Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study

OBJECTIVES

To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework.

DESIGN

Qualitative correlational study to evaluate a national intervention programme.

SETTING

Primary healthcare in two care homes in rural Germany.

PARTICIPANTS

Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists.

INTERVENTIONS

Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF.

RESULTS

860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health.

PRIMARY OUTCOME

A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents.

SECONDARY OUTCOMES

Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants.

CONCLUSIONS

Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Oral health improvement for nursing home residents through delegated remotivation and reinstruction (MundZaRR Study): study protocol of a cluster-randomised controlled trial

INTRODUCTION

Oral health and oral health-related quality of life (OHrQL) of residents in German long-term residential care (LRC) are poor. We will develop an evidence-based catalogue of interventions ('Oral Health Toolbox') and provide care-accompanying reinstruction and remotivation of nursing staff by dental assistants (DA). We hypothesise that such intervention will significantly improve OHrQL, daily oral hygiene/care behaviour and is cost-effective.

METHODS AND ANALYSIS

A scoping review will be used to identify possible intervention components. Mixed methods will be used to identify barriers and enablers of oral hygiene and care in German LRC. The result will be the 'Oral Health Toolbox', a two-phased instrument supporting both initial intervention allocation to improve oral health/hygiene and reinstruction/remotivation. A two-arm clustered, randomised controlled trial (ratio of 1:1 via block randomisation) will be performed in LRC in Rhineland-Palatinate, Germany. Each nursing home represents a cluster. Based on a feasibility study, considering clustering and possible attrition, we aim at recruiting 618 residents in 18 clusters. In the intervention group, dentists will assign one or more intervention component from the box (phase 1). During follow-up, nursing staff will be reinstructed and remotivated by DA, who use the box to decide how to maintain the intervention (phase 2). In the control group residents will receive care as usual. The primary outcome, OHrQL, will be measured using the General Oral Health Assessment Index. Secondary outcomes include pain condition, general health-related quality of life, caries increment, oral/prosthetic hygiene and gingival status, incidence of dental emergencies and hospitalisations, and cost-utility/effectiveness. The endpoints will be measured at baseline and after 12 months. For our primary outcome, a mixed-linear model will be used within an intention-to-treat analysis. A process evaluation using mixed methods will be conducted alongside the trial.

ETHICS AND DISSEMINATION

Ethical approval by the University of Kiel was granted (D480/18).

TRIAL REGISTRATION NUMBER

NCT04140929.

Immunologische Ex-vivo-Untersuchung zur Wirkung potenzierter Substanzen bei parodontaler Entzündung unter Verwendung der Durchflusszytometrie

<b><i>Hintergrund:</i></b> Bei der Behandlung parodontaler Entzündungen werden in der Versorgungspraxis auch homöopathische Mittel eingesetzt. Noch ist weniger über deren grundlegende Wirkprinzipien bekannt. Ziel dieser Arbeit war es daher, die Auswirkungen potenzierter Substanzen bei parodonta­ler Entzündung mittels Durchflusszytometrie zu untersuchen. <b><i>Material und Methoden:</i></b> Lymphozyten aus Blutproben von drei Parodontitis-Patienten und drei gematchten gesunden Probanden wurden extrahiert und mit stark verdünnten wässrigen Extrakten (D12 und C200) aus Mercurius solubilis, Silicea, Sulphur, Tuberculinum oder Placebo inkubiert. Um die Lymphozytenexpression zu untersuchen, wurde die Durchflusszytometrie für CD45R0- und CD25-Antikörper angewandt. Die statistische Analyse wurde unter Verwendung von Histogramm- und bivariaten Dot-Plot-Analysen durchgeführt. <b><i>Ergebnisse:</i></b> Veränderungen der Expression von CD25 und CD45R0 wurden bei Mercurius C200, Mercurius D12, Silicea D12 und Sulphur D12 beobachtet. Mit 36,47% zeigte Sulphur D12 die höchsten Veränderungen in der CD45R0-Expression zwischen Verum und Placebo bei den Parodontitis-Patienten. Die CD25-Expression war in Mercurius D12 mit 18,68% am höchsten. Aufgrund der hohen Variabilität konnten die Ergebnisse jedoch nicht durch statistische Analysen untermauert werden. <b><i>Diskussion:</i></b> Diese Studie konnte zeigen, wie Effekte hoch verdünnter Substanzen mit modernen immunologischen Methoden analysiert werden können. Obwohl die Schlussfolgerungen aufgrund der hohen Variabilität der Lymphozytenexpression begrenzt sind, könnten die Ergebnisse dieser Pilotstu­die weitere Untersuchungen anregen.

