Antibodies against Periodontal Microorganisms and Cognition in Older Adults.

INTRODUCTION: Markers of poor oral health are associated with impaired cognition and higher risk of Alzheimer disease (AD) and thus may help predict AD. OBJECTIVES: The aim of this study was to evaluate the cross-sectional association between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and cognition in middle-aged and older adults. METHODS: The study population consisted of participants of the third National Health and Nutrition Examination Survey (NHANES III) (1988 to 1994), who were 60 y and older, among whom cognition and IgG antibodies against 19 periodontal microorganisms were measured (N = 5,162). RESULTS: In multivariable quantile regression analyses, the Orange-Red (Prevotella melaninogenica, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis) and Yellow-Orange (Staphylococcus intermedius, Streptococcus oralis, Streptococcus mutans, Fusobacterium nucleatum, Peptostreptococcus micros, Capnocytophaga ochracea) cluster scores were negatively associated with cognition. A 1-unit higher cluster score for the Orange-Red cluster was associated on average with a lower cognitive score (ß for 30th quantile = -0.2640; 95% confidence interval [CI], -0.3431 to -0.1848). Similarly, a 1-unit higher score for the Yellow-Orange cluster was associated with a lower cognitive score (ß for 30th quantile = -0.2445; 95% CI, -0.3517 to -0.1372). CONCLUSION: Groups of IgG antibodies against periodontal microorganisms were associated with lower cognition among free living adults 60 years and older, who were previously undiagnosed with cognitive impairment. Though poor oral health precedes the development of dementia and AD, oral health information is currently not used, to our knowledge, to predict dementia or AD risk. Combining our findings with current algorithms may improve risk prediction for dementia and AD. KNOWLEDGE TRANSLATION STATEMENT: IgG antibodies against periodontal microorganisms were associated with lower cognition among adults 60 years and older previously undiagnosed with cognitive impairment. Periodontal disease may predict cognition among older adults.

Serum IgG Antibodies against Periodontal Microbes and Cancer Mortality.

INTRODUCTION: Periodontitis is a chronic inflammatory condition initiated by microorganisms and is positively linked to systemic conditions such as cancer, cardiovascular disease, and diabetes mellitus. OBJECTIVES: To prospectively investigate associations between empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms and cancer mortality in a representative sample of the US population. METHODS: We evaluated 6,491 participants aged ≥40 y from the Third National Health and Nutrition Examination Survey (1988 to 1994), who had complete data on IgG antibody titers against 19 selected periodontal microorganisms and were free of cardiovascular disease and cancer. In a prior study, antibodies were categorized into 4 mutually exclusive groups via cluster analysis: red-green, orange-red, yellow-orange, and orange-blue. Cluster scores were estimated by summing z scores of the antibody titers making up each cluster. Participants were followed up to death until December 31, 2011. Cox proportional hazard models were applied to estimate hazard ratios (HRs) and 95% CIs for all-cancer mortality by tertiles of cluster scores. RESULTS: During follow-up for a median of 15.9 y, there were 2,702 deaths (31.3%), including 631 cancer-related deaths (8.1%). After adjusting for multiple confounders, the orange-blue cluster was inversely associated with cancer mortality (tertile 2 vs. tertile 1: HR = 0.67, 95% CI = 0.54 to 0.84; tertile 3 vs tertile 1: HR = 0.62, 95% CI = 0.46 to 0.84). The association between the yellow-orange cluster and all-cancer mortality was also inverse but not significant, and the orange-red cluster and the red-green cluster were not associated with all-cancer mortality. CONCLUSIONS: Antibodies against Eubacterium nodatum and Actinomyces naeslundii may be novel predictors of cancer mortality. If further studies establish a causal relationship between these antibodies and cancer mortality, they could be targets to prevent possible systemic effects of periodontal disease with potential interventions to raise their levels. KNOWLEDGE TRANSFER STATEMENT: Periodontal antibodies against Eubacterium nodatum and Actinomyces naeslundii were inversely associated with cancer mortality among adults followed up for an average of 16 y. Periodontal antibodies may predict cancer mortality.

Periodontal Antibodies and All-Cause and Cardiovascular Disease Mortality.

