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Background: Dental instrumentation with hand-held devices is associated with discomfort, fatigue and musculoskeletal diseases or repetitive stress injuries. The goal of this in vivo study was to determine the effect of an ergonomic handle sheath on muscle work, comfort and fatigue associated with (a) piezoelectric scaling by hygienists with and without musculoskeletal disorders (MSDs), and (b) dental cavity preparation by healthy dentists using a dental micromotor. Materials and Methods: Two groups of ten hygienists each tested the piezoelectric scaler. Hygienists in Group 1 had no MSDs, while those in Group 2 had been diagnosed with MSDs. Additionally, ten dentists with no MSDs used a dental micromotor to prepare four standardized cavities. Time-based work in four muscles, comfort and fatigue were recorded in the presence and absence of an add-on soft, insulating handle sheath. Data were analyzed using a repeated measures analysis of variance model with Tukeys post-hoc test. Results: Comfort, fatigue and muscle work were significantly better for both devices when the sheath was used. While hygienists with MSDs used more muscle work to complete the set scaling task, and the sheath-related reduction in work was somewhat greater, these MSD-related differences did not quite reach significance. Conclusions: The results of this pilot study show that the ergonomic performance of an ultrasonic scaler and a dental micromotor may be improved by the use of an ergonomic handle sheath.

(1) Background: Musculoskeletal disorders (MSDs), discomfort, fatigue, pain, and other acute and chronic work-related injuries are common among dental clinicians. Hand instruments constitute a primary risk factor for these conditions. The overall goal of this study was to compare in dental hygienists with healthy hands, and in those with MSDs, the effect of three different handle designs on instrumentation-related muscle work, comfort, fatigue, and quality of tactile feedback. (2) Methods: Clinicians tested three periodontal curettes: one with a novel adaptive silicone handle, another with a rigid resin handle, and the third with a rigid silicone handle. Ten hygienists-five with MSDs and five without-each scaled three typodonts using the three different curettes. Statistical analysis was performed using a General Linear Model (GLIM) and Tukeys post hoc test, and a significance level of p < 0.05 was implemented. (3) Results: On average, mean comfort and fatigue across all instruments were significantly worse in testers with MSDs, who also expended significantly more work to complete the same task. In all testers, a novel adaptive handle design was associated with significantly reduced total muscle work and post-instrumentation fatigue, as well as better comfort than conventional rigid handle designs. (4) Conclusions: An adaptive curette handle design demonstrated significantly better ergonomic outcomes than conventional rigid curette handle designs. Hygienists with MSDs expend significantly more muscle work during dental instrumentation.

Objectives: The objectives of this retrospective study were to analyze telehealth utilization for two specialty care practices: oral medicine (OM) and oral and maxillofacial surgery (OMFS) during the first 2 years of the pandemic, its impact as a new treatment modality and on participating providers, as well as identify the type of patient visit that most readily adopted telehealth. Methods: Retrospective study of patients who sought specialty services, OM and OMFS, at an outpatient clinic in a university health system setting between March 1, 2019, and February 28, 2022. Source data were obtained from Epic, an electronic medical record application. Data were graphed using Tableau and Microsoft Excel software. Statistical analysis was performed utilizing chi-squared test and analysis of variance (ANOVA). Results: OMFS utilized telehealth 12% of the time, and OM 8% of the time. The majority (87%) of telehealth visits were for return patients (RPs). Compared with the first year of the pandemic, there was a decrease in the number of telehealth visits in the second year (p = 0.0001). As of August 2022, new patient (NP) telehealth encounters have largely returned to prepandemic levels (0-1.5%), whereas RP telehealth visits remained at an average level of 11.4% (9.4-12.4%). Surveyed providers consider telehealth as an effective complement to in-person care and will continue its use (4.2/5 Likert scale). Conclusions: Telehealth has become a viable pathway of care for OM and OMFS who previously did not utilize the remote platform to deliver healthcare. As a new treatment modality, telehealth is perceived as impactful in increasing access to specialty care by participating providers. NP visits are now almost completely in person, but telehealth continues for RPs. Ongoing demand for telehealth highlights urgency to develop appropriate standards and effective remote diagnostic/monitoring tools to maximize telehealth's capability to leverage finite health care resources and increase access to specialty care.

