Metal mixtures and oral health among children and adolescents in the National Health and Nutrition Examination Survey (NHANES), 2017-2020.

INTRODUCTION: Dental caries is the most common non-communicable human disease, yet little is known about the role of environmental metals, despite teeth consisting of a hard matrix of trace elements. We conducted a cross-sectional study of associations between environmental metals and objective assessment of dental caries and subjective assessments of oral health among a representative sample of U.S. children and adolescents. METHODS: Data were from the 2017-March 2020 pre-pandemic data file of the National Health and Nutrition Examination Survey (NHANES). To account for metal mixtures, we used weighted quantile sum (WQS) regression to estimate the joint impact of multiple trace elements assessed in blood and urine with oral disease outcomes. RESULTS: The blood metal mixture index was associated with a 32% (95% CI: 1.11, 1.56) increased risk of decayed surfaces while the urine metal mixture index was associated with a 106%, RR (95% CI = 2.06 (1.58, 2.70) increased caries risk. For both blood and urine, Mercury (Hg) had the largest contribution to the mixture index followed by Lead (Pb). The WQS blood metal mixture index was also significantly associated with poorer self-rated oral health, although the magnitude of the association was not as strong as for the objective oral disease measures, RR (95% CI) = 1.04 (1.02, 1.07). DISCUSSION: Increased exposure to a metal mixture was significantly related to poorer objective and subjective oral health outcomes among U.S. children and adolescents. These are among the first findings showing that metal mixtures are a significant contributor to poor oral health.

Management Outcomes of Hand Dermatitis in a Tertiary Hospital in Southwest Nigeria.

BACKGROUND: Hand dermatitis (HD) is inflammation of the skin of the hands. It ranges in severity and has a significant impact on quality of life (QoL). The physical and psychosocial burden of the disease is comparable with psoriasis in impairment of the QoL of the patient and depression. Quality of life correlates with disease severity. AIM: To evaluate the management outcome of HD with a disease severity tool by the physician and quality of life index. MATERIALS AND METHODS: This was a cross-sectional study of a cohort of patients with HD over 24 weeks in the dermatology clinic of a tertiary hospital in Nigeria. Disease severity and quality of life were measured using the physician global assessment (PGA) and dermatology life quality index (DLQI), respectively. These were re-administered 6 weeks after treatment. Results were collated and analyzed. RESULTS: One hundred and seventy-seven (13.3%) of 1,329 patients had HD with F/M ratio of 1.2: 1; a mean age of 34.6 ± 7.4 years. Comparing PGA scores at baseline and 6 weeks, a statistically significant improvement was noted P < 0.001. The mean DLQI score at baseline was 10.38 and reduced to 3.02 post-treatment. The difference between the two means of the DLQI was ≥5 from baseline signifying improved quality of life. The domain of symptoms and feelings was the most affected at baseline and most improved afterward. CONCLUSION: HD has a significant impact on its sufferers and this correlates with disease severity. Appropriate management improves disease outcome and patients' quality of life.

Cross-Sectional Study of Trichoscopy Features, Prevalence, Types of Hair Loss and Hair Care Practices at a Lagos Urban Market.

BACKGROUND: Hair loss studies have mostly been clinical with no trichoscopy features of the hair loss documented in Nigeria. OBJECTIVE: The objective of this study was to determine the community prevalence, types of hair loss, trichoschopy features and the risk factors for the observed hair loss types. METHODS: This was a cross-sectional descriptive study of traders (Fitz Patrick's skin types V-VI) at an urban market. The traders were clinically evaluated for hair loss. Sociodemographic, clinical and trichoscopy data were recorded using a study questionnaire. Data was analyzed using SPSS version 22.0. Statistics such as means, medians, frequencies, t-test and chi-square test were presented. Levels of significance of all tests was set at, P<0.05%. RESULTS: A total of 307 participants (32.6% male and 67.4% female) with a mean age of 42.7±12.8 years were studied. The prevalence of hair loss was 68.7% (51% in males and 77.3% in females) and the mean age of those with hair loss was 44.8±12.3 years. The pattern of hair loss was patterned, diffuse and localized in 94.3%, 3.8% and 1.9% respectively. The main types of hair loss were androgenetic alopecia (26.9%) and traction alopecia (71.7%). The prevalent hair practices were; braids and weave-on (extensions) in 78.2%, turban-like head gear in 76.9%, and chemical relaxers in 73.8%. Trichoscopy features characteristic of the observed hair loss types were documented. CONCLUSION: Hair loss is common in the community. The common hair care practices and increasing age could be contributors to hair loss.

