The relation of dietary choline to cognitive performance and white-matter hyperintensity in the Framingham Offspring Cohort.

BACKGROUND: Choline is the precursor to the neurotransmitter acetylcholine. Loss of cholinergic neurons is associated with impaired cognitive function, particularly memory loss and Alzheimer disease (AD). Brain atrophy and white-matter hyperintensity (WMH) are also associated with impaired cognitive function and AD. OBJECTIVE: The objective was to determine whether a relation exists between dietary choline intake, cognitive function, and brain morphology in a large, nondemented community-based cohort. DESIGN: A dementia-free cohort of 1391 subjects (744 women, 647 men; age range: 36-83 y; mean ± SD age: 60.9 ± 9.29 y) from the Framingham Offspring population completed a food-frequency questionnaire administered from 1991 to 1995 (exam 5; remote intake) and from 1998 to 2001 (exam 7; concurrent intake). Participants underwent neuropsychological evaluation and brain MRI at exam 7. Four neuropsychological factors were constructed: verbal memory (VM), visual memory (VsM), verbal learning, and executive function. MRI measures included WMH volume (WMHV). RESULTS: Performance on the VM and VsM factors was better with higher concurrent choline intake in multivariable-adjusted models for VM (average change in neuropsychological factor per 1-unit change in choline = 0.60; 95% CI: 0.29, 0.91; P < 0.01) and VsM (0.66; 95% CI: 0.19, 1.13; P < 0.01). Remote choline intake was inversely related to log-transformed WMHV (average change in log WMHV per 1-unit change in choline = -0.05; 95% CI: -0.10, -0.01; P = 0.02). Furthermore, an inverse association was observed between remote higher choline intake and presence of large WMVH (OR: 0.56; 95% CI: 0.34, 0.92; P = 0.01). CONCLUSION: In this community-based population of nondemented individuals, higher concurrent choline intake was related to better cognitive performance, whereas higher remote choline intake was associated with little to no WMHV.

Knee pain correlates with union after tibial nailing.

OBJECTIVES: The purpose of this study is to evaluate the change in quantitatively scored knee pain during union. DESIGN: This is a retrospective review of prospectively collected data over a 15-year period. SETTING: Academic medical center. PATIENTS: All patients treated with an intramedullary nail were evaluated for knee pain and union. Four hundred twenty-eight patients with 443 tibia fractures were included. INTERVENTION: All tibia fractures were treated with an intramedullary nail. OUTCOMES: Patient-based knee pain was scored from 0 to 3. Fracture union was also graded using a modified Hammer score based on cortical bridging and remodeling. RESULTS: We found a significant inverse association between pain and union score (P < 0.01). In contradistinction, there was not a correlation between time from surgery and pain (P = 0.13). Because union score and time were related, a model was created with both parameters. This model demonstrated a statistical correlation with union score (P < 0.01), but not for time from surgery (P = 0.18). CONCLUSIONS: We postulated that knee pain may correlate with either union or time from surgery. We found a statistically significant, negative correlation between knee pain and fracture union. There was no such association between pain and time from surgery.

Periodontitis and incidence of cerebrovascular disease in men.

OBJECTIVE: To identify associations between periodontitis and incidence of cerebrovascular disease. METHODS: We analyzed data of 1,137 dentate men in the Veterans Affairs Normative Aging and Dental Longitudinal Study who were followed with triennial medical/dental exams for up to 34 years (mean, 24 years). We evaluated incidence of cerebrovascular events consistent with stroke or transient ischemic attack in relation to mean radiographic alveolar bone loss (a measure of periodontitis history) and cumulative periodontal probing depth (a measure of current periodontal inflammation). Cox proportional hazards models were fit controlling for age, baseline socioeconomic status, and time-varying effects of established cardiovascular risk factors. RESULTS: Eighty incident cases of cerebrovascular disease occurred from 27,506 person-years. Periodontal bone loss was significantly associated with an increased hazard rate (HR) of cerebrovascular disease (HR, 3.52; 95% confidence interval [CI], 1.59-7.81 comparing highest to lowest bone loss category; p for trend, <0.001). There was a stronger effect among men aged <65 years (HR, 5.81; 95% CI, 1.63-20.7) as compared with men aged > or =65 years (HR, 2.39; 95% CI, 0.91-6.25). Periodontal probing depth was not associated with a significantly increased rate of cerebrovascular disease in the combined or age-stratified analyses. INTERPRETATION: These results support an association between history of periodontitis-but not current periodontal inflammation-and incidence of cerebrovascular disease in men, independent of established cardiovascular risk factors, particularly among men aged <65 years.

