Carotid artery calcification in panoramic radiographs associates with oral infections and mortality.

AIM: To study the prevalence of carotid artery calcification (CAC) in relation to apical and marginal periodontitis, subgingival dysbiotic bacterial species and serum and saliva immune responses against them. In addition, the aim was to analyse the association of CAC with angiographically verified coronary artery disease (CAD) and mortality. METHODOLOGY: In the present random Parogene cohort, the patients had an indication for coronary angiography. Apical and marginal periodontitis were diagnosed during clinical and radiographic oral examinations, and CAC on panoramic radiographs (n = 492). Presence and severity of CAD were registered from angiography. Subgingival dysbiotic bacterial species were quantitated using checkerboard DNA-DNA-hybridization, and serum and saliva antibody levels were determined by immunoassays. The cohort was followed-up for 10 years or until death (median 9.9, range 0.21-10.4) via linkage to the national death register. The statistical models were adjusted for age, gender, smoking, hypertension, diabetes and dyslipidemia. RESULTS: A total of 102 (20.7%) patients had detectable CAC, which was moderate in 81 (16.4%) and severe in 21 (4.3%). CAC was associated (OR, 95% CI) with severe apical periodontitis (2.25, 1.15-4.41), root canal fillings (1.15, 1.04-1.26), alveolar bone loss (2.66, 1.21-5.84), severe periodontal inflammation (2.23, 1.11-4.47), high level of gram-negative subgingival species (2.73, 1.34-5.50), saliva IgG against dysbiotic species (1.05, 1.01-1.10/unit) and severe (2.58, 1.36-4.90) and chronic (2.13, 1.15-3.93) CAD. A total of 105 (20.7%) patients died during the follow-up and 53 (10.4%) deaths were because of cardiovascular diseases (CVD). Severe CAC predicted worse survival with HRs (95% CI) of 3.08 (1.58-6.06) for all-cause and 3.43 (1.42-8.25) for CVD death. CONCLUSIONS: CAC on panoramic tomography was associated with (i) apical and marginal periodontitis and dysbiotic bacterial species giving rise to an immunological response, and with (ii) severe, chronic CAD and increased mortality. The results further emphasize the role of oral infections in CAD and the importance of referring a patient with CAC for a cardiovascular evaluation.

Association between dental factors and mortality.

AIM: To study whether oral parameters such as endodontic infections, root canal fillings, number of teeth or wearing removable dentures at baseline are associated with cardiovascular- and all-cause mortality in a follow-up of approximately 8 years. METHODOLOGY: The Finnish Parogene cohort consists of 508 Finnish adults (mean age 63.3 years, SD 9.1) with cardiac symptoms, all of whom had undergone coronary angiography for accurate baseline coronary status. Extensive clinical and radiographic oral examinations were performed, and additional data were acquired from medical records and questionnaires. Root canal fillings and endodontic lesions, as well as their co-occurrence, were determined from panoramic radiographs. The mortality data were assessed via record linkage with the Finnish Causes of Death register (mean follow-up time 7.81 years, SD 1.45 years). A total of n = 471 dentate patients were included in the statistical analyses. RESULTS: A total of n = 69 deaths were recorded, of which n = 41 were due to cardiovascular diseases (CVDs, ICD-10 I00-I99). The deceased had fewer root canal fillings (mean 1.57; SD 1.64 vs. mean 2.30; SD 2.34, P = 0.03) than the survivors. The number of missing teeth was associated with smoking, occluded coronary arteries and diabetes. Cox regression with Firth's penalized maximum-likelihood method using age as timescale revealed an inverse association (HR; 95%CI) between mortality and number of teeth (all-cause 0.91; 0.86-0.96, CVD mortality 0.89; 0.83-0.96), use of removable dentures (all-cause 0.24; 0.09-0.62, CVD mortality 0.20; 0.06-0.72), root canal fillings (all-cause 0.82; 0.70-0.94, CVD mortality 0.79; 0.63-0.96) and having root canal fillings in all teeth with apical rarefactions (all-cause 0.27; 0.06-0.79, CVD mortality 0.09; 0.01-0.63), when gender, smoking, occluded coronary arteries, periodontal inflammatory burden index and the number of teeth were adjusted for. CONCLUSIONS: The number of missing teeth appeared to be the strongest predictor of mortality in this study, whereas endodontic infections per se had no independent association. Nevertheless, signs of professional intervention in these problems, such as root canal fillings and removable dentures, appeared to be associated with improved survival, which might partly be explained by the utilization of healthcare services.