CONTEXTE: Les études sur la perte de cheveux ont surtout été cliniques et aucune caractéristique trichoscopique de la perte de cheveux n'a été documentée au Nigeria. OBJECTIF: L'objectif de cette étude était de déterminer la prévalence communautaire, les types de perte de cheveux, les caractéristiques de la trichoscopie et les facteurs de risque pour les types de perte de cheveux observés. MÉTHODES: Il s'agissait d'une étude descriptive transversale de commerçants (types de peau V-VI de Fitz Patrick) sur un marché urbain. Les commerçants ont été évalués cliniquement pour la perte de cheveux. Les données sociodémographiques, cliniques et trichoscopiques ont été enregistrées à l'aide d'un questionnaire d'étude. Les données ont été analysées à l'aide de SPSS version 22.0. Des statistiques telles que les moyennes, les médianes, les fréquences, le test t et le test du chi-deux ont été présentées. Le niveau de signification de tous les tests a été fixé à P<0,05%. RÉSULTATS: Un total de 307 participants (32,6% d'hommes et 67,4% de femmes) avec un âge moyen de 42,7±12,8 ans ont été étudiés. La prévalence de la perte de cheveux était de 68,7 % (51 % chez les hommes et 77,3 % chez les femmes) et l'âge moyen des personnes présentant une perte de cheveux était de 44,8±12,3 ans. La perte de cheveux était structurée, diffuse et localisée dans 94,3 %, 3,8 % et 1,9 % des cas respectivement. Les principaux types de perte de cheveux étaient l'alopécie androgénétique (26,9 %) et l'alopécie de traction (71,7 %). Les pratiques capillaires prédominantes étaient les suivantes : tresses et tissage (extensions) dans 78,2 % des cas, coiffure en turban dans 76,9 % des cas et défrisage chimique dans 73,8 % des cas. Les traits trichoscopiques caractéristiques des types de perte de cheveux observés ont été documentés. CONCLUSION: La perte de cheveux est fréquente dans la communauté. Les pratiques courantes de soins capillaires et l'âge croissant pourraient contribuer à cette perte de cheveux. Mots clés: Trichoscopie, Perte de cheveux, Pratique des soins capillaires, Communauté, Africaine, Prévalence.

Covid 19: A Prospective Observational Study on the Cutaneous Manifestations of Patients in Lagos, Nigeria.

BACKGROUND: Cutaneous manifestations of COVID-19 have been documented from Europe, USA, and China but none from Africa to date. Skin findings among Africans differ from Caucasians and it is important to report these in Nigerians with COVID-19. METHODS: A prospective observational review involving patients seen at the Emergency triage, and Isolation wards of the Lagos University Teaching Hospital. Demographic and clinical data were captured; skin and appendages were examined by a dermatologist between 0800hrs and 1600hours to minimise visual errors of artificial light masking cutaneous lesions. RESULTS: Of 235 participants, 17 (7.23%) had recent onset skin rash, with 7 (41.2%) experienced itching and 11 confirmed with COVID-19. There was a male: female ratio of 97:43 (2.3:1) among COVID-19 patients. Cutaneous findings were seen in 12 (5.1%) participants, with the face and trunk mostly affected and acne plus papular eruptions predominating. There was no significant relationship between COVID-19 and recent onset skin rash (χ2, p = 0.87). Only 2 of the 17 participants had a previously existing dermatoses ((χ2, p = 0.84). There was no significant relation between use of medications and onset of rashes (χ2, p = 0.72) or between those with co-morbidities and onset of rashes (χ2, p = 0.51). CONCLUSION: Cutaneous manifestations were found among Nigerian patients with SARS-CoV-2 infection. Most presented with pruritus and papular eruptions and no morphologic pattern was demonstrated. Physicians and dermatologists need to be aware and look out for skin changes in SARS-CoV-2 infection as they may be early pointers to COVID-19. Keywords: Cutaneous findings, manifestations, Skin, COVID-19, Nigeria.