Study design, recruitment, and baseline characteristics: the Department of Veterans Affairs Dental Diabetes Study.

OBJECTIVES: We are conducting a clinical trial of the efficacy of periodontal therapy in the improvement of glycaemic control in veterans with poorly controlled diabetes. This report describes study design, recruitment and randomization and compares baseline characteristics of the sample frame with those randomized into study groups. METHODS: Veterans with poorly controlled diabetes were randomized in two groups: immediate periodontal therapy ("early treatment") or usual care followed by periodontal therapy ("deferred treatment"). Half of each group continued care for 12 months; the other half returned to their usual care. We studied baseline patient characteristics, self-reported health measures, and clinical examination data. We examined means for continuous variables, frequencies for categorical variables and compared groups using t-tests and chi(2) tests (alpha=0.05 for both). RESULTS: The 193 randomized participants were younger (58 years) and had slightly higher HbA1c (10.2%) than the 2534 non-randomized participants (64 years, HbA1c =9.8%). The deferred treatment group was more likely than the early treatment group to have a history of stroke, transient ischaemic attacks, and less likely to be current or former smokers. CONCLUSIONS: The mechanism for randomization was largely successful in this study.

Risk of tooth loss after cigarette smoking cessation.

INTRODUCTION: Little is known about the effect of cigarette smoking cessation on risk of tooth loss. We examined how risk of tooth loss changed with longer periods of smoking abstinence in a prospective study of oral health in men. METHODS: Research subjects were 789 men who participated in the Veterans Administration Dental Longitudinal Study from 1968 to 2004. Tooth status and smoking status were determined at examinations performed every 3 years, for a maximum follow-up time of 35 years. Risk of tooth loss subsequent to smoking cessation was assessed sequentially at 1-year intervals with multivariate proportional hazards regression models. Men who never smoked cigarettes, cigars, or pipes formed the reference group. Hazard ratios were adjusted for age, education, total pack-years of cigarette exposure, frequency of brushing, and use of floss. RESULTS: The hazard ratio for tooth loss was 2.1 (95% confidence interval [CI], 1.5-3.1) among men who smoked cigarettes during all or part of follow-up. Risk of tooth loss among men who quit smoking declined as time after smoking cessation increased, from 2.0 (95% CI, 1.4-2.9) after 1 year of abstinence to 1.0 (95% CI, 0.5-2.2) after 15 years of abstinence. The risk remained significantly elevated for the first 9 years of abstinence but eventually dropped to the level of men who never smoked after 13 or more years. CONCLUSION: These results indicate that smoking cessation is beneficial for tooth retention, but long-term abstinence is required to reduce the risk to the level of people who have never smoked.

Three-dimensional reconstruction of fracture callus morphogenesis.

Rat and mouse femur and tibia fracture calluses were collected over various time increments of healing. Serial sections were produced at spatial segments across the fracture callus. Standard histological methods and in situ hybridization to col1a1 and col2a1 mRNAs were used to define areas of cartilage and bone formation as well as tissue areas undergoing remodeling. Computer-assisted reconstructions of histological sections were used to generate three-dimensional images of the spatial morphogenesis of the fracture calluses. Endochondral bone formation occurred in an asymmetrical manner in both the femur and tibia, with cartilage tissues seen primarily proximal or distal to the fractures in the respective calluses of these bones. Remodeling of the calcified cartilage proceeded from the edges of the callus inward toward the fracture producing an inner-supporting trabecular structure over which a thin outer cortical shell forms. These data suggest that the specific developmental mechanisms that control the asymmetrical pattern of endochondral bone formation in fracture healing recapitulated the original asymmetry of development of a given bone because femur and tibia grow predominantly from their respective distal and proximal physis. These data further show that remodeling of the calcified cartilage produces a trabecular bone structure unique to fracture healing that provides the rapid regain in weight-bearing capacity to the injured bone.