BackgroundTo compare fatigue, comfort, and muscle work associated with the use of two periodontal curettes during scaling: one with a novel adaptive design, the other with a conventional non-adaptive design.MethodsTwelve hygienists scaled a typodont using two Universal Barnhart 5/6 curettes: (1) a prototype featuring an adaptive silicone-covered handle (Curette A), and (2) a stainless-steel curette (Curette B). Surface Electromyography (sEMG) traced muscle work. Hand positions, fatigue, comfort, pinch, and grasp strength were recorded. Paired t-tests and a repeated measures ANOVA with covariates were tested for differences. The significance level was set at p < 0.05.ResultsCurette A performed significantly better in all categories. Pinch and grasp strength and fatigue were significantly reduced post-instrumentation for Curette B. Curette A required significantly less (i) total muscle work and (ii) work in individual muscles. Comfort, correct grasp, and blade adaptation were significantly better using Curette A.ConclusionsA curette featuring a novel adaptive handle design demonstrated significantly improved ergonomic performance. Additional clinical studies are needed to solidify our understanding of the potential short- and long-term benefits of the novel curette handle design.Practical implicationsA novel adaptive curette handle design that enables the clinician to adapt the instrument across the index finger may reduce musculoskeletal burden and fatigue, as well as improve comfort during periodontal instrumentation.

The impact of Candida sp. in the development of oral cancer remains uncertain and requires sensitive analytical approaches for clarification. Given the invasive capabilities of these microorganisms in penetrating and invading host tissues through hyphal invasion, this study sought to detect the presence of five Candida sp. in oral biopsy tissue samples from non-smoker patients. Samples were obtained from patients at varying stages of oral carcinogenesis, including dysplasia, carcinoma in situ, OSCC, and histologically benign lesions, and analyzed using Real-Time PCR. Oral tissue samples from 80 patients (46 males and 34 females) were included. Significantly higher C. albicans presence was detected in the mild/moderate dysplasia group compared to the healthy (p = 0.001), carcinoma in situ (p = 0.031) and OSCC groups (p = 0.000). Similarly, C. tropicalis carriage was higher in tissues with mild/moderate dysplasia compared to healthy (p = 0.004) and carcinoma in situ (p = 0.019). Our results showed a significant increase in the presence of C. albicans and C. tropicalis within the mild/moderate dysplasia group compared to other cohorts. Coexistence of these two microorganisms was observed, suggesting a potential transition from a commensal state to an opportunistic pathogen, which could be particularly linked to the onset of oral neoplasia.

Natasha Evelyn Anne Murray,1,2 Mikkel B Quam,1 Annelies Wilder-Smith1,31Institute of Public Health, University of Heidelberg, Heidelberg, Germany; 2Population Health, Waikato District Health Board, Hamilton, New Zealand; 3Lee Kong Chian School of Medicine, Nanyang Technological University, SingaporeAbstract: Dengue is currently regarded globally as the most important mosquito-borne viral disease. A history of symptoms compatible with dengue can be traced back to the Chin Dynasty of 265–420 AD. The virus and its vectors have now become widely distributed throughout tropical and subtropical regions of the world, particularly over the last half-century. Significant geographic expansion has been coupled with rapid increases in incident cases, epidemics, and hyperendemicity, leading to the more severe forms of dengue. Transmission of dengue is now present in every World Health Organization (WHO) region of the world and more than 125 countries are known to be dengue endemic. The true impact of dengue globally is difficult to ascertain due to factors such as inadequate disease surveillance, misdiagnosis, and low levels of reporting. Currently available data likely grossly underestimates the social, economic, and disease burden. Estimates of the global incidence of dengue infections per year have ranged between 50 million and 200 million; however, recent estimates using cartographic approaches suggest this number is closer to almost 400 million. The expansion of dengue is expected to increase due to factors such as the modern dynamics of climate change, globalization, travel, trade, socioeconomics, settlement and also viral evolution. No vaccine or specific antiviral therapy currently exists to address the growing threat of dengue. Prompt case detection and appropriate clinical management can reduce the mortality from severe dengue. Effective vector control is the mainstay of dengue prevention and control. Surveillance and improved reporting of dengue cases is also essential to gauge the true global situation as indicated in the objectives of the WHO Global Strategy for Dengue Prevention and Control, 2012–2020. More accurate data will inform the prioritization of research, health policy, and financial resources toward reducing this poorly controlled disease. The objective of this paper is to review historical and current epidemiology of dengue worldwide and, additionally, reflect on some potential reasons for expansion of dengue into the future.Keywords: evolution, geographic expansion, travel, climate change