CONTEXTE: Des manifestations cutanées du COVID-19 ont été documentées en Europe, aux Etats-Unis et en Chine, mais aucune en Afrique à ce jour. Les manifestations cutanées chez les Africains diffèrent de celles des Caucasiens et il est important de les signaler chez les Nigérians atteints de COVID-19. MÉTHODES: Une étude observationnelle prospective impliquant des patients vus au triage des urgences et dans les services d'isolement de l'hôpital universitaire de Lagos. Les données démographiques et cliniques ont été saisies ; la peau et les appendices ont été examinés par un dermatologue entre 8h00 et 16h00 pour minimiser les erreurs visuelles de la lumière artificielle masquant les lésions cutanées. RÉSULTATS: Sur 235 participants, 17 (7,23 %) ont présenté une éruption cutanée d'apparition récente, dont 7 (41,2 %) ont eu des démangeaisons et 11 ont été confirmées par le COVID-19. Il y avait un rapport hommes/femmes de 97:43 (2,3:1) parmi les patients atteints de COVID-19. Des signes cutanés ont été observés chez 12 (5,1 %) participants, le visage et le tronc étant les plus touchés, avec une prédominance de l'acné et des éruptions papuleuses. Il n'y avait pas de relation significative entre le COVID-19 et les éruptions cutanées d'apparition récente (χ2, p = 0,87). Seulement 2 des 17 participants avaient une dermatose déjà existante ((χ2, p = 0,84). Il n'y avait pas de relation significative entre la prise de médicaments et l'apparition d'éruptions cutanées (χ2, p = 0,72) ou entre les personnes présentant des comorbidités et l'apparition d'éruptions cutanées (χ2, p = 0,51). CONCLUSION: Des manifestations cutanées ont été constatées chez les patients nigérians atteints d'une infection par le SRAS-CoV-2. La plupart d'entre eux présentaient un prurit et des éruptions papuleuses et aucun modèle morphologique n'a été mis en évidence. Les médecins et les dermatologues doivent être attentifs et rechercher les modifications cutanées dans l'infection par le SRAS-CoV-2, car elles peuvent être des signes précurseurs du COVID-19. MOTS CLÉS: Résultats cutanés, manifestations, Peau, COVID-19, Nigéria.

Female Androgenetic Alopecia amongst Market Women in Lagos, Nigeria.

Background: Studies on androgenetic alopecia in Nigerian females are few. The aim of this study was to determine the prevalence of female androgenetic alopecia, its severity and trichoscopic features. Methods: This was a cross-sectional descriptive study of androgenetic alopecia amongst 207 adult female traders at an urban market in Lagos, Nigeria. The study was conducted in February 2020. All recruited female traders were examined. Documentation of clinical findings, sociodemographic data and trichoscopy features was done using a predesigned questionnaire. Severity of female androgenetic alopecia was assessed using the Olsen's scale he IBM statistics software version 22. Results: The prevalence of female androgenetic alopecia (FAGA) was 4.8% (10/207) and median age of the participants was 59 (IQR 45,63) years. The severity of FAGA based on Olsen's scale was grade I, II and III in 30%, 20% and 50% respectively and severity increased with age. Trichoscopy features included prominent white dots (90%), reduced hair density (90%), vellus hairs (70%), preserved honeycomb pigment network (70%) and variable hair diameter (60%). Conclusion: Androgenetic alopecia is uncommon in females. When present, it is noted to be severe. Trichoscopy features among African females in Nigeria are comparable to trichoscopy features in studies from other parts of the world.

Contexte: Les études sur l'alopécie androgénétique chez les femmes nigérianes sont peu nombreuses. Le but de cette étude était de déterminer la prévalence de l'alopécie androgénétique féminine, sa gravité et ses caractéristiques trichoscopiques. Méthodes: Il s'agissait d'une étude descriptive transversale de l'alopécie androgénétique parmi 207 femmes adultes commerçantes sur un marché urbain de Lagos, au Nigeria. L'étude a été menée en février 2020. Toutes les commerçantes recrutées ont été examinées. Les résultats cliniques, les données sociodémographiques et les caractéristiques de la trichoscopie ont été documentés à l'aide d'un questionnaire préétabli. La sévérité de l'alopécie androgénétique féminine a été évaluée à l'aide de l'échelle d'Olsen. Les données ont été analysées à l'aide du logiciel de statistiques IBM version 22. Résultats: La prévalence de l'alopécie androgénétique féminine (AAF) était de 4,8 % (10/207) et l'âge médian des participants était de 59 ans (IQR 45,63). Selon l'échelle d'Olsen, la gravité de l'alopécie androgénique féminine était de grade I, II et III dans 30 %, 20 % et 50 % des cas respectivement, et la gravité augmentait avec l'âge. Les caractéristiques de la trichoscopie comprenaient des points blancs proéminents (90 %), une densité capillaire réduite (90 %), des poils vellus (70 %), un réseau pigmentaire en nid d'abeille préservé (70 %) et un diamètre variable des poils (60 %). Conclusion: L'alopécie androgénétique est peu fréquente chez la femme. Lorsqu'elle est présente, on note qu'elle est sévère. Les caractéristiques de la trichoscopie chez les femmes africaines au Nigeria sont comparables aux caractéristiques de la trichoscopie dans les études d'autres parties du monde. Mots clés: Alopécie androgénétique féminine, Trichoscopie, Prévalence, Gravité, Gradation.

