Germany. Each nursing home represents a cluster. Based on a feasibility study, considering clustering and possible attrition, we aim at recruiting 618 residents in 18 clusters. In the intervention group, dentists will assign one or more intervention component from the box (phase 1). During follow-up, nursing staff will be reinstructed and remotivated by DA, who use the box to decide how to maintain the intervention (phase 2). In the control group residents will receive care as usual. The primary outcome, OHrQL, will be measured using the General Oral Health Assessment Index. Secondary outcomes include pain condition, general health-related quality of life, caries increment, oral/prosthetic hygiene and gingival status, incidence of dental emergencies and hospitalisations, and cost-utility/effectiveness. The endpoints will be measured at baseline and after 12 months. For our primary outcome, a mixed-linear model will be used within an intention-to-treat analysis. A process evaluation using mixed methods will be conducted alongside the trial. ETHICS AND DISSEMINATION: Ethical approval by the University of Kiel was granted (D480/18). TRIAL REGISTRATION NUMBER: NCT04140929.

Interventions to improve oral health of older people: A scoping review.

OBJECTIVES: A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care. DATA: We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention. SOURCES: Studies retrieved via MEDLINE, EMBASE, CINAHL. STUDY SELECTION: Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81). CONCLUSIONS: Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures. CLINICAL SIGNIFICANCE: While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.

[Immunologische Ex-vivo-Untersuchung zur Wirkung potenzierter Substanzen bei parodontaler Entzündung unter Verwendung der Durchflusszytometrie]. / Immunological ex vivo Study on the Effects of Potentiated Substances in Periodontal Inflammation Using Flow Cytometry.

Hintergrund: Bei der Behandlung parodontaler Entzündungen werden in der Versorgungspraxis auch homöopathische Mittel eingesetzt. Noch ist weniger über deren grundlegende Wirkprinzipien bekannt. Ziel dieser Arbeit war es daher, die Auswirkungen potenzierter Substanzen bei parodonta-ler Entzündung mittels Durchflusszytometrie zu untersuchen. Material und Methoden: Lymphozyten aus Blutproben von drei Parodontitis-Patienten und drei gematchten gesunden Probanden wurden extrahiert und mit stark verdünnten wässrigen Extrakten (D12 und C200) aus Mercurius solubilis, Silicea, Sulphur, Tuberculinum oder Placebo inkubiert. Um die Lymphozytenexpression zu untersuchen, wurde die Durchflusszytometrie für CD45R0- und CD25-Antikörper angewandt. Die statistische Analyse wurde unter Verwendung von Histogramm- und bivariaten Dot-Plot-Analysen durchgeführt. Ergebnisse: Veränderungen der Expression von CD25 und CD45R0 wurden bei Mercurius C200, Mercurius D12, Silicea D12 und Sulphur D12 beobachtet. Mit 36,47% zeigte Sulphur D12 die höchsten Veränderungen in der CD45R0-Expression zwischen Verum und Placebo bei den Parodontitis-Patienten. Die CD25-Expression war in Mercurius D12 mit 18,68% am höchsten. Aufgrund der hohen Variabilität konnten die Ergebnisse jedoch nicht durch statistische Analysen untermauert werden. Diskussion: Diese Studie konnte zeigen, wie Effekte hoch verdünnter Substanzen mit modernen immunologischen Methoden analysiert werden können. Obwohl die Schlussfolgerungen aufgrund der hohen Variabilität der Lymphozytenexpression begrenzt sind, könnten die Ergebnisse dieser Pilotstu-die weitere Untersuchungen anregen. BACKGROUND: Several homeopathic remedies are applied in the treatment of periodontal inflammation. Still, little is known about their basic working principles. We therefore aimed at investigating the effects of homeopathic drugs in periodontal inflammation by flow cytometry. MATERIAL AND METHODS: Lymphocytes from blood samples of three periodontitis patients and three matched healthy volunteers were extracted and incubated with highly diluted (D12 and C200) aqueous extracts from Mercurius solubilis, Silicea, Sulphur, Tuberculinum, or placebo. To investigate lymphocyte expression, flow cytometry was applied for CD45R0 and CD25 antibodies. Statistical analysis was performed using histogram and bivariate dot-plot analysis. RESULTS: Changes in CD25 and CD45R0 expression were observed in Mercurius C200, Mercurius D12, Silicea D12, and Sulfur D12. With 36.47%, Sulfur D12 showed the highest differences in CD45R0 expression in periodontitis patients between verum and placebo. CD25 expression was highest in Mercurius D12 with 18.68%. Due to high variability, the results could, however, not be underpinned by statistical analyses. CONCLUSION: This study demonstrated how effects of highly diluted substances can be analyzed using modern immunological methods. Although conclusions are limited due to high variability in lymphocyte expression, results from our pilot study might encourage further investigations.