Case report of an internal granuloma investigated by light and scanning electron microscopy

There is no doubt that the main reason for an internal grauloma is a traumatic event. The trauma may be physical or chemical as in the case of caries or coronal pulpectomy. In most of the cases it is diagnosed by hazard or, when in case of fracture or mobility, extraction is the only therapy to be performed. If diagnosed in time root canal treatment may be adequate.

In the presented case no single specific event could be determined being the cause of this large internal granuloma extending from the coronal third of the root canal to the whole crown just leaving an eggshell of enamel that fractured and mimicked mobility of the whole tooth to the patient finally causing him to attend the clinic. As the patient presented severe aggressive periodontitis and mobility of all teeth it first was assumed that periodontitis was the ethiological reason in this case. Due to secondary trauma the front teeth were labially positioned thus probably being exposed to traumatic insults more frequently. Clinically the upper right medial incisor appeared discoloured darkly not showing the typical pink spot. Without any force the coronal part of the right medial incisor could be removed manually and the root was extracted using a periostal extractor. As it was not suitable to leave the patient with a missing tooth in the front the wound was sutured and as a temporary solution the tooth was reconstructed with composite intraorally and fixed to the neighbour teeth adhesively. The histopathology of the internal granuloma and the crown was investigated.

[Lymphocyte migration under exposure of homeopathic remedies for periodontal inflammation - a controlled pilot study]

BACKGROUND

Several homeopathic remedies are applied in the treatment of periodontal inflammation. However, little is known about their basic active principles. Therefore, we aimed at investigating the effects of homeopathic drugs in periodontal inflammation by observing lymphocyte migration activity in vitro.

MATERIAL AND METHODS

Lymphocytes from blood samples of 3 periodontitis patients and 3 matched healthy volunteers were extracted and embedded in collagen matrix migration assays together with highly diluted (D12 and C200) aqueous extracts from Mercurius solubilis, Silicea, Sulphur, Tuberculinum, or placebo. Lymphocyte migration and lymphocyte speed were observed in a 60-min time frame. Statistical analysis was performed using univariate statistics and SiZer time series analysis.

RESULTS

While C-dilutions did not reveal clear differences between placebo and substances, strong effects were observed in D-dilutions compared to placebo. The strongest effects were achieved in lymphocytes exposed to Sulfur D12. While most specific effects were observed in Sulphur D12 showing an activating effect on periodontitis patient lymphocytes (mean activity: 11,1% (placebo) vs. 23,8% (verum)), there was no effect in healthy volunteers (25,8% (placebo) vs. 25,6% (verum)). SiZer analysis confirmed this effect to be significant.

CONCLUSION

The basic active principles of highly diluted substances are still a matter of controversial debate. Although conclusions are limited due to low sample size, results from our pilot study might encourage further investigations on the role of highly diluted Sulphur in the treatment of periodontitis. Apart from a reproduction study with Sulphur, other immunological experiments, i.e. the investigation of cell limes via flow cytometry, should be performed to underpin these results.

A systematic review and meta-analysis on the use of Hypericum perforatum (St. John's Wort) for pain conditions in dental practice

BACKGROUND

Hypericum perforatum (St. John's Wort) has been used for a variety of medicinal indications. Most recent research has focussed on its use in herbal form for depression, but its claimed analgesic and anti-inflammatory properties in homeopathic form have also led to a number of studies in patients with acute pain conditions. This systematic review overviews the literature on the use of St. John's Wort for pain conditions in homeopathic dental practice.

