A comparison of screening methods in two early phase oral leukoplakia clinical trials.

OBJECTIVES/INTRODUCTION: Clinical trial accrual for oral dysplasia is difficult in the United States and elsewhere. Patients with dysplastic oral leukoplakia progress to frank invasive carcinoma at a rate of 5-37% over 5 years. We compared two clinical trial screening efforts to hopefully devise better accrual strategies to these types of clinical trials. METHODS: For the first trial, we identified 244 patients with dysplastic oral leukoplakia in our university database and a media campaign. Patients were notified and screened by examination and biopsy. For the second clinical trial, we established a preneoplastic lesions clinic and teaching and communications network with regional oral healthcare professionals. RESULTS: Only one of 244 patients accrued to the first clinical trial through an organized screening effort based on database/medical records review. The second clinical trial accrued 16/30 screened patients through redirected efforts in teaching, communications, and a preneoplastic lesions clinic. CONCLUSION: We conclude that significant difficulties resulted from medical record/database review of leukoplakia patients as a screening method for leukoplakia clinical trial entry. We feel that persistent direct contact and education of healthcare professionals who are likely to examine leukoplakia patients improved accrual to the second clinical trial.

A metaproteomic analysis of the human salivary microbiota by three-dimensional peptide fractionation and tandem mass spectrometry.

Metagenomics uses gene expression patterns to understand the taxonomy and metabolic activities of microbial communities. Metaproteomics applies the same approach to community proteomes. Previously, we used a novel three-dimensional peptide separation method to identify over 2000 salivary proteins. This study used those data to carry out the first metaproteomic analysis of the human salivary microbiota. The metagenomic software MEGAN generated a phylogenetic tree, which was checked against the Human Oral Microbiome Database (HOMD). Pathway analyses were performed with the Clusters of Orthologous Groups and MetaCyc databases. Thirty-seven per cent of the peptides were identifiable only at the level of cellular organisms or bacteria. The rest were distributed among five bacterial phyla (61%), archea (0.5%), and viruses (0.8%); 29% were assignable at the genus level, and most belonged to Streptococcus (17%). Eleven per cent of all peptides could be assigned to species. Most taxa were represented in HOMD and they included well-known species such as periodontal pathogens. However, there also were 'exotic' species including aphid endosymbionts; plant, water, and soil bacteria; extremophiles; and archea. The pathway analysis indicated that peptides were linked to translation (37%), followed by glycolysis (19%), amino acid metabolism (8%), and energy production (8%). The taxonomic structure of the salivary metaproteome is very diverse but is dominated by streptococci. 'Exotic' species may actually represent close relatives that have not yet been sequenced. Salivary microbes appear to be actively engaged in protein synthesis, and the pathway analysis is consistent with the metabolism of salivary glycoproteins.

FOXP3 T regulatory cells in lesions of oral lichen planus correlated with disease activity.

OBJECTIVE: The aim of this study was to determine the correlation between the number of FOXP3(+) T cell in lesions and the disease activity of patients with oral lichen planus (OLP). MATERIALS AND METHODS: The expression of FOXP3 was investigated using immunohistochemical staining and real-time RT-PCR in 23 OLP lesions and 12 controls. Changes of FOXP3(+) Treg in peripheral blood from three patients' pre and post-treatment were assessed using flow cytometry. RESULTS: Few FOXP3(+) cells were detected in controls, but an increased number of FOXP3(+) cells were observed in lesions (n = 20, 40.99 +/- 24.68 cells per high-power field - hpf). Furthermore, the frequency of FOXP3(+) Treg in reticular OLP (n = 7, 63.6 +/- 23.2 cells per hpf) was significantly higher than that in erythematous/erosive OLP (n = 13, 28.8 +/- 16.8 cells per hpf, P = 0.001). In addition, negative correlation was found between the number of FOXP3(+) Treg and disease activity (correlation oefficient = -0.557, P = 0.013). The proportion of FOXP3(+) Treg showed remarkable increase in peripheral blood from patients after treatment (1.39 +/- 0.71%vs 4.91 +/- 1.59%). CONCLUSIONS: These data indicated that FOXP3(+) Treg were involved in the pathogenesis of OLP and correlated with disease's subtype and activity.