Osteoporosis and the risk of tooth loss.

Osteoporosis and osteopenia may influence periodontal disease and tooth loss. Although many studies suggest that in elderly men and women, maintenance of normal bone mineral density is associated with improved tooth retention, the evidence is still inconclusive. Hormone replacement therapy and calcium and vitamin D supplements that are used to prevent or treat osteoporosis appear to have beneficial effects on tooth retention as well. Future prospective studies, including randomized clinical trials, are needed to confirm these findings.

Enhancement of experimental fracture-healing by systemic administration of recombinant human parathyroid hormone (PTH 1-34).

BACKGROUND: Recombinant human parathyroid hormone (PTH [1-34]; teriparatide) is a new treatment for postmenopausal osteoporosis that can be systemically administered for the primary purpose of increasing bone formation. Because several studies have described the enhancement of fracture-healing and osteointegration in animals after use of PTH, we sought to critically analyze this skeletal effect. METHODS: Two hundred and seventy male Sprague-Dawley rats underwent standard, closed femoral fractures and were divided into three groups that were administered daily subcutaneous injections of 5 or 30 mug/kg of PTH (1-34) or vehicle (control). The dosing was administered for up to thirty-five days. Groups were further divided into three subgroups and were killed on day 21, 35, or 84 after the fracture. The bones were subjected to mechanical torsion testing, histomorphometric analysis, or microquantitative computed tomography. RESULTS: By day 21, calluses from the group treated with 30 mug of PTH showed significant increases over the controls with respect to torsional strength, stiffness, bone mineral content, bone mineral density, and cartilage volume. By day 35, both groups treated with PTH showed significant increases in bone mineral content and density and total osseous tissue volume, and they demonstrated significant decreases in void space and cartilage volume (p < 0.05). Torsional strength was significantly increased at this time-point in the group treated with 30 mug of PTH (p < 0.05). While dosing was discontinued on day 35, analyses performed after eighty-four days in the group treated with 30 mug of PTH showed sustained increases over the controls with respect to torsional strength and bone mineral density. No change was noted in osteoclast density at the time-points measured, suggesting that treatment with PTH enhanced bone formation but did not induce bone resorption. CONCLUSIONS: These data show that daily systemic administration of PTH (1-34) enhances fracture-healing by increasing bone mineral content and density and strength, and it produces a sustained anabolic effect throughout the remodeling phase of fracture-healing.

Predictors of tooth loss in two US adult populations.

OBJECTIVES: This study determines tooth loss rate over a 10-year period and identifies predictors of tooth loss in two separate US adult longitudinal study populations. METHODS: Subjects from the Baltimore Longitudinal Study of Aging (BLSA), consisting of 47 men and 47 women, ages ranging from 30 to 69 years, were compared to subjects from the VA Dental Longitudinal Study (VADLS) in Boston, MA, consisting of 481 men in the same age range. Baseline and follow-up examinations were performed on each cohort over a 10-year period. Using multivariate regression models, significant predictors of tooth loss were identified. RESULTS: A mean rate of tooth loss of 1.5 teeth lost per 10 years was noted in the VADLS cohort compared to 0.6 teeth lost per 10 years in the BLSA (P < .001). Combining subjects from both populations, significant predictors of tooth loss were baseline values of: percent of teeth with restorations, mean probing pocket depth score, age, tobacco use, alcohol consumption, number of teeth present, and male sex. However, the set of significant predictor variables differed between the two populations and sexes. In BLSA men, number of teeth present, percent of teeth with restorations, mean probing pocket depth score, and alcohol consumption, but not age, were significant, while in BLSA women, only age was a significant predictor. CONCLUSIONS: Over a 10-year period, the incidence of tooth loss, the rates of tooth loss, and the predictors of tooth loss were found to vary by population and by sex. These results illustrate the limits of generalizing tooth loss findings across different study cohorts and indicate that there may exist important differences in risk factors for tooth loss among US adult populations.