BackgroundGingivitis is a non-specific inflammatory lesion in response to the accumulation of oral biofilm and is a necessary precursor to periodontitis. Enhanced oral hygiene practices, including utilization of a dentifrice that could significantly improve plaque accumulation and gingival inflammation, is desirable to prevent and treat gingivitis and potentially prevent progression to periodontitis. This clinical study aimed to investigate the effect of a new stannous fluoride-containing dentifrice with 2.6% ethylenediamine tetra acetic acid (EDTA) as an anti-tartar agent to reduce plaque index and gingival index over a 3-month study period compared to other commercially-available fluoride-containing dentifrices.MethodsThis double-blind, randomized controlled clinical study evaluated plaque, gingival inflammation, and sulcular bleeding in patients using one of five commercially available fluoride-containing dentifrices The dentifrices tested contained: 0.454% stannous fluoride and 2.6% EDTA (D1), 0.24% sodium fluoride (C), and 0.454% stannous fluoride (D2-D4). One hundred fifty subjects participated over a 3-month period. Co-primary endpoints were improvements in plaque index (PI) and modified gingival index (mGI) from baseline values. No professional cleaning was performed during the study period.ResultsAll subjects in the study demonstrated statistically significant improvements in all measures of oral hygiene over the 3-month study period. Subjects using dentifrice 1 (D1) showed statistically significantly greater reductions in PI, mGI, and modified sulcular bleeding index (mSBI) compared with all other commercially-available dentifrices tested (p

BackgroundGingivitis is a nonspecific inflammatory lesion in response to the accumulation of oral biofilm and is a necessary precursor to periodontitis. Enhanced oral hygiene practices are necessary to reverse gingivitis and a dentifrice that could provide significant clinical reductions in plaque accumulation and gingival inflammation would be desirable to treat gingivitis and potentially prevent progression to periodontitis. This clinical study aimed to investigate the effect of a novel stannous fluoride-containing dentifrice with 2.6% ethylenediamine tetra-acetic acid (EDTA) as an antitartar agent to reduce Plaque Index (PI) and Gingival Index over a 3-month study period.MethodsThis double-blind, randomized controlled clinical study evaluated plaque, gingival inflammation, and sulcular bleeding in patients using either a novel dental gel containing 0.454% stannous fluoride and 2.6% EDTA or a dentifrice with 0.24% sodium fluoride. Sixty subjects participated over a 3-month period. Co-primary endpoints were improvements in PI and Modified Gingival Index (mGI) from baseline values. No professional cleaning was performed during the study period.ResultsAll subjects in the study demonstrated statistically significant improvements in all measures of oral hygiene over the 3-month study period. Subjects using the novel dental gel showed statistically significantly greater reductions in PI (ΔPI) [(-1.43 ± 0.34; -0.49 ± 0.13) (p