Peripheral blood gene expression profiling in Sjögren's syndrome.

Sjögren's syndrome (SS) is a common chronic autoimmune disease characterized by lymphocytic infiltration of exocrine glands. The affected cases commonly present with oral and ocular dryness, which is thought to be the result of inflammatory cell-mediated gland dysfunction. To identify important molecular pathways involved in SS, we used high-density microarrays to define global gene expression profiles in the peripheral blood. We first analyzed 21 SS cases and 23 controls, and identified a prominent pattern of overexpressed genes that are inducible by interferons (IFNs). These results were confirmed by evaluation of a second independent data set of 17 SS cases and 22 controls. Additional inflammatory and immune-related pathways with altered expression patterns in SS cases included B- and T-cell receptor, insulin-like growth factor-1, granulocyte macrophage-colony stimulating factor, peroxisome proliferator-activated receptor-alpha/retinoid X receptor-alpha and PI3/AKT signaling. Exploration of these data for relationships to clinical features of disease showed that expression levels for most interferon-inducible genes were positively correlated with titers of anti-Ro/SSA (P<0.001) and anti-La/SSB (P<0.001) autoantibodies. Diagnostic and therapeutic approaches targeting interferon-signaling pathway may prove most effective in the subset of SS cases that produce anti-Ro/SSA and anti-La/SSB autoantibodies. Our results strongly support innate and adaptive immune processes in the pathogenesis of SS, and provide numerous candidate disease markers for further study.

Methamphetamine abuse and dentistry.

Methamphetamine is a highly addictive powerful stimulant that increases wakefulness and physical activity and produces other effects including cardiac dysrhythmias, hypertension, hallucinations, and violent behavior. The prevalence of methamphetamine use is estimated at 35 million people worldwide and 10.4 million people in the United States. In the United States, the prevalence of methamphetamine use is beginning to decline but methamphetamine trafficking and use are still significant problems. Dental patients who abuse methamphetamine can present with poor oral hygiene, xerostomia, rampant caries ('Meth mouth'), and excessive tooth wear. Dental management of methamphetamine users requires obtaining a thorough medical history and performing a careful oral examination. The most important factor in treating the oral effects of methamphetamine is for the patient to stop using the drug. Continued abuse will make it difficult to increase salivary flow and hinder the patient's ability to improve nutrition and oral hygiene. Local anesthetics with vasoconstrictors should be used with care in patients taking methamphetamine because they may result in cardiac dysrhythmias, myocardial infarction, and cerebrovascular accidents. Thus, dental management of patients who use methamphetamine can be challenging. Dentists need to be aware of the clinical presentation and medical risks presented by these patients.

Microarrays: applications in dental research.

Revolutionary advances are underway that will dramatically change our understanding of oral diseases. The phenomenal progress being made in biomedical research is in large part fueled by advances in our overall knowledge of the human genome, development of microarray technology that allows comprehensive and unbiased evaluation of global biologic pathways and networks, and expanded computational abilities. Expectations are that nearly all clinical areas in dentistry and oral medicine will be affected by advances in molecular medicine, which in turn, promises to lead to more accurate diagnosis, effective disease monitoring, and development of targeted and specific therapies. This review provides a brief overview of microarray technologies and highlights several key examples from research efforts in dentistry and oral medicine using these powerful new tools.

Proinflammatory cytokine levels in saliva before and after treatment of (erosive) oral lichen planus with dexamethasone.