Low dietary quality among older adults with self-perceived ill-fitting dentures.

OBJECTIVE: To examine dietary quality and nutrient intakes of participants wearing dentures with and without poor fit as determined by questionnaire and dental exam. DESIGN: Nutrient intakes, Healthy Eating Index (HEI) score, and serum nutrient values were examined among individuals wearing either adequate- or poor-fitting dentures and individuals who had at least 18 teeth. SUBJECTS/SETTING: Data was collected from 4,820 participants in the Third National Health and Nutrition Examination Survey ages 50 years and older with at least 18 teeth (n=3,207) or those wearing dentures (n=1,613), who responded to a questionnaire about denture fit and had their dentures evaluated by a dentist. STATISTICAL ANALYSES PERFORMED: Analysis of covariance and multivariate linear regression analyses were used to examine associations between individuals fully dentate, wearing good-or ill-fitting dentures, and nutritional status indicators. RESULTS: The group with self-perceived ill-fitting dentures compared with the group with natural teeth had significantly lower total HEI (66.5 vs 68.5 P<.002), vegetables (6.3 vs 6.8 P<.01), and variety scores (7.8 vs 8.2 P<.02); lower ascorbic acid (P<.009) and carotene intakes (P<.004). The group with self-perceived good-fitting dentures did not differ significantly from the dentate group. However, both groups wearing dentures had significantly lower serum levels of vitamins C and E, beta carotene, folate, lutein, and lycopene/zeaxanthin compared with the dentate group. APPLICATIONS/CONCLUSIONS: Dietary quality and intake of certain nutrients was poorer among the group with self-perceived ill-fitting dentures than among those wearing adequate dentures or those with natural teeth. Administering a simple questionnaire to patients about their perceptions of denture fit may be useful in identifying denture wearers at increased risk of dietary inadequacy.

Relationship between dental panoramic radiographic findings and biochemical markers of bone turnover.

UNLABELLED: We investigated whether mandibular cortical measures on dental panoramic radiographs are associated with biochemical markers of bone turnover in 82 postmenopausal women. Mandibular cortical shape was significantly associated with biochemical markers and spinal BMD. Our results suggest that dentists may be able to identify postmenopausal women with low BMD by using dental panoramic radiographs. INTRODUCTION: Recent studies suggest that mandibular inferior cortical shape and width on dental panoramic radiographs may be useful screening tools for low skeletal bone mineral density (BMD) or increased risk of osteoporotic fracture. However, little is known as to whether these measures are associated with bone turnover. We investigated relationships among dental panoramic radiographic findings, spine BMD, and biochemical markers of bone turnover in postmenopausal women. MATERIALS AND METHODS: Of 609 women who visited our clinic for BMD assessment between 1996 and 2002, 82 Japanese postmenopausal women, 46-68 years of age (54.1 +/- 4.9 years), were recruited for this study. Mandibular inferior cortical shape (normal, mild/moderate erosion, severe erosion) and width were evaluated on dental panoramic radiographs. BMD at the lumbar spine (L2-L4) was measured by DXA and categorized as normal (T-score > -1.0), osteopenia (T-score, -1.0 to -2.5), or osteoporosis (T-score < -2.5). Bone turnover was estimated by serum total alkaline phosphatase (ALP) and urinary N-telopeptide cross-links of type I collagen (NTx), corrected for creatinine. RESULTS: The odds of low spine BMD in subjects with any cortical erosion were 3.8 (95% CI, 1.2-12.5). Mandibular cortical erosion was significantly associated with increased NTx (p < 0.001) and ALP (p < 0.05) levels. The associations of spine BMD with NTx and ALP were similar. Mandibular cortical width was significantly associated with spine BMD but not with NTx and ALP levels. CONCLUSIONS: Our results suggest that mandibular inferior cortical shape on dental panoramic radiographs may be an indicator of bone turnover and spine BMD in postmenopausal women. Dentists may be able to identify postmenopausal women with increased risk of osteopenia and osteoporosis on routine dental panoramic radiographs.