Efforts are underway to improve the accuracy of non-specialist screening for oral cancer (OC) risk, yet better screening will only translate into improved outcomes if at-risk individuals comply with specialist referral. Most individuals from low-resource, minority, and underserved (LRMU) populations fail to complete a specialist referral for OC risk. The goal was to evaluate the impact of a novel approach on specialist referral compliance in individuals with a positive OC risk screening outcome. A total of 60 LRMU subjects who had screened positive for increased OC risk were recruited and given the choice of referral for an in-person (20 subjects) or a telehealth (40 subjects) specialist visit. Referral compliance was tracked weekly over 6 months. Compliance was 30% in the in-person group, and 83% in the telehealth group. Approximately 83-85% of subjects from both groups who had complied with the first specialist referral complied with a second follow-up in-person specialist visit. Overall, 72.5% of subjects who had chosen a remote first specialist visit had entered into the continuum of care by the study end, vs. 25% of individuals in the in-person specialist group. A two-step approach that uses telehealth to overcome barriers may improve specialist referral compliance in LRMU individuals with increased OC risk.

Late detection and specialist referral result in poor oral cancer outcomes globally. High-risk LRMU populations usually do not have access to oral medicine specialists, a specialty of dentistry, whose expertise includes the identification, treatment, and management of oral cancers. To overcome this access barrier, there is an urgent need for novel, low-cost tele-health approaches to expand specialist access to low-resource, remote and underserved individuals. The goal of this study was to compare the diagnostic accuracy of remote versus in-person specialist visits using a novel, low-cost telehealth platform consisting of a smartphone-based, remote intraoral camera and custom software application. A total of 189 subjects with suspicious oral lesions requiring biopsy (per the standard of care) were recruited and consented. Each subject was examined, and risk factors were recorded twice: once by an on-site specialist, and again by an offsite specialist. A novel, low-cost, smartphone-based intraoral camera paired with a custom software application were utilized to perform synchronous remote video/still imaging and risk factor assessment by the off-site specialist. Biopsies were performed at a later date following specialist recommendations. The study's results indicated that on-site specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histological diagnosis, which did not significantly differ from the accuracy of remote specialist telediagnosis (sensitivity: 95%; specificity: 84%). These preliminary findings suggest that remote specialist visits utilizing a novel, low-cost, smartphone-based telehealth tool may improve specialist access for low-resource, remote and underserved individuals with suspicious oral lesions.

Convolutional neural networks have demonstrated excellent performance in oral cancer detection and classification. However, the end-to-end learning strategy makes CNNs hard to interpret, and it can be challenging to fully understand the decision-making procedure. Additionally, reliability is also a significant challenge for CNN based approaches. In this study, we proposed a neural network called the attention branch network (ABN), which combines the visual explanation and attention mechanisms to improve the recognition performance and interpret the decision-making simultaneously. We also embedded expert knowledge into the network by having human experts manually edit the attention maps for the attention mechanism. Our experiments have shown that ABN performs better than the original baseline network. By introducing the Squeeze-and-Excitation (SE) blocks to the network, the cross-validation accuracy increased further. Furthermore, we observed that some previously misclassified cases were correctly recognized after updating by manually editing the attention maps. The cross-validation accuracy increased from 0.846 to 0.875 with the ABN (Resnet18 as baseline), 0.877 with SE-ABN, and 0.903 after embedding expert knowledge. The proposed method provides an accurate, interpretable, and reliable oral cancer computer-aided diagnosis system through visual explanation, attention mechanisms, and expert knowledge embedding.

(1) Background: Periodontal instrumentation with dental curettes is associated with discomfort, fatigue, and musculoskeletal diseases. The goal of this study was to compare comfort, fatigue, and muscle work using three different curettes. (2) Methods: Eight hygienists each scaled three typodonts using the three different curettes. Curette A was a prototype with a novel adaptive design, Curette B had a conventional stainless-steel design, and Curette C featured a conventional silicon-covered handle. Time-based work in four muscles, comfort, fatigue, tactile feedback, grip and blade position, and pinch and grasp strength were recorded. Statistical analysis was performed using a General Linear Model (GLIM) and Tukey’s post hoc test. The level of significance was set at p < 0.05. (3) Results: Comfort, correct grasp, fingertip placement, and blade-to-tooth adaptation were significantly better with Curette A (p < 0.05). While pinch and grasp strength were significantly reduced post-instrumentation for Curettes B and C (p < 0.05), they remained unchanged for Curette A. Curette A required significantly less total muscle work and work in individual muscles, resulting in significantly less post-instrumentation fatigue than for Curettes B and C, but similar levels of tactile feedback (p < 0.05). (4) Conclusions: The ergonomic performance of a prototype adaptive periodontal curette was significantly better than that of two conventional instruments with rigid handle designs.