Periodontitis is positively linked to cardiovascular disease (CVD), diabetes, cancer, and increased mortality. Empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms have been associated with hyperglycemia. We further investigated associations between these serum IgG antibody clusters and all-cause and CVD mortality in a representative US population. Participants free of CVD and cancer and aged ≥40 y at baseline (N = 6,491) from the Third National Health and Nutrition Examination Survey (1988 to 1994) were followed up until December 31, 2011. Antibodies were categorized into 4 clusters: red-green, orange-red, yellow-orange, and orange-blue. Over a 23-y follow-up, 2,702 deaths occurred, including 810 CVD-related deaths. In fully adjusted Cox proportional hazard models, the red-green cluster was positively associated with all-cause mortality (tertile 3 vs. tertile 1: hazard ratio [HR] = 1.43, 95% CI = 1.08 to 1.90, P = 0.015). The yellow-orange cluster was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.78, 95% CI = 0.63 to 0.97, P = 0.028) and CVD mortality (tertile 2 vs. tertile 1: HR = 0.57, 95% CI = 0.42 to 0.77, P = 0.005). The orange-blue cluster (composed of antibodies against Eubacterium nodatum and Actinomyces naeslundii) was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.55 to 0.78, P < 0.0001) and CVD mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.47 to 0.88, P = 0.007). These antibodies could predict prognosis or be potential intervention targets to prevent systemic effects of periodontal disease if further studies establish a causal relationship.

Vitamin D and progression of carotid intima-media thickness in HIV-positive Canadians.

OBJECTIVES: Based on a growing body of evidence implicating low vitamin D status in the development of cardiovascular disease (CVD), we hypothesized that in Canadian HIV-positive adults, low 25-hydroxyvitamin D (25(OH)D) concentration would be associated with increased subclinical vascular disease progression. METHODS: We prospectively studied the relationship between baseline 25(OH)D and subsequent progression of carotid intima-media thickness (CIMT) between 2002 and 2011, in the Canadian HIV Vascular Study using stored blood specimens. RESULTS: Of the 128 participants, 89.1% were men, the mean age (standard deviation [SD]) was 46.5 (8.2) years, 93.8% were white, and 36.7% were current smokers. Mean (SD) annual CIMT follow-up was 5.9 (1.8) years (maximum 8.5 years), providing approximately 750 patient-years of follow-up. Mean (SD) CIMT progression was 0.027 (0.030) mm/year. Mean (SD) 25(OH)D was 95.0 (46.9) nmol/L. Only 13.3% of participants were vitamin D deficient (25(OH)D < 50 nmol/L), whereas 61.7% had a 25(OH)D exceeding the sufficiency threshold (75 nmol/L). Vitamin D quartiles were inversely associated with body mass index (BMI) (P = 0.034), total cholesterol to high-density lipoprotein (HDL) cholesterol ratio (P = 0.001) and parathyroid hormone concentration (P = 0.003), but not efavirenz exposure (P = 0.141). In linear regression analyses, baseline 25(OH)D as a continuous variable was inversely associated with CIMT progression in univariable (P < 0.001) and multivariable (P < 0.001) models. CONCLUSIONS: Baseline 25(OH)D was associated with CIMT progression in this relatively vitamin D replete, predominately white and male, Canadian HIV-positive population. Future research needs to establish causality as this may warrant more targeted screening or supplementation.

Cross-Sectional Analysis of Alcohol Intake and Serum Antibodies to Oral Microorganisms.