Longitudinal validation of a risk calculator for periodontal disease.

BACKGROUND: Risk assessment and utilization of the results are important components of prevention, diagnosis and treatment of periodontal diseases. Risk assessment is relatively new to dentistry. Currently risk is assessed by subjective evaluation and results vary widely among clinicians. We have developed a computer-based risk assessment tool, the Periodontal Risk Calculator (PRC), for objective, quantitative assessment of risk. The purpose of the study reported here was to evaluate the accuracy and validity of this tool. METHODS: Clinical records and radiographs of 523 subjects enrolled in the VA Dental Longitudinal Study of Oral Health and Disease, covering a period of 15 years, were used. Information from baseline examinations was entered into the risk calculator and a risk score on a scale of l-5 for periodontal deterioration was calculated for each subject. Actual periodontal status in terms of alveolar bone loss determined using digitized radiographs, and tooth loss determined from the clinical records, was assessed at years 3, 9 and 15. The strength of the association between risk prediction and actual outcome was determined statistically. RESULTS: The risk scores were strong predictors of future periodontal status measured as worsening severity and extent of alveolar bone loss and tooth loss, especially loss of periodontally affected teeth. Over the entire 15-year period, risk scores consistently ranked groups from least to most bone loss and tooth loss. Risk groups differed greatly from one another. By year 3, the incidence rate of bone loss of group 5 was 3.7-fold greater than for group 2, and by year 15, the loss of periodontally affected teeth was 22.7-fold greater than for group 2 (p<0.001). By year 15, 83.7% of subjects in risk group 5 had lost one or more periodontally affected teeth compared to 20.2% of subjects in group 2. CONCLUSIONS: Risk scores calculated using the PRC and information gathered during a standard periodontal examination predict future periodontal status with a high level of accuracy and validity. Use of the risk assessment tool over time may be expected to result in more uniform and accurate periodontal clinical decision-making, improved oral health, reduction in the need for complex therapy and reduction in health-care cost.

Vitamin D receptor alleles, periodontal disease progression, and tooth loss in the VA dental longitudinal study.

BACKGROUND: The relationship between the vitamin D receptor (VDR) genotype and periodontal disease is not known. This study compared periodontal disease progression among polymorphisms of 2 VDR genes in men in the VA Dental Longitudinal Study. METHODS: Subjects were 125 medically healthy, middle-aged men who had serial oral examinations over a mean 23-year period. Probing depth, gingival bleeding on probing, clinical attachment loss (CAL), and alveolar bone loss (ABL) from radiographs were measured at each examination. Progression of periodontal disease was defined as the percentage of teeth per decade that increased ABL by > or = 40%, and the percentage of teeth per decade that developed CAL > or = 5 mm. ApaI and TaqI polymorphisms were determined from buffy coat cells following polymerase chain reaction (PCR) amplification. Mean changes in oral status were adjusted for baseline values of smoking status, number of teeth present, and periodontal status by analysis of covariance. RESULTS: Genotype distributions were 41 AA, 58 Aa, 26 aa; and 53 TT, 46 Tt, 26 tt. The AA genotype showed the highest rates of progression of ABL (5 +/- 1% versus 1 +/- 1% and 2 +/- 1% teeth in Aa and aa, respectively; P = 0.03), CAL (37 +/- 4% versus 17 +/- 4% and 27 +/- 6% teeth; P = 0.004), and tooth loss (2 +/- 0.3 versus 1 +/- 0.3 and 1 +/- 0.4 teeth; P = 0.04). When genotype combinations were examined, progression of ABL, CAL, and tooth loss was highest in the AATT and AATt genotypes. CONCLUSIONS: The ApaI polymorphism of the VDR gene is associated with oral bone loss, clinical attachment loss, and tooth loss in older men. Analysis of the VDR alleles may prove useful for predicting periodontal disease.

Nutritional status of the older adult is associated with dentition status.