COVID-19 and Dental and Dental Hygiene Students' Career Plans.

OBJECTIVE: The aims of this study were to investigate whether dental and dental hygiene students' career plans postgraduation were affected by the coronavirus disease 2019 (COVID-19) pandemic and to examine wellness and readiness for clinical practice among students who reported a change in career plans. METHODS: An anonymous online REDCap survey was developed and emailed to 436 dental and dental hygiene students at a US dental school. The survey consisted of 81 questions that covered demographics, career plans postgraduation, and readiness and wellness measures. An open-ended question assessing how students' career plans have changed during the pandemic was also included. RESULTS: A total of 252 students completed the survey, of whom 11.5% reported that their plans for future dental practice have changed since the COVID-19 outbreak. Students who reported a change to their career plans had significantly higher mean perceived stress (20.1 vs. 16.3; P = 0.003) and anxiety (9.2 vs. 6.2; P = 0.004) scores and lower mean resilience (18.9 vs. 20.9; P = 0.01) scores than those who reported no change to their career plans. Concerns were raised regarding the limited employment opportunities, long-term stability of the dental profession, and the interruptions to clinical education and licensure examinations consequent to the pandemic. CONCLUSIONS: A comprehensive effort inclusive of adeptly designed clinical and curriculum experiences paired with wellness interventions and support tailored to students is needed. These measures need to support trainees across varying years in training and resilience levels to be effective for dental and dental hygiene students as they approach their future career intentions in the dental profession. Additional longitudinal research is needed to assess if change in career intentions during the COVID-19 pandemic corresponds with actual change postpandemic and affects the dental profession. KNOWLEDGE TRANSFER STATEMENT: This study explores the potential short-term change in career intentions of dental hygiene and dental students during the COVID-19 pandemic. Findings can inform workforce planning as well as interventions developed and implemented by academic dental institutions to support student wellness during unexpected and prolonged emergency situations.

Prevalence and Patterns of Dental Care Utilization among US-Born and Non-US Born Hispanics in the Hispanic Community Health Study/Study of Latinos.

OBJECTIVES: Access to routine dental services is important to maintaining good oral health. The aims of this study were to describe the dental care utilization patterns of a diverse group of Hispanic/Latino men and women and assess differences in dental care utilization by perceived need for dental care and proxy measures of acculturation. METHODS: Data from 13,792 participants of the Hispanic Community Health Study were analyzed with SAS 9.4. Time since last dental visit was dichotomized into <1 and ≥1 y. Acculturation measures included the language and social subscales of the Short Acculturation Scale for Hispanics, the Multiethnic Study of Atherosclerosis nativity subscore, and immigrant generation. Survey logistic regression adjusted for demographic (age and sex) and health-related variables, estimated associations among perceived need for dental care, acculturation measures, and dental care utilization. RESULTS: About a quarter (23%) of the participants were born in the 50 US states, excluding territories, while 77% were non-US born. Overall, 74% perceived a need for dental care. Upon covariate adjustment, perceiving a need for dental care was associated with reduced odds of reporting a past-year dental visit (odds ratio, 0.32; 95% CI, 0.28 to 0.37), while there appeared to be no meaningful association between proxy measures of acculturation and past-year dental visit. Having health insurance was significantly associated with a past-year dental visit (odds ratio, 2.23; 95% CI, 1.99 to 2.49) for all groups combined and among the different Hispanic/Latino background groups. CONCLUSIONS: Acculturation affects general health and contributes to general health disparities; however, its role in dental care utilization remains questionable. Given that acculturation is a process that occurs over several years, longitudinal studies that evaluate oral health trajectories along the acculturation continuum are needed. KNOWLEDGE TRANSFER STATEMENT: The results of this study are valuable for dental public health program planning and implementation for minority groups, as it describes the varying patterns of dental care utilization among US-born and non-US born Hispanics/Latinos and identifies factors that may partly explain dental care utilization patterns, such as acculturation.

Unravelling the Diagnosis - The Role of Histopathology in Mycosis Fungoides.