MATERIAL AND METHODS

PubMed, EMBASE, AMED, CAMbase and the electronic archives of Thieme Publishers were searched with the search terms "(Hypericum OR St. Johns Wort) AND pain". We reviewed and meta-analysed the evidence on Hypericum in pain after tooth extraction was carried out.

RESULTS

Twenty one relevant articles were found: four described general recommendations, three basic research, six reported studies in dental care and eight were expert opinions or case reports. Four studies were eligible for the meta-analysis. There was marked high heterogeneity in the effects pain (Chi-Squared = 26.46; I(2) = 0.89). The overall effect of 0.24 (95% CI: [0.06; 1.03]) favours Hypericum but is not statistically significant.

CONCLUSION

Although case reports suggest therapeutic potential of Hypericum for pain conditions in dental care, this effect is not currently supported by clinical studies. All studies included in this meta-analysis used Arnica montana as well as Hypericum the results are more influenced by Arnica than Hypericum. Further clinical controlled trials of Hypericum alone in dental practice should be performed.

Characterization and analysis of migration patterns of dentospheres derived from periodontal tissue and the palate

BACKGROUND AND OBJECTIVE

Stem cells derived from periodontal and palatal tissues may be useful for regenerative therapies of periodontal tissues. In addition to the use of single periodontium-derived stem cells (pdSCs) and palatal-derived stem cells (paldSCs), the application of pdSC and paldSC dentospheres, providing a pool of vital stem cells, may be a useful approach. As cell migration is a prerequisite for stem cells to regenerate a three-dimensional tissue environment, we characterized pdSCs and paldSCs and investigated the migratory activity of dentospheres within a three-dimensional environment. We also investigated the capacity of the dentospheres to grow on zirconium dioxide surfaces.

MATERIAL AND METHODS

The capacity of pdSCs and paldSCs to differentiate into the neuronal and osteogenic lineages was proved by RT-PCR and immunohistochemistry through the detection of specific lineage markers, such as alkaline phosphatase, glutamate decarboxylase 1 (also known as GAD67, the 67-kDa isoform of glutamate decarboxylase), neurofilament-M and β-III-tubulin. The expression profile of surface molecules on pdSCs and paldSCs was analyzed by flow cytometry. Adhesion and growth of pdSC/paldSC dentospheres on zirconium dioxide surfaces were determined using confocal laser-scanning microscopy. The migratory behavior of the cells was analyzed using a three-dimensional collagen matrix migration assay.

RESULTS

Both pdSCs and paldSCs were positive for epidermal growth factor receptor, CC chemokine receptor 2 and CXC chemokine receptor 4 expression and were able to grow on zirconium dioxide surfaces. Cell-migration experiments revealed that both stem-cell populations responded similarly to epidermal growth factor (EGF), monocyte chemotactic protein 1 (MCP-1) and stromal cell-derived factor 1alpha (SDF-1α). Stimulation with EGF resulted in an increased migratory activity of both stem-cell types, whereas the locomotory behavior of the cells was impaired by both MCP-1 and SDF-1α.

CONCLUSION

Dentospheres represent a pool of vital pdSCs/paldSCs. As a result of the migratory activity demonstrated, along with the capacity to grow on zirconium dioxide surfaces, dentospheres may be useful for regenerative purposes in periodontal tissues.

The ability of human periodontium-derived stem cells to regenerate periodontal tissues: a preliminary in vivo investigation

Periodontium-derived stem cells (pdSCs) can be cultured as dentospheres and differentiated into various cells of the neuronal lineage such as glial cells, thereby demonstrating their stem cell state. This study investigated whether pdSCs could be differentiated into the osteogenic lineage and, if so, whether these cells are able to regenerate periodontal tissue in vivo in an athymic rat model. Human adult pdSCs were isolated during minimally invasive periodontal surgery and expanded in vitro. To induce osteogenic differentiation, expanded pdSCs were cultured for 3 weeks in osteogenic differentiation media. Staining for alkaline phosphatase expression was positive, suggesting osteogenic differentiation. For in vivo studies, pdSCs were delivered onto suitable collagen sponges and implanted into periodontal defects on the right buccal cortex of the mandible in 16 immunodeficient nude rats. Histologic analysis of samples from the test side revealed reformation of periodontal ligament-like tissue, collagen fibers, and elements of bone, but no functional periodontal tissue regeneration. The data show that human adult pdSCs are capable of regenerating elements of bone and collagen fibers in an in vivo animal model.