Association of Endodontic Lesions with Coronary Artery Disease.

An endodontic lesion (EL) is a common manifestation of endodontic infection where Porphyromonas endodontalis is frequently encountered. EL may associate with increased risk for coronary artery disease (CAD) via similar pathways as marginal periodontitis. The aim of this cross-sectional study was to delineate the associations between EL and CAD. Subgingival P. endodontalis, its immune response, and serum lipopolysaccharide were examined as potential mediators between these 2 diseases. The Finnish Parogene study consists of 508 patients (mean age, 62 y) who underwent coronary angiography and extensive clinical and radiographic oral examination. The cardiovascular outcomes included no significant CAD ( n = 123), stable CAD ( n = 184), and acute coronary syndrome (ACS; n = 169). EL was determined from a panoramic tomography. We combined data of widened periapical spaces (WPSs) and apical rarefactions to a score of EL: 1, no EL ( n = 210); 2, ≥1 WPS per 1 apical rarefaction ( n = 222); 3, ≥2 apical rarefactions ( n = 76). Subgingival P. endodontalis was defined by checkerboard DNA-DNA hybridization analysis, and corresponding serum antibodies were determined by ELISA. In our population, 50.4% had WPSs, and 22.8% apical rarefactions. A total of 51.2% of all teeth with apical rarefactions had received endodontic procedures. Subgingival P. endodontalis levels and serum immunoglobulin G were associated with a higher EL score. In the multiadjusted model (age, sex, smoking, diabetes, body mass index, alveolar bone loss, and number of teeth), having WPSs associated with stable CAD (odds ratio [OR] = 1.94, 95% confidence interval [95% CI] = 1.13 to 3.32, P = 0.016) and highest EL score were associated with ACS (OR = 2.46, 95% CI = 1.09 to 5.54, P = 0.030). This association was especially notable in subjects with untreated teeth with apical rarefactions ( n = 59, OR = 2.72, 95% CI = 1.16 to 6.40, P = 0.022). Our findings support the hypothesis that ELs are independently associated with CAD and in particular with ACS. This is of high interest from a public health perspective, considering the high prevalence of ELs and CAD.

Missing Teeth Predict Incident Cardiovascular Events, Diabetes, and Death.

Periodontitis, the main cause of tooth loss in the middle-aged and elderly, associates with the risk of atherosclerotic vascular disease. The objective was to study the capability of the number of missing teeth in predicting incident cardiovascular diseases (CVDs), diabetes, and all-cause death. The National FINRISK 1997 Study is a Finnish population-based survey of 8,446 subjects with 13 y of follow-up. Dental status was recorded at baseline in a clinical examination by a trained nurse, and information on incident CVD events, diabetes, and death was obtained via national registers. The registered CVD events included coronary heart disease events, acute myocardial infarction, and stroke. In Cox regression analyses, having ≥5 teeth missing was associated with 60% to 140% increased hazard for incident coronary heart disease events (P < 0.020) and acute myocardial infarction (P < 0.010). Incident CVD (P < 0.043), diabetes (P < 0.040), and death of any cause (P < 0.019) were associated with ≥9 missing teeth. No association with stroke was observed. Adding information on missing teeth to established risk factors improved risk discrimination of death (P = 0.0128) and provided a statistically significant net reclassification improvement for all studied end points. Even a few missing teeth may indicate an increased risk of CVD, diabetes, or all-cause mortality. When individual risk factors for chronic diseases are assessed, the number of missing teeth could be a useful additional indicator for general medical practitioners.