Early Healing Events after Periodontal Surgery: Observations on Soft Tissue Healing, Microcirculation, and Wound Fluid Cytokine Levels.

Early wound healing after periodontal surgery with or without enamel matrix derivative/biphasic calcium phosphate (EMD/BCP) was characterized in terms of soft tissue closure, changes of microcirculation, and expression of pro- and anti-inflammatory cytokines in gingival crevicular fluid/wound fluid (GCF/WF). Periodontal surgery was carried out in 30 patients (18 patients: application of EMD/BCP for regeneration of bony defects; 12 patients: surgical crown lengthening (SCL)). Healthy sites were observed as untreated controls. GCF/WF samples were collected during two post-surgical weeks. Flap microcirculation was measured using laser Doppler flowmetry (LDF). Soft tissue healing was evaluated after two weeks. GCF/WF levels of interleukin 1ß (IL-1ß), tumour necrosis factor (TNF-α), IL-6, and IL-10 were determined using a multiplex immunoassay. Surgery caused similar reductions of flap microcirculation followed by recovery within two weeks in both EMD/BCP and SCL groups. GCF/WF and pro-inflammatory cytokine levels were immediately increased after surgery, and returned only partially to baseline levels within the two-week observation period. Levels of IL-10 were temporarily reduced in all surgical sites. Flap dehiscence caused prolonged elevated levels of GCF/WF, IL-1ß, and TNF-α. These findings show that periodontal surgery triggers an immediate inflammatory reaction corresponding to the early inflammatory phase of wound healing, and these inflammation measures are temporary in case of maintained closure of the flap. However, flap dehiscence causes prolonged inflammatory exudation from the periodontal wound. If the biological pre-conditions for periodontal wound healing are considered important for the clinical outcome, care should be taken to maintain primary closure of the flap.

Case report of an internal granuloma investigated by light and scanning electron microscopy.

There is no doubt that the main reason for an internal grauloma is a traumatic event. The trauma may be physical or chemical as in the case of caries or coronal pulpectomy. In most of the cases it is diagnosed by hazard or, when in case of fracture or mobility, extraction is the only therapy to be performed. If diagnosed in time root canal treatment may be adequate.In the presented case no single specific event could be determined being the cause of this large internal granuloma extending from the coronal third of the root canal to the whole crown just leaving an eggshell of enamel that fractured and mimicked mobility of the whole tooth to the patient finally causing him to attend the clinic. As the patient presented severe aggressive periodontitis and mobility of all teeth it first was assumed that periodontitis was the ethiological reason in this case. Due to secondary trauma the front teeth were labially positioned thus probably being exposed to traumatic insults more frequently. Clinically the upper right medial incisor appeared discoloured darkly not showing the typical pink spot. Without any force the coronal part of the right medial incisor could be removed manually and the root was extracted using a periostal extractor. As it was not suitable to leave the patient with a missing tooth in the front the wound was sutured and as a temporary solution the tooth was reconstructed with composite intraorally and fixed to the neighbour teeth adhesively. The histopathology of the internal granuloma and the crown was investigated.

[Lymphocyte migration under exposure of homeopathic remedies for periodontal inflammation - a controlled pilot study]. / Lymphozytenmigration unter Exposition homöopathischer Arzneimittel bei parodontaler Entzündung - eine kontrollierte Pilotstudie.