Mycosis fungoides is an extra-nodal indolent non-Hodgkin lymphoma of T- cell origin that is characterized by skin involvement. The course of the disease is typically slowly progressive with non-specific clinical and histopathologic features which may evade diagnosis for years. Chemo-therapeutic agents to control the disease are effective if employed early, but the prognosis and therapy is dependent on the stage of the disease at presentation. We report a case of a 25-year old man with a clinical diagnosis of Tinea incognito and histologic features of non-specific dermatitis at first presentation. With poor hospital attendance and inconsistent therapy, his clinical features and histology reports over the next couple of years were consistent with psoriasis, then mycosis fungoides. He is currently stable on chemotherapeutic agents. With different histopathology results over a three- year span, it is possible that the patient had both diseases occurring separately. It is also possible that psoriasis was a harbinger of mycosis fungoides and the change in clinical presentation which necessitated repeated biopsies eventually revealed the picture.

Exposure to Adverse Childhood Experiences and Oral Health Measures in Adulthood: Findings from the 2010 Behavioral Risk Factor Surveillance System.

INTRODUCTION: Adverse childhood experiences (ACEs) are negative life events occurring before the age of 18 y. ACEs are risk factors for heart disease and diabetes in adult life. Furthermore, individuals who experience ACEs are more likely to smoke and become obese-factors associated with poor oral health. OBJECTIVE: This study investigated likely associations between ACEs and the oral health measures of the 2010 Behavioral Risk Factor Surveillance System (BRFSS). METHODS: Data from 16,354 participants of the 2010 BRFSS were analyzed with SAS 9.4. ACE scores were calculated in 2 domains: abuse (emotional, physical, or sexual) and household challenges (parental separation or divorce, intimate partner violence, household substance abuse, household mental illness, and incarceration). ACE scores, ranging from 0 to 8, were categorized into 0, 1, 2, 3, and ≥4. The 2010 BRFSS oral health measures included >1 y since last dental visit, ≥6 teeth extracted, and ≥2 y since last dental cleaning. Survey logistic regression estimated prevalence odds ratios and 95% CIs, adjusted for age, sex, race/ethnicity, and educational attainment. RESULTS: The weighted mean ACE score was 1.74 (95% CI = 1.68 to 1.81), and the weighted and age-standardized percentages of study participants with ACE scores of 0, 1, 2, 3, and ≥4 were 33.1%, 24.3%, 14.9%, 9.69%, and 18.1%, respectively. There appeared to be a dose-response association between categories of ACE scores and the oral health measures. Specifically, when compared with participants with an ACE score of 0, participants with ACE scores of 1, 2, 3, and ≥4 had adjusted prevalence odds ratios (95% CIs) of 1.10 (0.82 to 1.47), 1.20 (0.90 to 1.60), 1.35 (0.98 to 1.85), and 1.72 (1.31 to 2.26), respectively, for reporting ≥2 y since last dental cleaning. CONCLUSIONS: Findings suggest that ACEs may be associated with poor oral health measures in adulthood, even after adjusting for important oral diseases risk factors. Longitudinal follow-up studies are needed to delineate pathways by which this relationship occurs. KNOWLEDGE TRANSFER STATEMENT: Our findings indicate that exposure to childhood trauma may have negative impacts on oral health in adulthood. Oral health practitioners need to be aware of the potential impacts of childhood trauma on health behaviors that ultimately affect oral health outcomes.

Cigarettes, E-cigarettes, and Adolescents' Oral Health: Findings from the Population Assessment of Tobacco and Health (PATH) Study.

INTRODUCTION: Adolescents are a population group that actively uses tobacco products; however, limited reports are available on the effects of tobacco products on adolescents' oral health. OBJECTIVES: This study investigated associations between self-reported use of cigarettes and e-cigarettes on the oral health status of a representative sample of US adolescents. METHODS: Data came from 13,650 adolescents aged 12 to 17 y who participated in the 2013-2014 wave of the Population Assessment of Tobacco and Health study. Participants self-reported current use (i.e., past 30 d) and ever use of cigarettes and e-cigarettes, as well as past-year diagnoses with dental problems by a doctor, dentist, or other health professional (self-reported by parent or emancipated youth). Survey-adjusted logistic regression was used to estimate prevalence odds ratios (PORs) and 95% CIs. RESULTS: The proportion of adolescents who self-reported current use of only cigarettes was 3.2%, while 1.7% reported current use of only e-cigarettes. Similarly, 1.4% reported current use of both cigarettes and e-cigarettes, while 7.1% reported ever use of both. About 22% self-reported a provider diagnosis with dental problems in the past year. The covariate-adjusted associations between current cigarette and e-cigarette use on self-reported provider-diagnosed dental problems in the past year were, respectively, POR = 1.50 (95% CI, 1.18 to 1.90) and POR = 1.11 (95% CI, 0.79 to 1.55), while self-reported current use of both was associated with POR = 1.72 (95% CI, 1.24 to 2.38). Ever use of cigarettes and e-cigarettes was likewise associated with increased prevalence odds of self-reported past-year diagnosis with dental problems, although to a lesser magnitude. CONCLUSION: Findings suggest that dual use of e-cigarettes and conventional cigarettes is associated with poor oral health outcomes among adolescents. However, studies of a longitudinal nature are needed to confirm these findings. KNOWLEDGE TRANSFER STATEMENT: The results of this study are relevant to public health and oral health practitioners seeking to intervene during developmental periods in which adolescents may have access to tobacco products in the home and in social settings.