The global met need for emergency obstetric care: a systematic review.

BACKGROUND: Of the 287,000 maternal deaths every year, 99% happen in low- and middle-income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as 'Met need for EmOC'. OBJECTIVE: To estimate the global met need for EmOC and to examine the correlation between met need, maternal mortality ratio and other indicators. SEARCH STRATEGY: A systematic review was performed according to the PRISMA guidelines. Searches were made in PubMed, EMBASE and Google Scholar. SELECTION CRITERIA: Studies containing data on met need in EmOC were selected. DATA COLLECTION AND ANALYSIS: Analysis was performed with data extracted from 62 studies representing 51 countries. World Bank data were used for univariate and multiple linear regression. MAIN RESULTS: Global met need for EmOC was 45% (IQR: 28-57%), with significant disparity between low- (21% [12-31%]), middle- (32% [15-56%]), and high-income countries (99% [99-99%]), (P = 0.041). This corresponds to 11.4 million (8.8-14.8) untreated complications yearly and 951 million (645-1174 million) women without access to EmOC. We found an inverse correlation between met need and maternal mortality ratio (r = -0.42, P < 0.001). Met need was significantly correlated with the proportion of births attended by skilled birth attendants (ß = 0.53 [95% CI 0.41-0.65], P < 0.001). AUTHORS' CONCLUSIONS: The results suggest a considerable inadequacy in global met need for EmOC, with vast disparities between countries of different income levels. Met need is a powerful indicator of the response to maternal mortality and strategies to improve EmOC act in synergy with the expansion of skilled birth attendance.

Priorities in emergency obstetric care in Bolivia--maternal mortality and near-miss morbidity in metropolitan La Paz.

OBJECTIVE: To document the frequency and causes of maternal mortality and severe (near-miss) morbidity in metropolitan La Paz, Bolivia. DESIGN: Facility-based cross-sectional study. SETTING: Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government-subsidised programme. POPULATION: All maternal deaths and women with near-miss morbidity. METHODS: Inclusion of near-miss using clinical and management-based criteria. MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR), severe morbidity ratio (SMR), mortality indices and proportion of near-miss cases at hospital admission. RESULTS: MMR was 187/100,000 live births and SMR was 50/1000 live births, with a relatively low mortality index of 3.6%. Severe haemorrhage and severe hypertensive disorders were the main causes of near-miss, with 26% of severe haemorrhages occurring in early pregnancy. Sepsis was the most common cause of death. The majority of near-miss cases (74%) were in critical condition at hospital admission and differed from those fulfilling the criteria after admission as to diagnostic categories and socio-demographic variables. CONCLUSIONS: Pre-hospital barriers remain to be of great importance in a setting of this type, where there is wide availability of free maternal health care. Such barriers, together with haemorrhage in early pregnancy, pre-eclampsia detection and referral patterns, should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival at hospital should be analysed separately as that provides additional information about factors that contribute to maternal ill-health.

A multilevel analysis of condom use among adolescents in the European Union.

OBJECTIVES: This study examined which individual and national factors affect condom use among adolescents. STUDY DESIGN: Multilevel analysis. METHODS: This study reviewed the data on bullying, alcohol use and condom use provided by 18 European countries and subnational entities in the Health Behaviour in School-Aged Children survey. Another eight contextual variables were also analysed. Three multilevel logistic regression models were applied consecutively (analysing for crude geographical and school variance in condom use, adjusting for gender and adjusting all variables for one another). RESULTS: Among the 15-year-olds studied, 7.0% of the total variance in condom use was explained by school-related factors (intraschool-level correlation) and 5.8% by national/subnational factors. In the empty model, condom use was significantly associated with gender, alcohol consumption, predominant national religion and national prevalence of human immunodeficiency virus (HIV). In the full model, there was also a significant association with the Human Development Index ranking, gross domestic product, Gini coefficient and the Gender-related Development Index. CONCLUSIONS: This study suggests that while alcohol, gender, human development level, income, religion and HIV prevalence affect condom use in young Europeans, these factors do not explain all or even most of the variation. Nonetheless, since some of these factors are not traditionally associated with young people's sexual and reproductive health, these findings should enable more nuanced health policy programming.