The objective of this study was to evaluate the relation between alcohol intake and groups of periodontal antibody titers among individuals with normal glucose tolerance (NGT), prediabetes and diabetes. This was a cross-sectional analysis of the National Health and Nutrition Examination Survey III (NHANES III) 1988-1994 data, among individuals 40 y and older with information on alcohol intake and serum immunoglobulin G (IgG) antibody data against 19 oral microorganisms. Participants were excluded if they did not have teeth, reported that they were taking insulin, or having gestational diabetes. The sample size for this analysis was 3,219. Periodontal antibodies were grouped into four clusters using cluster analysis: Orange-Red, Red-Green, Yellow- Orange, and Orange-Blue. Cluster scores were computed for each individual by summing z-scores of standardized log-transformed IgG titers of antibodies against periodontal microorganisms making up each respective cluster. Each cluster score was modeled as an outcome. Alcohol consumption was assessed in g/day using self-reported number of days of drinking in the past 12 mo and the average number of drinks consumed per day on days when they drank. Overall, alcohol intake was positively associated with periodontal antibodies of the Orange-Red cluster (P. melaninogenica, P. intermedia, P. nigrescens, and P. gingivalis), and inversely associated with the Yellow-Orange cluster (S. intermedius, S. oralis, S. mutans, F. nucleatum, P. micra, C. ochracea) after multivariable adjustment. The association between alcohol intake and the Orange-Red cluster was strongest among individuals with diabetes; this relation was seen among individuals with and without periodontal damage. The Orange-Red cluster was positively associated with periodontal damage among individuals with diabetes. Alcohol intake was not associated with any antibody cluster among individuals with NGT or prediabetes. The effect of alcohol intake on periodontal disease may be greater among individuals with diabetes but this finding needs to be confirmed in prospective studies. Knowledge Transfer Statement: The results of this study can be used by clinicians when treating patients with periodontal disease and diabetes.

Oral health and ventilator-associated pneumonia among critically ill patients: a prospective study.

OBJECTIVE: To evaluate the association between oral health and ventilator-associated pneumonia (VAP) among critically ill patients. METHODS: A prospective cohort study was conducted among 162 critically ill patients newly intubated and treated with mechanical ventilator in one tertiary hospital in Thailand. Oral health status was assessed using Oral Health Assessment Tool (OHAT), Plaque Index (PI), and number of teeth. VAP, defined as Clinical Pulmonary Infection Score >6, was assessed on Day 4 after intubation. Hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression adjusted for confounders. RESULTS: Critically ill patients had deteriorating oral health status after intubation. Early-onset VAP developed in 69 patients (42.6%), with VAP incidence of 117 episodes per 1000 ventilator-days. Moderately unhealthy and unhealthy oral conditions based on OHAT scores were associated with a 2.92-fold (95% CI: 1.26-6.74) and 3.22-fold (95% CI: 1.34-7.76) increased risk of VAP. Patients with moderate-to-very poor oral hygiene assessed by PI had increased VAP risk of 1.66-folds (95% CI: 1.001-2.75). The number of teeth was not associated with VAP development. CONCLUSIONS: There is a strong association between poor oral health and increased risk for early-onset VAP. Routine oral care possibly prevents VAP development among critically ill patients treated with mechanical ventilator.

Mediterranean diet and mortality risk in metabolically healthy obese and metabolically unhealthy obese phenotypes.

BACKGROUND: The Mediterranean diet has been consistently associated with reduced mortality risk. Few prospective studies have examined whether the benefits from a Mediterranean diet are equally shared by obese individuals with varying metabolic health. OBJECTIVE: The objective of this study was to investigate the association between Mediterranean diet, metabolic phenotypes and mortality risk in a representative obese US population. METHODS: Data from 1739 adults aged 20-88 years were analyzed from participants of the National Health and Nutrition Examination Survey III, 1988-1994 followed up for deaths until 31 December 2011 in a prospective cohort analysis. Mediterranean Diet Scores (MDS) were created to assess the adherence to Mediterranean diet. Participants were classified as metabolically healthy obese (MHO) phenotype (0 or 1 metabolic abnormality) or metabolically unhealthy obese (MUO) phenotype (two or more metabolic abnormalities), based on high glucose, insulin resistance, blood pressure, triglycerides, C-reactive protein and low high-density lipoprotein cholesterol. RESULTS: The MHO phenotype (n=598) was observed in 34.8% (s.e., 1.7%) of those who were obese (mean body mass index was 33.4 and 34.8 in MHO and MUO phenotypes, respectively). During a median follow-up of 18.5 years, there were 77 (12.9%) and 309 (27.1%) deaths in MHO and MUO individuals, respectively. In MHO individuals, the multivariable-adjusted hazard ratio (HR) of all-cause mortality in the highest tertile compared with the first tertile of MDS was 0.44 (95% confidence interval (CI), 0.26-0.75; P for trend <0.001), after adjustment for potential confounders. A five-point (1 s.d.) increment in the adherence to MDS was associated with a 41% reduction in the risk of all-cause mortality (HR, 0.59; 95% CI, 0.37-0.94). Similar findings were obtained when we restricted our analyses to those with or without prevalent diabetes mellitus and hypertension. We did not observe mortality risk reduction in either individuals with MUO phenotype or all obese participants combined. CONCLUSIONS: Adherence to a Mediterranean dietary pattern appears to reduce mortality in the MHO phenotype, but not among the MUO phenotype in an obese population.