OBJECTIVE: To explore the potential of detecting the level of proinflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha), interleukin-1-alpha (IL-1-alpha), IL-6, and IL-8 in whole unstimulated saliva (WUS) in monitoring the therapeutic effects of topical dexamethasone on these salivary cytokines in subjects with erosive oral lichen planus (OLP). STUDY DESIGN: Thirteen definitively diagnosed OLP subjects were enrolled in the study as were 13 age- and sex-matched controls. The OLP subjects were treated with 0.1% dexamethasone oral rinse for 6 weeks. Prior to treatment and at the end of clinical trial, the visual analog scale (VAS) for symptoms was recorded, WUS was collected and these proinflammatory cytokines were analyzed by ELISA. RESULTS: Following the dexamethasone treatment, the levels of TNF-alpha, IL-1-alpha, IL-6, and IL-8 were decreased significantly, and IL-1-alpha and IL-8 were detected at a level without a statistically significant difference from controls. VAS value was decreased significantly and was found to significantly correlate with the decrease in IL-1-alpha and IL-8 levels. CONCLUSIONS: These preliminary results indicate that salivary analysis of NF-kappaB-dependent cytokines may be applied to monitoring the therapeutic response of OLP.

Clinical evaluation of a commercially available oral moisturizer in relieving signs and symptoms of xerostomia in postirradiation head and neck cancer patients and patients with Sjögren's syndrome.

A major complication of irradiation therapy for head and neck cancer is salivary gland dysfunction and xerostomia. The purpose of this clinical investigation was to evaluate the effects of a commercially available oral moisturizer (Optimoist) on salivary flow rate, symptoms of xerostomia, oral pH, oral microflora, and swallowing in postirradiation head and neck cancer patients (XRT) and patients with Sjögren's syndrome (SS). Subjects who were post-XRT and subjects with SS (n = 24; mean age = 54.1) discontinued their use of any salivary substitute or moisturizer for 2 weeks prior to entering the study. Baseline whole unstimulated saliva was collected for 5 minutes using a standard sialometric technique. Candida albicans and Lactobacillus cultures were performed using kits from Orion Diagnostica, Inc., and a pH analysis was performed on the salivary sample using a Markson (model 00663) pH meter. Swallowing was assessed by clinical measures by videofluoroscopic techniques. Several subjective assessments were performed to evaluate symptoms of xerostomia. Subjects were instructed in the use of a daily diary and to use only the provided article ad libitum for a period of 2 weeks. After the 2-week period, the results indicated significant subjective and objective improvements in signs and symptoms of xerostomia. Whole unstimulated salivary flow rate improved from (mean +/- SEM) 0.1150 +/- 0.02 to 0.2373 +/- 0.09 mL/min. Salivary pH did not change. Global subjective improvement in xerostomia improved in 58% of the subjects. Candida colonization decreased in 43% of the subjects. There was no change in Lactobacilli colonization. Swallowing objectively improved in 75% of subjects. These results indicate significant improvement in both signs of hyposalivation and symptoms of xerostomia with the use of Optimoist in postirradiation head and neck cancer patients and patients with SS.

An update on the management for the dental patient with Sjögren's syndrome and xerostomia.

Sjögren's syndrome is a chronic and uncomfortable inflammatory condition for the individuals who suffer from it. There are many and varied systemic and oral complications associated with Sjögren's syndrome. It is also a complex and challenging condition for the dentist to diagnose and manage. The key concepts are early recognition and intervention to prevent the secondary complications from hyposalivation. To the degree possible, salivary flow should be restored by either artificial salivas or stimulated by secretogogues or both, which is usually the case. Atrophy and secondary infections of the oral mucosa should be properly identified, effectively treated, and frequently monitored. Pilocarpine HCl (Salagen) has been shown to be effective in increasing salivary flow in patients with SS. Preventive and supportive therapy including supplemental fluorides, dietary assessment, and frequent professional recalls are imperative to maintaining the oral health of the patient with SS.

Sjögren's syndrome.

Sjögren's syndrome (SS) is a progressive autoimmune rheumatic disorder. Its precise etiology is unknown, although several contributing factors have been identified. One theory is that the condition results from complications related to infection with the Epstein-Barr virus. Primary exposure to or reactivation of Epstein-Barr virus elicits expression of the human leukocyte antigen complex. This is recognized by T lymphocytes (CD 4+) resulting in the release of cytokines (tumor necrosis factor, interleukin-2, interferon-gamma, and others). A genetic marker specific for Sjögren's syndrome, HLA-DR4, has been identified. According to the World Health Organization, the prevalence of Sjögren's syndrome is unknown. A recent epidemiologic study in Sweden estimated the prevalence in the adult population to be 2.7%. In the United States, 10 years ago, the number of patients with Sjögren's syndrome was thought to be fewer than 100,000. This number today is estimated to be more than 1 million. Sjögren's syndrome has been reported in nearly every major country of the world, and the geographic distribution of cases appears to be relatively uniform. Sjögren's syndrome typically affects women (90%) during the fourth or fifth decade of life. Isolated cases of Sjögren's syndrome in children have been reported.