Highly Efficient Neural Differentiation of Human Somatic Stem Cells, Isolated by Minimally Invasive Periodontal Surgery

Neural stem cells (NSCs) are potential sources for cell therapy of neurodegenerative diseases and for drug screening. Despite their potential benefits, ethical and practical considerations limit the application of NSCs derived from human embryonic stem cells (ES) or adult brain tissue. Thus, alternative sources are required to satisfy the criteria of ready accessibility, rapid expansion in chemically defined media and reliable induction to a neuronal fate. We isolated somatic stem cells from the human periodontium that were collected during minimally invasive periodontal access flap surgery as part of guided tissue regeneration therapy. These cells could be propagated as neurospheres in serum-free medium, which underscores their cranial neural crest cell origin. Culture in the presence of epidermal growth factor (EGF) and fibroblast growth factor-2 (FGF-2) under serum-free conditions resulted in large numbers of nestin-positive/Sox-2-positive NSCs. These periodontium-derived (pd) NSCs are highly proliferative and migrate in response to chemokines that have been described as inducing NSC migration. We used immunocytochemical techniques and RT-PCR analysis to assess neural differentiation after treatment of the expanded cells with a novel induction medium. Adherence to substrate, growth factor deprivation, and retinoic acid treatment led to the acquisition of neuronal morphology and stable expression of markers of neuronal differentiation by more than 90% of the cells. Thus, our novel method might provide nearly limitless numbers of neuronal precursors from a readily accessible autologous adult human source, which could be used as a platform for further experimental studies and has potential therapeutic implications.

Adjunctive periodontal treatment with Centella asiatica and Punica granatum extracts in supportive periodontal therapy

BACKGROUND

Centella asiatica and Punica granatum are medicinal plants that have been reported to promote tissue healing and modulate host responses. Preliminary study revealed positive clinical effects of an innovative preparation from the two herbal extracts in the form of biodegradable chips as a subgingival adjunct to scaling and root planing. The purpose of this research was to evaluate further augmenting efficacy the combined herbal preparation may have among maintenance patients in comparison to standard supportive periodontal therapy (SPT), with additional monitoring of certain inflammatory markers.

METHODS

Fifteen patients in the recall programme who had completed conventional periodontal therapy with remaining probing pocket depths of 5-8 mm were enrolled. After baseline examination and collection of gingival crevicular fluid (GCF) samples, SPT was provided and the target teeth in the test group received subgingival delivery of the medicated chips. The clinical parameters, which included probing pocket depth (PD), attachment level (AL), bleeding index (BI), gingival index (GI) and plaque index (PI) were recorded and GCF samples were collected at baseline, 3 and 6 months.

RESULTS

The results showed significant improvement of PD, AL, and GI at 3 and 6 months and of BI at 6 months in the test group as compared to control. No significant differences in PI were found between the two treatment modalities at all subsequent visits. The test group also showed statistically greater reduction of IL-1beta at both 3 and 6 months and lower IL-6 concentration, which almost reached the level of significance at 6 months.

CONCLUSION

The results indicate that adjunctive local delivery of extracts from C. asiatica in combination with P. granatum significantly improved clinical signs of chronic periodontitis and IL-1beta level in maintenance patients.