Effect of Long-Term Periodontal Care on Hemoglobin A1c in Type 2 Diabetes.

This was a prospective cohort study evaluating 126,805 individuals with diabetes and periodontal disease receiving care at all Veterans Administration medical centers and clinics in the United States from 2005 through 2012. The exposures were periodontal treatment at baseline (PT0) and at follow-up (PT2). The outcomes were change in HbA1c following initial treatment (ΔHbA1c1) and follow-up treatment (ΔHbA1c2), and diabetes control was defined as HbA1c at <7% and <9% following initial and follow-up treatment, respectively. Marginal structural models were used to account for potential confounding and selection bias. The objective was to evaluate the impact of long-term treatment of periodontal disease on glycemic control among individuals with type 2 diabetes. Participants were 64 y old on average, 97% were men, and 71% were white. At baseline, the average diabetes duration was 4 y, 12% of participants were receiving insulin, and 60% had HbA1c <7%. After an average 1.7 y of follow-up, the mean HbA1c increased from 7.03% to 7.21%. About 29.4% of participants attended their periodontal maintenance visit following baseline. Periodontal treatment at baseline and follow-up reduced HbA1c by -0.02% and -0.074%, respectively. Treatment at follow-up increased the likelihood of individuals achieving diabetes control by 5% and 3% at the HbA1c <7% and HbA1c <9% thresholds, respectively, and was observed even among never smokers. HbA1c reduction after periodontal treatment at follow-up was greater (ΔHbA1c2 = -0.25%) among individuals with higher baseline HbA1c. Long-term periodontal care provided in a clinical setting improved long-term glycemic control among individuals with type 2 diabetes and periodontal disease.

Association between Serum Antibodies to Oral Microorganisms and Hyperglycemia in Adults.

We conducted a cross-sectional analysis to evaluate the relationship between serum antibody titers against 19 selected oral microorganisms and measures of hyperglycemia in a large, nationally representative data set. The study population consisted of 7,848 participants from the National Health and Nutrition Examination Survey III (1988-1994) who were at least 40 yrs old, with complete serum IgG antibody data against 19 oral microorganisms. The 19 antibody titers were grouped into 4 categories via cluster analysis--orange-red, yellow-orange, orange-blue, and red-green--named to reflect predominant antibody titers against microorganisms in Socransky's classification scheme for oral microbes. Linear regression models weighted for complex survey design were used in which fasting blood glucose, fasting insulin, and HbA1c were outcomes and antibody cluster scores were exposures, adjusting for potential confounders. Higher orange-red cluster scores were associated with increased hyperglycemia, while higher orange-blue cluster scores were related with decreased hyperglycemia. A 1-unit-higher orange-red cluster score was associated with 0.46 mg/dL higher fasting blood glucose (p = .0038), and a 1-unit-higher orange-blue cluster score was associated with 0.34% lower HbA1c (p = .0257). Groups of antibody titers against periodontal microorganisms were associated with hyperglycemia independent of known risk factors.

Associations of dietary intake patterns identified using reduced rank regression with markers of arterial stiffness among youth with type 1 diabetes.