A comparison of three methods for detecting Candida albicans in patients with Sjögren's syndrome.

OBJECTIVE: An immediate chairside technique (Latex Candida) for the detection of Candida albicans was compared with a simple tube culturing technique (Oricult) and the traditional laboratory culturing technique in patients with Sjögren's syndrome. METHOD AND MATERIALS: Subjects with primary (n = 9) and secondary (n = 9) Sjögren's syndrome (mean age of 56.7 years; all female) and an age- and sex-matched group of control subjects (n = 9) were selected. Three different methods for culturing Candida albicans were performed for each subject. One culturette was plated on a trypticase soy-agar streptomycin-vancomycin medium plate and incubated for 48 hours at 37 degrees C. Another swab was plated on a reagent paper with the Latex Candida test kit. The third swab was placed in a culture media tube using the Oricult kit and incubated for 48 hours at 37 degrees C. RESULTS: All three techniques indicated a significant difference in the prevalence of Candida between the control group and both Sjögren's groups. The Latex Candida technique indicated that 78% of all Sjögren's subjects were positive for Candida, while the other two tests indicated that 83% were positive. CONCLUSION: The Latex Candida technique was comparable to Oricult and streptomycin-vancomycin culturing techniques for negative results and was correctly positive for 90% of cases.

Candida albicans levels in patients with Sjögren's syndrome before and after long-term use of pilocarpine hydrochloride: a pilot study.

OBJECTIVE: The purpose of this study was to compare the quantities of oral Candida albicans in patients with primary and secondary Sjögren's syndrome before and after the use of orally administered pilocarpine hydrochloride for 1 year. METHOD AND MATERIALS: Twelve female subjects with primary (n = 4) and secondary (n = 8) Sjögren's syndrome (mean age +/- SEM = 56.7 +/- 5.7 years) were enrolled in the study, after meeting rigid enrollment criteria. Oropharyngeal collection of samples and culturing was performed on each subject. Cultures specific for Candida albicans were plated into a culture media tube using the Oricult kit and also by serial dilutions and plating by a streptomycin-vancomycin technique. Cultures were incubated for 48 hours at 37 degrees C. The subjects used 5 mg of pilocarpine hydrochloride, administered orally three times daily, for 1 year, after which both of the Candida cultures were repeated. None of the subjects used antifungal medications, none smoked, and all were dentate. RESULTS: There was a significant difference in the prevalence of Candida after the use of pilocarpine hydrochloride for both groups. At the start of the study, 75% of all subjects were positive for Candida. Following the use of pilocarpine, 25% had positive cultures. There was also a decrease in the prevalence of clinical manifestations of infection from 75% of subjects to 25%. There was a significant decrease in the numbers of Candida cultured following the use of pilocarpine. CONCLUSION: Long-term administration of pilocarpine hydrochloride resulted in a significant reduction in Candida albicans colonization in patients with primary or secondary Sjögren's syndrome.

An evaluation of a chemical cautery agent and an anti-inflammatory ointment for the treatment of recurrent aphthous stomatitis: a pilot study.