BACKGROUND: Several homeopathic remedies are applied in the treatment of periodontal inflammation. However, little is known about their basic active principles. Therefore, we aimed at investigating the effects of homeopathic drugs in periodontal inflammation by observing lymphocyte migration activity in vitro. MATERIAL AND METHODS: Lymphocytes from blood samples of 3 periodontitis patients and 3 matched healthy volunteers were extracted and embedded in collagen matrix migration assays together with highly diluted (D12 and C200) aqueous extracts from Mercurius solubilis, Silicea, Sulphur, Tuberculinum, or placebo. Lymphocyte migration and lymphocyte speed were observed in a 60-min time frame. Statistical analysis was performed using univariate statistics and SiZer time series analysis. RESULTS: While C-dilutions did not reveal clear differences between placebo and substances, strong effects were observed in D-dilutions compared to placebo. The strongest effects were achieved in lymphocytes exposed to Sulfur D12. While most specific effects were observed in Sulphur D12 showing an activating effect on periodontitis patient lymphocytes (mean activity: 11,1% (placebo) vs. 23,8% (verum)), there was no effect in healthy volunteers (25,8% (placebo) vs. 25,6% (verum)). SiZer analysis confirmed this effect to be significant. CONCLUSION: The basic active principles of highly diluted substances are still a matter of controversial debate. Although conclusions are limited due to low sample size, results from our pilot study might encourage further investigations on the role of highly diluted Sulphur in the treatment of periodontitis. Apart from a reproduction study with Sulphur, other immunological experiments, i.e. the investigation of cell limes via flow cytometry, should be performed to underpin these results.

A systematic review and meta-analysis on the use of Hypericum perforatum (St. John's Wort) for pain conditions in dental practice.

BACKGROUND: Hypericum perforatum (St. John's Wort) has been used for a variety of medicinal indications. Most recent research has focussed on its use in herbal form for depression, but its claimed analgesic and anti-inflammatory properties in homeopathic form have also led to a number of studies in patients with acute pain conditions. This systematic review overviews the literature on the use of St. John's Wort for pain conditions in homeopathic dental practice. MATERIAL AND METHODS: PubMed, EMBASE, AMED, CAMbase and the electronic archives of Thieme Publishers were searched with the search terms "(Hypericum OR St. Johns Wort) AND pain". We reviewed and meta-analysed the evidence on Hypericum in pain after tooth extraction was carried out. RESULTS: Twenty one relevant articles were found: four described general recommendations, three basic research, six reported studies in dental care and eight were expert opinions or case reports. Four studies were eligible for the meta-analysis. There was marked high heterogeneity in the effects pain (Chi-Squared = 26.46; I(2) = 0.89). The overall effect of 0.24 (95% CI: [0.06; 1.03]) favours Hypericum but is not statistically significant. CONCLUSION: Although case reports suggest therapeutic potential of Hypericum for pain conditions in dental care, this effect is not currently supported by clinical studies. All studies included in this meta-analysis used Arnica montana as well as Hypericum the results are more influenced by Arnica than Hypericum. Further clinical controlled trials of Hypericum alone in dental practice should be performed.

The ability of human periodontium-derived stem cells to regenerate periodontal tissues: a preliminary in vivo investigation.

Periodontium-derived stem cells (pdSCs) can be cultured as dentospheres and differentiated into various cells of the neuronal lineage such as glial cells, thereby demonstrating their stem cell state. This study investigated whether pdSCs could be differentiated into the osteogenic lineage and, if so, whether these cells are able to regenerate periodontal tissue in vivo in an athymic rat model. Human adult pdSCs were isolated during minimally invasive periodontal surgery and expanded in vitro. To induce osteogenic differentiation, expanded pdSCs were cultured for 3 weeks in osteogenic differentiation media. Staining for alkaline phosphatase expression was positive, suggesting osteogenic differentiation. For in vivo studies, pdSCs were delivered onto suitable collagen sponges and implanted into periodontal defects on the right buccal cortex of the mandible in 16 immunodeficient nude rats. Histologic analysis of samples from the test side revealed reformation of periodontal ligament-like tissue, collagen fibers, and elements of bone, but no functional periodontal tissue regeneration. The data show that human adult pdSCs are capable of regenerating elements of bone and collagen fibers in an in vivo animal model.

Influence of enamel matrix derivative on primary CD4+ T-helper lymphocyte migration, CD25 activation, and apoptosis.