BACKGROUND/OBJECTIVES: Youth with type 1 diabetes (T1DM) are at substantially increased risk for adverse vascular outcomes, but little is known about the influence of dietary behavior on cardiovascular disease (CVD) risk profile. We aimed to identify dietary intake patterns associated with CVD risk factors and evaluate their impact on arterial stiffness (AS) measures collected thereafter in a cohort of youth with T1DM. SUBJECTS/METHODS: Baseline diet data from a food frequency questionnaire and CVD risk factors (triglycerides, low density lipoprotein-cholesterol, systolic blood pressure, hemoglobin A1c, C-reactive protein and waist circumference) were available for 1153 youth aged ⩾10 years with T1DM from the SEARCH for Diabetes in Youth Study. A dietary intake pattern was identified using 33 food groups as predictors and six CVD risk factors as responses in reduced rank regression (RRR) analysis. Associations of this RRR-derived dietary pattern with AS measures (augmentation index (AIx75), n=229; pulse wave velocity, n=237; and brachial distensibility, n=228) were then assessed using linear regression. RESULTS: The RRR-derived pattern was characterized by high intakes of sugar-sweetened beverages (SSB) and diet soda, eggs, potatoes and high-fat meats and low intakes of sweets/desserts and low-fat dairy; major contributors were SSB and diet soda. This pattern captured the largest variability in adverse CVD risk profile and was subsequently associated with AIx75 (ß=0.47; P<0.01). The mean difference in AIx75 concentration between the highest and the lowest dietary pattern quartiles was 4.3% in fully adjusted model. CONCLUSIONS: Intervention strategies to reduce consumption of unhealthy foods and beverages among youth with T1DM may significantly improve CVD risk profile and ultimately reduce the risk for AS.

A role for the DtxR family of metalloregulators in gram-positive pathogenesis.

Given the central role of transition metal ions in a variety of biochemical processes, the colonization, survival, and proliferation of a bacterium within a host hinges upon its ability to overcome the metal ion deprivation that characterizes nutritional immunity. Metalloregulatory, or 'metal-sensing' proteins have evolved in bacteria to mediate metal ion homeostasis by activating or repressing the expression of genes encoding metal ion transport systems upon binding their cognate metal ion. Yet increasing evidence in the literature supports an additional role for these metalloregulatory proteins in pathogenesis. Herein, we survey studies on the DtxR family of metalloregulators, namely DtxR (Cornyebacterium diphtheriae), SloR (Streptococcus mutans), MtsR (Streptococcus pyogenes), and MntR (Staphylococcus aureus) to describe how metalloregulation enables adaptive virulence gene expression within the mammalian host. This research has important implications for drug design, as the generation of hyper-repressive metalloregulatory proteins may represent a mechanism by which to attenuate bacterial pathogenicity. The fact that metalloregulators are unique to prokaryotes makes these proteins especially attractive therapeutic targets.

Factors associated with fruit and vegetable consumption among adults.

BACKGROUND: The higher consumption of fruit and vegetables is considered to be an indicator of healthy eating and the protective effects of fruit and vegetable (FV) consumption for noncommunicable diseases have been investigated extensively. The present study aimed to investigate the association between fruit and vegetable intake (FVI), health behaviours and socio-demographic factors among adult Canadians. METHODS: This analysis was based on the information from the Canadian Community Health Survey, Cycle 3.1. Daily intake of fruit and vegetables from a total number of 15,512 apparently healthy individuals, aged 18-64 years, were assessed using a structured questionnaire, which included 20 questions on the frequency of consumption of different types of fruit and vegetables. Multiple logistic regression models were used to determine the association between FVI and some socio-economic factors and lifestyle behaviour among adult Canadians. RESULTS: In total 77% of Canadian adults consumed fruit and vegetables less than five times per day. Females were more likely to consume more fruit [odds ratio (OR) 2.05; 95% confidence interval (CI) 1.75-2.4], vegetables (OR 1.95; 95% CI 1.65-2.29) and FV (OR 2.52; 95% CI 2.20-2.90) than males. Single/never married individuals, individuals with higher levels of education, never smokers, former drinkers and older people reported more consumption of fruit and vegetables than others. CONCLUSIONS: The results obtained in the present study indicate an association between FVI and some socio-economic and healthy lifestyle behaviours, and that a substantial gap exists between the recommended level and the actual intake of the FV among the Canadian population. Because a higher intake of FV improves public health, it is imperative to tailor nutrition education at the individual and community levels in Canadian populations.

The usefulness of using Ramfjord teeth in predicting periodontal status of a Tanzanian adult population.