OBJECTIVE: Recurrent aphthous stomatitis is a very common condition, currently treated with anti-inflammatory agents, which palliate the symptoms. The purpose of this clinical trial was to compare a medication commonly used to treat recurrent aphthous stomatitis, Kenalog-in-Orabase, and a newer agent, Debacterol. METHOD AND MATERIALS: Sixty patients diagnosed with recurrent aphthous stomatitis were enrolled in the study. Twenty patients were assigned to each of the two treatment groups, and 20 age- and sex-matched patients were assigned to the control group, which received no treatment. After the diagnosis was made, clinical examinations and ulcer measurements were performed, and a subjective evaluation of symptoms (100-mm visual analog scale) was completed by each subject. The subjects did not use any other medications. Both agents were applied topically (the frequency varied depending on the group of subjects) at specified intervals. Ulcer measurements and subjective evaluations were made at days 0, 3, 6, and 10 for all subjects. RESULTS: In both treatment groups, by day 10, 100% of the ulcers had clinically healed and were no longer causing pain. Patients in the Debacterol group reported a significantly greater decrease in pain at 3 days (> 70%) than did subjects in the other groups (< 20%), although the size of the ulcer did not differ significantly in any of the groups. After day 6, 80% of the ulcers in the Debacterol group had clinically disappeared and no longer caused symptoms, as compared to about 30% in the other groups. CONCLUSION: Patients subjectively reported significantly greater relief from symptoms with Debacterol than with Kenalog-in-Orabase or no treatment. The relief of symptoms associated with recurrent aphthous stomatitis may or may not correspond to clinical improvement, and these two topical medications may affect signs and symptoms of the lesions differently.

Prevalence, density, and manifestations of oral Candida albicans in patients with Sjögren's syndrome.

OBJECTIVE: Various investigators have reported a high prevalence of oral Candida species in patients with salivary gland dysfunction (SGD). The purpose of this study was to assess the prevalence of oral Candida albicans, its oral manifestations, and to compare the number of colony-forming units of Candida albicans in patients with primary Sjögren's syndrome and secondary Sjögren's syndrome with the whole unstimulated salivary flow rate in each group. METHOD: An age-sex-matched group of control subjects was selected for comparison. Oropharyngeal collection of samples and culturing was performed on each subject. Quantitative cultures specific for Candida albicans were performed. RESULTS: The frequency distribution indicated that > 80% of all SS subjects were positive for Candida albicans vs. none of the controls. The most common lesion was angular cheilitis followed by chronic atrophic candidiasis. The subjects with Sjögren's syndrome also demonstrated significantly high numbers of Candida albicans colony-forming units. CONCLUSIONS: This study indicates significantly higher Candida albicans colonization in patients with primary or secondary Sjögren's syndrome as compared to a control population. Candida albicans colonization was higher in patients with secondary Sjögren's syndrome than in patients with primary Sjögren's syndrome; however, the amount of Candida albicans was not universally relative to salivary flow.

Oral pilocarpine HCl stimulates labial (minor) salivary gland flow in patients with Sjögren's syndrome.

Pilocarpine HCl has been shown to stimulate parotid and submandibular gland salivary flow. The purpose of this study was to determine whether this cholinergic-muscarinic drug also stimulates labial (minor) salivary gland (LSG) flow and to relate that with whole unstimulated salivary (WUS) flow rates. Subjects diagnosed with primary Sjögren's syndrome (SS-1; n = 9) or secondary Sjögren's syndrome (SS-2; n = 9) were enrolled in this study after meeting stringent enrollment criteria. An age-gender matched control group was also enrolled. The labial saliva was collected in a standardized manner on Periopaper for 5 min and the volume was analysed by the Periotron. Whole unstimulated salivary samples were collected for 5 min by the method of Mandel and Wotman (1976). Each subject was dosed with pilocarpine HCl (5 mg; tablets; p.o.). After 60 min the LSG flow as well as the WUS flow was determined again as previously. The results indicated a significant (> 180%) increase in both labial salivary gland flow as well as whole salivary flow in the SS-1 and SS-2 subjects (mean +/- s.e.m.): [SS-1: WUS = 0.1080 +/- 0.03 vs 0.2242 +/- 0.03 ml per 5 min; LSG = 93.1 +/- 22.2 vs 167.8 +/- 15.9 microliters/5 min; P < 0.001; SS-2: WUS = 0.1384 +/- 0.02 vs 0.2775 +/- 0.09 ml per 5 min; LSG = 97.7 +/- 20.2 vs 182.8 +/- 17.9 microliters per 5 min; P < 0.001]. These results indicate a significant increase in labial salivary gland flow as well as whole salivary flow as stimulated by pilocarpine HCl in Sjögren's syndrome patients.