Widow inheritance and HIV/AIDS in rural Uganda.

Despite current efforts to combat HIV/AIDS through behavioural change, ingrained socio-cultural practices such as widow inheritance in south-western Uganda has not changed. Low education, unemployment, dowry, widows' socioeconomic demands and the inheritor's greed for the deceased's wealth, influence widow inheritance. Voluntary counselling and testing is needed for the widows and their inheritors; formal dowry should be removed from marriage and widow inheritance stripped of its sexual component.

Emergency obstetric care: impact on emerging issues.

Access to Emergency obstetric care (EmOC) remains a challenge for women. This paper presents a summary of issues and suggestions from one of the working groups at the FIGO precongress workshop on access of sexual and reproductive health care in November, 2006, in Kuala Lumpur.

Human resources and access to maternal health care.

The lack of human resources is one of the main bottlenecks to achieving the Millennium Development Goals on maternal and child health. A coherent national policy, recognized across government, needs to be in place to overcome this especially in countries severely affected by HIV/AIDS. Such a policy should cover selection of pre-service students, the qualifications of trainers and training sites, supportive supervision, career path development, a package of carefully thought-out incentives for the retention of staff, strategies for interaction with communities, and an agreed-upon health staff HIV/AIDS policy. Without such coherent human resource planning, a large number of countries will fail to reduce maternal and newborn mortality.

Observations on reproductive health programs in the Baltic States.

Public attention in Sweden has been drawn to three neighboring states that recently joined the European Union: Estonia, Latvia, and Lithuania. At this historic moment, it seems instructive to look at how the rapidly reformed health sectors of these ex-Soviet republics are responding to the vision of reproductive health articulated in Cairo 10 years ago. Reproductive health and rights have improved in these states in spite of recent reforms often acting to oppose improvement. Reforms such as the introduction of family medicine need continued adjustment, especially regarding antenatal care. One special challenge is the retention of essential mid-level providers, such as midwives, as the mode of HIV transmission becomes increasingly sexual.

Care for adolescent pregnancy and childbirth.

The rise in adolescent pregnancy in the 20th century has been influenced by declining age at menarche, increased schooling, delay of marriage, inadequate contraception and poverty. The main problems are preterm labor, hypertensive disease, anemia, more severe forms of malaria, obstructed labor in very young girls in some regions, poor maternal nutrition and poor breastfeeding. In many regions HIV infection is an important problem. The infants of adolescent mothers are more prone to low birth weight and increased neonatal mortality and morbidity. Antenatal care is often inadequate. The most important problem is the increased incidence of preterm labor and delivery, the youngest age groups running the highest risk. Technically, care of adolescents during labor need not differ from care of older women; most adolescents are not at increased risk during labor, although, they are more in need of empathic support. Generally, care of pregnant adolescents should be adjusted to their specific needs.

Characteristics of antenatal care attenders in a rural population in Tamil Nadu, South India: a community-based cross-sectional study.

The objectives of the study were to identify factors associated with utilisation of antenatal care facilities in a rural population in South India. A community-based, cross-sectional questionnaire study of 30 randomly selected areas was used. A total of 1254 women (95%) had at least one antenatal care visit. The median number of visits was four. High utilisation of antenatal care facilities was associated with low parity and adverse obstetrical history, short distance to healthcare facilities and literacy. It was concluded that antenatal care coverage was high. Information about the above few aspects can be used to target women who are at risk of getting inadequate antenatal care.

Strategies to reduce maternal mortality worldwide.

The challenge of reducing maternal mortality is increasingly being addressed by area-based efforts to improve access to care of obstetric emergencies. Improving coverage and quality of skilled attendance at birth is also being increasingly emphasized. Post-abortion care, better reproductive health services for adolescents, and improved family planning care are important ingredients in maternal mortality reduction. New developments in malaria, nutrition, violence and HIV/AIDS in relation to maternal health are highlighted, as well as measurement issues. Maternal mortality reduction is also being promoted today by using a human rights approach.