OBJECTIVE: This study was designed to examine associations between the number of posterior occlusal pairs of teeth and the nutritional status of older adults participating in the third National Health and Nutrition Examination Survey (NHANES III) survey. DESIGN: Impaired dentition was assessed by number of posterior occluding pairs of teeth (grinding teeth, n=8 pairs) and complete denture status. Nutritional status was measured by nutrient intake, Healthy Eating Index (HEI) score, serum values, and body mass index (BMI). Subjects/setting Data from 5,958 participants in NHANES III ages 50 years and over with dental examination were included in the analysis. Statistical analyses performed Analysis of covariance and multivariate linear regression analyses were performed to examine associations between number of tooth pairs and nutritional status indicators controlled for potential confounders. RESULTS: Compared with individuals with five to eight posterior occluding pairs (HEI=68.2), those with impaired dentition (no posterior pairs, one to four pairs remaining, or full dentures) had consistently lower HEI scores (HEI=64.3, 66.5, and 66.5, respectively), consumed fewer servings of fruits, and had lower serum values of beta carotene and ascorbic acid. Participants with one to four posterior pairs also had a higher mean BMI (28.0) than those with five or more pairs (27.2). Participants in one or more groups with impaired dentition had lower dietary intake levels of vitamin A, carotene, folic acid, and vitamin C, and scored less well on diet variety, cholesterol, and sodium components of the HEI. APPLICATIONS/CONCLUSIONS: Results show that dental health is closely associated with nutritional status and suggest that status of dentition should be considered in nutritional counseling and assessment of older adults.

Validity and accuracy of a risk calculator in predicting periodontal disease.

BACKGROUND: Research on the pathobiology of periodontal diseases has increased our knowledge of these diseases and is fostering a transition from the repair model to the medical or wellness model of periodontal care. Successful application of the wellness model depends on an accurate and valid assessment of disease risk, as well as institution of risk reduction as an integral part of prevention and treatment. A computer-based risk assessment tool has been developed. METHODS: The authors reviewed clinical records and radiographs of 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study to evaluate the validity of risk prediction using the computer-based tool. Data from baseline examinations was entered into the risk calculator, and a risk score on a scale from 1 (lowest risk) to 5 (highest risk) was calculated for each subject to predict periodontal deterioration. Actual periodontal status in terms of alveolar bone loss (determined from digitized radiographs) and tooth loss (determined from clinical records) was assessed at years 3, 9 and 15. The authors determined the statistical strength of the association between risk prediction and actual outcome. RESULTS: The risk scores were strong predictors of periodontal status, as measured by alveolar bone loss and loss of periodontally affected teeth. Risk scores consistently ranked risk score groups from least to most bone loss and tooth loss. Compared with a risk score of 2, the relative risk of tooth loss was 3.2 for a risk score of 3, 4.5 for a risk score of 4 and 10.6 for a risk score of 5. CONCLUSIONS AND PRACTICE IMPLICATIONS: Use of the risk assessment tool over time may result in more uniform and accurate periodontal clinical decision-making, improved oral health, reduction in the need for complex therapy, reduction in health care costs and a hastening of the transition from a repair model to a wellness model of care.

Smoking relapse after 2 years of abstinence: findings from the VA Normative Aging Study.

Little is known about the risk of cigarette smoking relapse after 2 or more years of abstinence. The rates and predictors of late smoking relapse were estimated in 483 men who participated in a prospective study for up to 35 years. Subjects are participants in the VA Normative Aging Study, a prospective observational study of aging in men that began in 1963. Subjects are evaluated approximately every 3 years with physical examinations and questionnaires. Smoking, alcohol use, caffeine consumption, and socioeconomic variables were obtained by questionnaire, and weight and height were measured at clinical examinations every 3 years since 1963. Predictors of smoking relapse were identified using proportional hazards regression models. The rate of smoking relapse in the 2nd-6th years of abstinence fluctuated between 2 and 4% per year, and fell to less than 1% only after 10 years of abstinence. In multivariate regression models, coffee and alcohol consumption, and use of cigars or pipes significantly increased the risk of smoking relapse. A small risk of smoking relapse remains for at least 10 years after smoking cessation. Use of other tobacco products, coffee and alcohol increased the risk of late relapse. These findings may be useful in identifying those at highest risk for late relapse and for motivating former smokers to continue long-term abstinence.