OBJECTIVES: The only partial mouth index that has been validated against full-mouth examinations in the East African population is the CPITN (Community Periodontal Index of Treatment Needs). Since the Ramfjord index can potentially shorten the examination time by almost half, we evaluated Ramfjord teeth in predicting full-mouth periodontal status of an adult population in Tanzania. MATERIAL AND METHODS: Pocket depth was measured for 192 consecutive patients aged from 15 to 77 years (36 years old on average); 86 (45%) females referred to the Department of Restorative Dentistry, Muhimbili National Hospital, Tanzania between January 1997 and December 1999, and the mean pocket depth for full-mouth and Ramfjord teeth was calculated. RESULTS: The correlation between the mean pocket depth calculated from the full-mouth and Ramfjord teeth was 0.96. The beta coefficient for the mean pocket depth measured by Ramfjord teeth to predict the full-mouth mean was 0.94, and was not affected by adjustment for age, missing teeth or sex. CONCLUSION: This overall high agreement between Ramjford teeth and full-mouth periodontal pocket situation confirms the epidemiological validity of Ramfjord's dental sample in our setting.

Periodontal disease and biomarkers related to cardiovascular disease.

Periodontal disease is a chronic infection of the gums characterized by a loss of attachment between the tooth and bone, and by bone loss. We evaluated cross-sectionally the association between periodontal disease and C-reactive protein (CRP), fibrinogen, factor VII, tissue plasminogen activator (t-PA), LDL-C, von Willebrand factor, and soluble tumor necrosis factor receptors 1 and 2. The final sample consisted of 468 men (ages 47-80 yrs), participating in the Health Professional Follow-up Study, who provided blood and were free of CVD, diabetes, and cancer. In multivariate regression models controlling for age, cigarette smoking, alcohol intake, physical activity, and aspirin intake, self-reported periodontal disease was associated with significantly higher levels of CRP (30% higher among periodontal cases compared with non-cases), t-PA (11% higher), and LDL-C (11% higher). Based on our data, periodontal disease showed significant associations with biomarkers of endothelial dysfunction and dyslipidemia, which may potentially mediate the association between periodontal and cardiovascular disease.

Water and sanitation associated with improved child growth.

OBJECTIVE: To examine the relation between household water and sanitation, and the risk of stunting and reversal of stunting in Khartoum and Crezira regions, Sudan. DESIGN: Prospective cohort study. SETTING: A total of 25 483 children aged 6-72 months from rural Sudan enrolled in an 18-month field trial in 1988 to study the effect of vitamin A supplementation on child health and survival. RESULTS: The mean height-for-age z-scores at baseline and the end of study were -1.66 and -1.55, respectively, for the group with water and sanitation facilities, and -2.03 and -1.94 for the group without water and sanitation, after adjustment for age, region, gender, mother's literacy, intervention group (vitamin A vs placebo), family wealth, breastfeeding and cleanliness. Among children of normal height-for-age at baseline, the risk of stunting (<-2 height-for-age z-score) was lowest in the group that came from homes that had both water and sanitation compared to children from homes without these facilities (multivariate RR=0.79, 95% CI 0.69-0.90). Among children stunted at baseline, those coming from homes with water and sanitation had a 17% greater chance of reversing stunting than those coming from homes without either facility (adjusted RR=1.17, 95% CI 0.99-1.38). We did not detect a synergistic association between access to water and sanitation. CONCLUSIONS: Water and sanitation are independently associated with improved growth of children. SPONSORSHIP: None.

Alcohol consumption increases periodontitis risk.

Alcohol consumption impairs neutrophil, macrophage, and T-cell functions, increasing the likelihood of infections. We examined the association between alcohol consumption and periodontitis, prospectively, among 39,461 male health professionals aged 40 to 75 years and free of periodontitis at the start of follow-up. Alcohol intake was assessed at baseline and updated every 4 years by a food-frequency questionnaire. Periodontal disease status was self-reported and validated against radiographs. Multivariate analysis was adjusted for age, smoking, diabetes, body-mass index, physical activity, time period, and caloric intake. During 406,160 person-years of follow-up, there were 2125 cases of periodontitis. Compared with non-drinkers, the relative risk (95% confidence interval) among men reporting usual alcohol intake of 0.1-4.9 g/day was 1.24 (1.09, 1.42); 5.0 to 14.9 g/day, 1.18 (1.04, 1.35); 15 to 29.9 g/day, 1.18 (1.01, 1.38); and > 30 g/day, 1.27 (1.08, 1.49). The results suggest that alcohol consumption is an independent modifiable risk factor for periodontitis.