Do Genetic Markers of Inflammation Modify the Relationship between Periodontitis and Nonalcoholic Fatty Liver Disease? Findings from the SHIP Study.

An association between periodontitis and nonalcoholic fatty liver disease (NAFLD) has been reported by experimental animal and epidemiologic studies. This study investigated whether circulating levels of serum C-reactive protein (CRP) and a weighted genetic CRP score representing markers of inflammatory burden modify the association between periodontitis and NAFLD. Data came from 2,481 participants of the Study of Health in Pomerania who attended baseline examination that occurred between 1997 and 2001. Periodontitis was defined as the percentage of sites (0%, <30%, ≥30%) with probing pocket depth (PD) ≥4 mm, and NAFLD status was determined using liver ultrasound assessment. Serum CRP levels were assayed at a central laboratory, and single-nucleotide polymorphisms previously identified through genome-wide association studies as robustly associated with serum CRP were combined into a weighted genetic CRP score (wGSCRP). Logistic regression models estimated the association between periodontitis and NAFLD within strata of serum CRP and separately within strata of the wGSCRP. The prevalence of NAFLD was 26.4% (95% confidence interval [CI], 24.6, 28.1) while 17.8% (95% CI, 16.0-19.6) had ≥30% of sites with PD ≥4 mm. Whereas the wGSCRP was not a modifier ( Pinteraction = 0.8) on the multiplicative scale, serum CRP modified the relationship between periodontitis and NAFLD ( Pinteraction = 0.01). The covariate-adjusted prevalence odds ratio of NAFLD comparing participants with ≥30% of sites with PD ≥4 mm to those with no site affected was 2.39 (95% CI, 1.32-4.31) among participants with serum CRP <1 mg/L. The corresponding estimate was 0.97 (95% CI, 0.57-1.66) for participants with serum CRP levels of 1 to 3 mg/L and 1.12 (95% CI, 0.65-1.93) for participants with serum CRP >3 mg/L. Periodontitis was positively associated with higher prevalence odds of NAFLD, and this relationship was modified by serum CRP levels.

Directed Acyclic Graphs for Oral Disease Research.

Directed acyclic graphs (DAGs) are nonparametric graphical tools used to depict causal relations in the epidemiologic assessment of exposure-outcome associations. Although their use in dental research was first advocated in 2002, DAGs have yet to be widely adopted in this field. DAGs help identify threats to causal inference such as confounders, bias due to subject selection, and inappropriate handling of missing data. DAGs can also inform the data analysis strategy based on relations among variables depicted on it. This article uses the example of a study of temporomandibular disorders (TMDs), investigating causal effects of facial injury on subsequent risk of TMD. We illustrate how DAGs can be used to identify 1) potential confounders, 2) mediators and the consequences of attempt to estimate direct causal effects, 3) colliders and the consequences of conditioning on colliders, and 4) variables that are simultaneously mediators and confounders and the consequences of adjustment for such variables. For example, one DAG shows that statistical adjustment for the pressure pain threshold would necessarily bias the causal relation between facial injury and TMD. Finally, we discuss the usefulness of DAGs during study design, subject selection, and choosing variables to be measured in a study.

Projections of U.S. Edentulism prevalence following 5 decades of decline.