BACKGROUND: Enamel matrix derivative (EMD) has a low immunogenic potential. To the best of our knowledge, there are no studies on the influence of EMD on lymphocyte migration as a sensitive cellular reaction parameter. This study investigated the influence of EMD on primary T-lymphocyte migration, CD25 activation, and activation-induced cell death. METHODS: After immunomagnetic-positive CD4+ lymphocyte separation from peripheral blood taken from three healthy volunteers per trial, the influence of EMD on cell locomotion was assessed in a three-dimensional collagen matrix migration model (CMMM). Direct CD4+ cell contact with EMD at concentrations of 25 and 100 microg/ml was mediated in a one-phase CMMM. We investigated the indirect influence of EMD in a two-phase CMMM: one collagen phase contained 25 and 100 microg EMD/ml, using the same concentrations, and a second adjacent phase contained T lymphocytes. After time-lapse videomicroscopy, the mean locomoting percentage of 30 randomly selected cells was analyzed. Using flow cytometry, CD25 receptor activation was assessed, and annexin V was used for apoptosis detection in lymphocytes challenged with 0, 1, 25, 50, and 100 microg EMD/ml. RESULTS: The one-phase CMMM revealed a reduction and the two-phase CMMM showed a dose-dependent increase in the mean locomoting cell percentage (P <0.001). Increasing EMD concentrations resulted in dose-dependent enhanced T-cell CD25 receptor expression and in increasing apoptosis (P <0.001). CONCLUSIONS: Our study showed immediate effects of EMD on primary CD4+ lymphocyte migration, CD25 activation, and apoptosis. CD4+ lymphocyte apoptosis may be a further possible background for uneventful early wound healing as seen clinically as the result of EMD application.

Highly efficient neural differentiation of human somatic stem cells, isolated by minimally invasive periodontal surgery.

Neural stem cells (NSCs) are potential sources for cell therapy of neurodegenerative diseases and for drug screening. Despite their potential benefits, ethical and practical considerations limit the application of NSCs derived from human embryonic stem cells (ES) or adult brain tissue. Thus, alternative sources are required to satisfy the criteria of ready accessibility, rapid expansion in chemically defined media and reliable induction to a neuronal fate. We isolated somatic stem cells from the human periodontium that were collected during minimally invasive periodontal access flap surgery as part of guided tissue regeneration therapy. These cells could be propagated as neurospheres in serum-free medium, which underscores their cranial neural crest cell origin. Culture in the presence of epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2) under serum-free conditions resulted in large numbers of nestin-positive/Sox-2-positive NSCs. These periodontium-derived (pd) NSCs are highly proliferative and migrate in response to chemokines that have been described as inducing NSC migration. We used immunocytochemical techniques and RT-PCR analysis to assess neural differentiation after treatment of the expanded cells with a novel induction medium. Adherence to substrate, growth factor deprivation, and retinoic acid treatment led to the acquisition of neuronal morphology and stable expression of markers of neuronal differentiation by more than 90% of the cells. Thus, our novel method might provide nearly limitless numbers of neuronal precursors from a readily accessible autologous adult human source, which could be used as a platform for further experimental studies and has potential therapeutic implications.

Adjunctive periodontal treatment with Centella asiatica and Punica granatum extracts in supportive periodontal therapy.

BACKGROUND: Centella asiatica and Punica granatum are medicinal plants that have been reported to promote tissue healing and modulate host responses. Preliminary study revealed positive clinical effects of an innovative preparation from the two herbal extracts in the form of biodegradable chips as a subgingival adjunct to scaling and root planing. The purpose of this research was to evaluate further augmenting efficacy the combined herbal preparation may have among maintenance patients in comparison to standard supportive periodontal therapy (SPT), with additional monitoring of certain inflammatory markers. METHODS: Fifteen patients in the recall programme who had completed conventional periodontal therapy with remaining probing pocket depths of 5-8 mm were enrolled. After baseline examination and collection of gingival crevicular fluid (GCF) samples, SPT was provided and the target teeth in the test group received subgingival delivery of the medicated chips. The clinical parameters, which included probing pocket depth (PD), attachment level (AL), bleeding index (BI), gingival index (GI) and plaque index (PI) were recorded and GCF samples were collected at baseline, 3 and 6 months. RESULTS: The results showed significant improvement of PD, AL, and GI at 3 and 6 months and of BI at 6 months in the test group as compared to control. No significant differences in PI were found between the two treatment modalities at all subsequent visits. The test group also showed statistically greater reduction of IL-1beta at both 3 and 6 months and lower IL-6 concentration, which almost reached the level of significance at 6 months. CONCLUSION: The results indicate that adjunctive local delivery of extracts from C. asiatica in combination with P. granatum significantly improved clinical signs of chronic periodontitis and IL-1beta level in maintenance patients.