Candies in hell: women's experiences of violence in Nicaragua.

The aim of this study was to describe the characteristics of domestic violence against women in León, Nicaragua. A survey was carried out among a representative sample of 488 women between the ages of 15-49. The physical aggression sub-scale of the Conflict Tactics Scale was used to identify women suffering abuse. In-depth interviews with formerly battered women were performed and narratives from these interviews were analysed and compared with the survey data. Among ever-married women 52% reported having experienced physical partner abuse at some point in their lives. Median duration of abuse was 5 years. A considerable overlap was found between physical, emotional and sexual violence, with 21% of ever-married women reporting all three kinds of abuse. Thirty-one percent of abused women suffered physical violence during pregnancy. The latency period between the initiation of marriage or cohabitation and violence was short, with over 50% of the battered women reporting that the first act of violence act took place within the first 2 years of marriage. Significant, positive associations were found between partner abuse and problems among children, including physical abuse. Both the survey data and the narrative analysis pointed to extreme jealousy and control as constant features of the abusive relationship. Further, the data indicate that battered women frequently experience feelings of shame, isolation and entrapment which, together with a lack of family and community support, often contribute to women's difficulty in recognizing and disengaging from a violent relationship. These findings are consistent with theoretical conceptualisations of domestic violence developed in other countries, suggesting that, to a large degree, women's experiences of violence transcend specific cultural contexts.

Reducing perinatal and maternal mortality in the world: the major challenges.

PIP: Effective reduction of perinatal and maternal mortality remains a major global challenge. The main causes of neonatal deaths are asphyxia, birth trauma, infection, prematurity, and malformation. However, there are several simple and noncostly measures that can avoid these problems. These are: 1) syphilis screening programs; 2) tetanus toxoid vaccination; 3) immunizing women twice during their pregnancy; 4) nutritional supplementation; and 5) prevention and treatment of severe anemia. Yet, the most important intervention that is both relatively simple and cost-effective can be implemented during pregnancy. On the other hand, reducing maternal mortality poses as a much bigger challenge. The primary concern in preventing mortality lies in avoiding pregnancy, evading the complications during pregnancy, or by controlling the complications if ever they arise. Furthermore, the WHO stated that the presence of a skilled attendant at birth is one of the most effective interventions in reducing maternal mortality. In general, perinatal and maternal mortality reduction requires long-term efforts and strengthening of the health care systems.^ieng

Fertility and infant mortality trends in Nicaragua 1964-1993. The role of women's education.

OBJECTIVES: To assess trends in fertility and infant mortality rates (IMR) in León, Nicaragua, and to examine the effect of women's education on these trends during 1964-1993, a period of rapid social change. DESIGN: Cross sectional survey, based on random cluster sampling. A retrospective questionnaire on reproductive events was used. SETTING: The municipality of León, which is the second largest city in Nicaragua, with a total population of 195,000 inhabitants. SUBJECTS: 10,867 women aged 15-49 years, corresponding to 176,281 person years of reproductive life. Their children contributed 22,899 person years under 12 months of age to the IMR analysis. MAIN OUTCOME MEASURES: Fertility rate (number of pregnancies per 1000 person years) for specific age groups and calendar periods, total fertility rate, and IMR. RESULTS: Fertility rates and IMR declined in parallel, especially during the 1980s. However, education specific fertility rates did not decline, but the proportion of educated young women increased from 20% to 46%. This had also an impact on the overall IMR decline, although IMR reduction mainly took place among infants of women without formal education, decreasing from 118 to 69 per 1000 during the observation period. CONCLUSIONS: In this demographic transition over three decades, fertility and IMR declined simultaneously. The decreasing trend in fertility was mainly explained by an increase in women's education, while the IMR decline seemed to be the result of health interventions, specially targeted to poorer groups of women and their infants. Thus, social differences in fertility rates remained unchanged, while equity in chances of child survival increased.