After decades of decline in prevalence of complete tooth loss (edentulism), the trend continues to be misinterpreted, producing flawed projections and misdirected health goals. We investigated population trends in edentulism among U.S. adults aged ≥ 15 yr by creating time-series data from 5 national cross-sectional health surveys: 1957-1958 (n ≈ 100,000 adults), 1971-1975 (n = 14,655 adults), 1988-1998 (n = 18,011 adults), 1999-2002 (n = 12,336 adults), and 2009-2012 (n = 10,522 adults). Birth cohort analysis was used to isolate age and cohort effects. Geographic and sociodemographic variation in prevalence was investigated with a sixth U.S. survey of 432,519 adults conducted in 2010. Prevalence through 2050 was projected with age-cohort regression models using Monte-Carlo simulation of prediction intervals. Across the 5-decade observation period, edentulism prevalence declined from 18.9% in 1957-1958 (95% confidence limits: 18.4%, 19.4%) to 4.9% in 2009-2012 (95% confidence limits: 4.0%, 5.8%). The most influential determinant of the decline was the passing of generations born before the 1940s, whose rate of edentulism incidence (5%-6% per decade of age) far exceeded later cohorts (1%-3% per decade of age). High-income households experienced a greater relative decline, although a smaller absolute decline, than low-income households. By 2010, edentulism was a rare condition in high-income households, and it had contracted geographically to states with disproportionately high poverty. With the passing of generations born in the mid-20th century, the rate of decline in edentulism is projected to slow, reaching 2.6% (95% prediction limits: 2.1%, 3.1%) by 2050. The continuing decline will be offset only partially by population growth and population aging such that the predicted number of edentulous people in 2050 (8.6 million; 95% prediction limits: 6.8 million, 10.3 million) will be 30% lower than the 12.2 million edentulous people in 2010.

Pityriasis amiantacea: a case report.

Pityriasis amiantacea (PA) is a papulosquamous condition of the scalp,characterized by asbestos - like thick scales attached to the hair shaft. It is thought to represent a reaction pattern to inflammatory skin disorders like psoriasis, seborrhoeic dermatitis, tinea capitis, atopic dermatitis and lichen planus, rather than a distinctive disease. The scaling may be localised or generalised, depending on the underlying condition and its duration.This report highlights the clinical features of pityriasis amiantacea secondary to atopic dermatitis and the differential features of other papulo-squamous scalp disorders such as scalp psoriasis, seborrhoeic dermatitis and lichen planus.Scalp psoriasis and seborrhoeic dermatitis are the commonest causes of PA as well as the closest differentials hence should be excluded in all cases. The longterm sequelae of PA include scalp fibrosis and permanent hair loss hence should be identified and treated promptly. The management modalities of PA will also be discussed.

Overview of dermatophyte infections at the dermatology outpatient clinic of a tertiary institution in Nigeria.

BACKGROUND: Dermatophytes are the commonest organisms causing superficial fungal infections. Earlier epidemiologic studies in Nigeria revealed dermatophyte infection as one of the top three reasons for visiting the dermatologists. OBJECTIVE: To determine the frequency, characteristics and predisposing factors to dermatophyte infections at the dermatology outpatient clinic of the Lagos University Teaching Hospital (LUTH) from March 2003 to September 2009. METHODS: The clinic records and case notes of patients were reviewed. Patients' data which includes demographic details, characteristics of disease, predisposing factors and clinical presentation findings were entered on Excel spreadsheets and analyzed using SPSS 15. Results were displayed using frequency tables. RESULTS: Dermatophyte infections were found in 8.39% of patients attending the dermatology outpatient clinic of LUTH. Tinea pedis was the most frequently seen, occurring in 33.6% of patients; followed by tinea corporis (20%), tinea manuum (18.6%) and tinea capitis (14.8%). Dermatophyte infection was most frequently seen in the 3rd and the 4th decades of life, except tinea capitis seen predominantly in the 1st decade of life and tinea intertrigo in the 5th decade. CONCLUSION: Dermatophyte infections occur at all age groups, although frequency of occurrence differs with age group and site of the body affected.

Skin tumors at the Lagos University Teaching Hospital, Nigeria.