Addicted schoolchildren: prevalence and characteristics of areca nut chewers among primary school children in Karachi, Pakistan.

OBJECTIVES: To evaluate the habits of betel quid use and areca nut chewing among school-aged children in Karachi, Pakistan. Areca nut (betel nut) is chewed by itself, in various scented preparations, and in betel quid (containing betel leaf, areca nut, slaked lime, condiments, sweeteners and sometimes tobacco) in various parts of Pakistan and India. It is associated with carcinogenesis, foreign body aspiration in children and oral submucous fibrosis, and may aggravate asthma. METHODS: We selected a stratified random sample of 160 primary school children between 4 and 16 years of age in Baba Island, Karachi. RESULTS: Seventy-four per cent of the children (118/159) used areca nut and 35% (55/159) used betel quid daily. More boys chewed areca nut than girls (72% vs 30%). The proportion of areca nut users increased by grade (from 48% in first grade to 90% in fifth grade). Most areca users first tried it with a family member (42%) or a friend (26%), and most (68%) consumed three or more packets a day. Children with fathers with three or fewer years of education were more likely to use areca nut (OR 3.2; 95% CI 1.2-8.4), and children whose mothers helped with homework less likely (OR 0.5; 95% CI 0.2-0.91; P = 0.027) to use it. Boys (OR 6.6; 95% CI 2.3-18.7) and areca nut users (OR 8.8; 95% CI2.8-27.0) were more likely to use betel quid. CONCLUSION: To reduce the use of areca nut, the Pakistan Government should consider imposing taxes on it, limiting advertising and actively communicating its health risks to the public.

What is the effect of riskshaw noise on its driver?

OBJECTIVE: Occupational hearing loss is common in the industrialized world. Road noise is a major contributor to perceived environmental noise. The objective of this study was to assess hearing loss in rickshaw drivers due to rickshaw noise. METHODS: Hearing loss in rickshaw drivers and taxi drivers of Karachi who were 50 years of age or younger was estimated, with a Smith Hearing Screening (SHS) questionnaire that was modified, translated into the national language, Urdu and field tested prior to administration. RESULTS: Interviews for 91 rickshaw drivers and 94 taxi drivers were completed. All subjects were male; mean ages were 34 and 33 years for rickshaw and taxi drivers respectively. None of the rickshaws were fitted with silencers. Rickshaw drivers were about thrice as likely to be screened as hearing impaired by the SHS questionnaire (RR 2.9, 95% confidence interval 1.6, 5.0), twice as likely to report tinnitus (RR 2.2, 95% confidence interval, 1.1, 3.3) and two and a half times as likely to have difficulty in following telephonic conversations (RR 2.4, 95% confidence interval 1.2, 4.8). CONCLUSION: There is loss of hearing and tinnitus among rickshaw drivers that could be attributed to their trade. Use of silencers by rickshaw drivers could result in less hearing loss among rickshaw drivers and less noise in the environment for the other 11 million residents in the city.

Clinical and functional staging of oral submucous fibrosis.

OBJECTIVE: To investigate the association of location of bands in oral submucous fibrosis and extent of mouth-opening. DESIGN: Cross-sectional study. SETTING: University hospital, Pakistan. SUBJECTS: 325 patients who presented with oral submucous fibrosis in Karachi between January 1992 and October 1994, of whom 288 had data sufficient for analysis. MAIN MEASURES: Location of fibrous bands in the mouth and interincisal distance (mm). RESULTS: All subjects with labial bands had bands in the fauces, and all but one who had labial bands also had buccal bands. All those with buccal bands also had bands in the fauces. Of those with buccal bands, 42% did not have labial bands. The proportion of patients with bands in all three sites increased from functional stage A (interincisal opening < or = 10 mm) to stage C (interincisal opening > or = 20 mm) with a simultaneous reduction in the proportion of people with bands in one or two sites (X2 = 105, df = 4, P < 0.0001). CONCLUSIONS: Bands are common at the back of the mouth in mild cases of oral submucous fibrosis and, as the disease increases in severity, are more likely to be found anteriorly as well.