Intrathecal antibody synthesis in Lyme neuroborreliosis: use of recombinant p41 and a 14-kDa flagellin fragment in ELISA

The intrathecal synthesis of IgM and IgG antibodies to Borrelia burgdorferi sonicate, to recombinant flagellin (41 kDa) and to a tryptic peptide of the flagellin (14-kDa fragment) was determined by ELISA in paired cerebrospinal fluid (CSF) and serum samples from 35 patients with Lyme neuroborreliosis (LNB) and in 10 patients with neurosyphilis. The antibody index (AI = QBb/QIg) was calculated from the ratio between CSF/serum quotients for specific antibodies (QBb) and total immunoglobulins (QIg). For the examination of IgG antibodies, the sonicate ELISA was performed with and without pre-absorption with Treponema phagedenis. Of 35 patients with LNB, 31 had intrathecal IgG response to B. burgdorferi demonstrated by sonicate ELISA (24 after absorption of cross-reactive antibodies), 29 had a response demonstrated by flagellin ELISA and 21 of 35 by 14-kDa ELISA. In patients with neurosyphilis the AI (IgG) was elevated in the sonicate ELISA in 7 of 10 samples (none of 10 after absorption of cross-reactive antibodies), in the flagellin ELISA in 5 of 10 samples and in the 14-kDa ELISA in none of 10 samples. Intrathecal synthesis of IgM antibodies to B. burgdorferi was demonstrated in patients with neuroborreliosis by sonicate ELISA in 20 of 35 samples, by flagellin ELISA in 16 of 35 samples and by 14-kDa ELISA in 9 of 35 samples. No intrathecal synthesis of B. burgdorferi-specific IgM could be detected by any assay in patients with neurosyphilis.(ABSTRACT TRUNCATED AT 250 WORDS)

The Sperm Attractant of the Marine Brown Alga Ascophyllum nodosum (Phaeophyceae)

Spermatozoids of the intertidal seaweed Ascophyllum nodosum (Fucales, Phaeophyceae) are attracted to eggs prior to fertilization. The attractant has been isolated and its structure identified as 1(3E, 5Z, 8Z)-undecatetraene (finavarrene). The relation of finavarrene to sex hormones in other brown algae is discussed.

Dictyota dichotoma (Phaeophyceae): Identification of the Sperm Attractant

Freshly released eggs of the marine brown alga Dictyota dichotoma secrete a substance that attracts spermatozoids. This compound has been identified as n-butyl-cyclohepta-2,5-diene. It is closely related to attractants in several other brown algae and confirms that a relation exists between phylogeny and attractant compounds.

Isolation of a spermatozoid-releasing and -attracting substance from female gametophytes of Laminaria digitata

SEVERAL dioecious marine brown algae have been valuable in studying chemical communication during sexual reproduction. For example, female gametes of Ectocarpus siliculosus, Cutleria multifida and Fucus serratus secrete olefinic hydrocarbons into the seawater to attract male gametes(1-3). A more complex system is found in the order Laminariales, which includes the large kelps. Mature female gametophytes in members of this group secrete highly volatile material with spermatozoid-attracting activity, which also induces explosive discharge of antheridia(4). We report here a study of this volatile material. It is now possible to attribute spermatozoid-releasing and -attracting activity to one specific compound.

MICROORGANISMS AND HYDROCARBONS IN THE NORTH SEA DURING JULY-AUGUST 1975

The 1975-1976 North Sea Oil Ecology Investigation is designed to determine the dynamics of oil pollution in the North Sea and to serve as a baseline study at the start of the rather extensive oil exploitation of the seabed of the North Sea. In designing the experiment, particular attention has been paid to the 1974-1975 research effort of the Gulf Universities Research Consortium directed towards determining the effect, if any, of offshore oil exploitation in Louisiana on the area's ecology. As a result, both projects address the distribution of hydrocarbons and their possible concentration in the water, sediment, and living organisms, and the determination of the rates of degradation and effect of hydrocarbons on the food web. Preliminary analyses and study of cruise data taken in the North Sea during July-August 1975 indicates that there appears to be a tendency for higher numbers of microorganisms to be associated with the most active oil field, “Ekofisk;” there is also some indication of microbial response to outflow from the Elbe River. The uniform low levels of hydrocarbons in the sediment suggest that microorganisms are active as shown by ratios of higher hydrocarbon bacteria to heterotrophs in the “Ekofisk” area.