INTRODUCTION: Skin tumours can be malignant or benign. Skin cancer is the most common malignancy among Caucasians and noted to be rare in Africans and negroid skin. In view of the rarity of skin cancers in Africans, there is delayed diagnosis; and consequent advanced presentation and poor prognosis. OBJECTIVE: This is to document the frequency of skin tumours (benign and malignant) from a 7-year review (January 2001 to December 2007) of histology reports of all skin samples seen at the pathology department of the Lagos University Teaching Hospital. METHODS AND MATERIALS: Reports of all skin samples seen at the pathology department between January 2001 and December 2008 were reviewed. The frequencies of various skin tumours (both benign and malignant) were determined and the result displayed using frequency tables. RESULTS: Skin tumours represented 19.8% of all reports made on skin during the study period. One hundred and twenty one (68.7%) were benign tumours while 55 (31.2%) were malignant tumours. There is a female preponderance for both malignant and benign tumours. The male to female ratio was 1:1.28 for benign tumours and 1:1.39 for malignant tumors. Squamous cell carcinoma (SCC) was the commonest malignant tumor, followed by malignant melanoma, Kaposi's sarcoma and dermatofibrosarcoma protuberans. Cutaneous papilloma was the commonest benign tumour. CONCLUSION: A wide range of skin tumours, benign and malignant were documented; hence there is need for more vigilance in order to diagnose them early.

The pityriasis rosea calendar: a 7 year review of seasonal variation, age and sex distribution.

BACKGROUND: The most accepted aetiologic factor for Pityriasis Rosea (PR) is viral infection and the evidences for this include the seasonal variation of the disease; intolerance to ampicillin; rarity of second attack; occasional household clustering of cases; and response to acyclovir in the early stage of the eruption. OBJECTIVE: This is a review of the seasonal variation, age and sex distribution of patients who presented with Pityriasis Rosea at the dermatology outpatient clinic of the Lagos University Teaching Hospital (LUTH) between January 2000 and December 2006. METHODS: Data was extracted from the clinic records and patients' records. The diagnosis of PR was made clinically based on the typical history, identification of the herald patch and characteristic 'Christmas tree' distribution of the exanthematic rash. RESULTS: The diagnosis of Pityriasis Rosea was made in 427 patients (3.7%) of the 11,535 patients seen during the study period. The highest number of patients was seen in October (49 patients--11.5%); followed by August (48 patients--11.2%), March (46 patients--10.8%) and September (40 patients--9.4%). The least number of patients with PR were seen in January (21 patients--4.9%) and February (23 patients--5.4%). Pityriasis Rosea was seen predominantly in persons between the ages 10 and 29 (255 patients--59.7%) with a male to female ratio of 1: 1.55. CONCLUSION: Pityriasis Rosea can be described as a disease of the rainy season found predominantly in the teenagers and young adults, with a female predilection.

Characteristics of vitiligo in Lagos, Nigeria.

BACKGROUND: Vitiligo is disfiguring in the darker racial ethnic group as a result of the sharp contrast between the normal skin and the depigmented skin. OBJECTIVE: To describe the epidemiology and clinical profile of vitiligo patients at the dermatology clinic of an urban tertiary hospital of Lagos University Teaching Hospital. METHODS: All consecutive patients with a diagnosis of vitiligo seen at the Dermatology Clinic between October 2003 and October 2006, were included in the study. The diagnosis of vitiligo was made based on the clinical findings of depigmented macules or patches with a sharp margin, normal texture, intact sensations and no scaling. RESULTS: The diagnosis of vitiligo was made in 186 (2.8%) patients, with a slight female preponderance. Vitiligo affected all age groups: the youngest presented at age one and the oldest at eighty six years of age. The face and the limbs were the most affected parts of the body. Fifteen (0.81%) patients presented with features suggestive of associated autoimmune disease like, Type 1 Diabetes. CONCLUSION: The frequency of vitiligo in this study is similar to those obtained in previous studies from different parts of Nigeria. The patients will benefit from other modalities of management apart from the medical management offered hence a designated centre for management of vitiligo will be a respite to them.

The causes of maternal deaths in eclampsia in Lagos, Nigeria.

A retrospective study of the primary causes of maternal deaths in the eclamptics treated in the Lagos University Teaching Hospital (LUTH) over a 20-year period, from 1st January 1967 through 31st December 1986, was carried out. During this period, a total of 845 cases of eclampsia were treated and 91 maternal deaths were associated with eclampsia or its complications. The maternal deaths included 66 predelivery and 25 postpartum eclamptics respectively. Most of the maternal deaths (n = 86) occurred in unbooked cases of eclampsia. The maternal mortality rate was 105/1000 eclamptic deliveries. The common primary causes of deaths in eclampsia in the LUTH during the period under study were renal failure (14.5%), cerebrovascular haemorrhage (12.7%), cardio-pulmonary failure (12.7%), disordered intravascular coagulation syndrome (DIC) (10.9%), and cardiac failure (8%). The Post Mortem Rate (PMR) in the dead eclamptics in the LUTH was 60%. Scrutiny of data suggested that many of the maternal deaths could have been avoided if the patients were brought to the hospital in good time for treatment.