SignificanceOral cancer is one of the most prevalent cancers, especially in middle- and low-income countries such as India. Automatic segmentation of oral cancer images can improve the diagnostic workflow, which is a significant task in oral cancer image analysis. Despite the remarkable success of deep-learning networks in medical segmentation, they rarely provide uncertainty quantification for their output.AimWe aim to estimate uncertainty in a deep-learning approach to semantic segmentation of oral cancer images and to improve the accuracy and reliability of predictions.ApproachThis work introduced a UNet-based Bayesian deep-learning (BDL) model to segment potentially malignant and malignant lesion areas in the oral cavity. The model can quantify uncertainty in predictions. We also developed an efficient model that increased the inference speed, which is almost six times smaller and two times faster (inference speed) than the original UNet. The dataset in this study was collected using our customized screening platform and was annotated by oral oncology specialists.ResultsThe proposed approach achieved good segmentation performance as well as good uncertainty estimation performance. In the experiments, we observed an improvement in pixel accuracy and mean intersection over union by removing uncertain pixels. This result reflects that the model provided less accurate predictions in uncertain areas that may need more attention and further inspection. The experiments also showed that with some performance compromises, the efficient model reduced computation time and model size, which expands the potential for implementation on portable devices used in resource-limited settings.ConclusionsOur study demonstrates the UNet-based BDL model not only can perform potentially malignant and malignant oral lesion segmentation, but also can provide informative pixel-level uncertainty estimation. With this extra uncertainty information, the accuracy and reliability of the model’s prediction can be improved.

Introduction Viral pathogens such as flaviviruses, coronaviruses, and influenza viruses pose unique challenges for adaptive immune responses because of the existence of many serotypes and/or the frequent emergence of new [...], NKT cells are innate-like T cells, recruited to the skin during viral infection, yet their contributions to long- term immune memory to viruses are unclear. We identified granzyme K, a product made by cytotoxic cells including NKT cells, as linked to induction of Th1-associated antibodies during primary dengue virus (DENV) infection in humans. We examined the role of NKT cells in vivo using DENV-infected mice lacking CD1d-dependent ([CD1d.sup.dep]) NKT cells. In CD1d-KO mice, Th1- polarized immunity and infection resolution were impaired, which was dependent on intrinsic NKT cell production of IFN- [gamma], since it was restored by adoptive transfer of WT but not IFN-[gamma]-KO NKT cells. Furthermore, NKT cell deficiency triggered immune bias, resulting in higher levels of Th2-associated IgG1 than Th1-associated IgG2a, which failed to protect against a homologous DENV rechallenge and promoted antibody-dependent enhanced disease during secondary heterologous infections. Similarly, Th2 immunity, typified by a higher IgG4/IgG3 ratio, was associated with worsened human disease severity during secondary infections. Thus, [CD1d.sup.dep] NKT cells establish Th1 polarity during the early innate response to DENV, which promotes infection resolution, memory formation, and long-term protection from secondary homologous and heterologous infections in mice, with consistent associations observed in humans. These observations illustrate how early innate immune responses during primary infections can influence secondary infection outcomes.

BackgroundCytomegalovirus (HCMV), Epstein-Barr virus (EBV), and herpes simplex virus type-1 (HSV-1) are pathogens.ObjectivesThe goal of the present double-blinded, randomized study was to compare the effect on oral viral load of twice daily use over 60 days of Lumineux MouthwashRvs. de-ionized water. The main composition of the mouthwash was Dead Sea salt.Methods30 participants were randomized to test or control. For 60 days, participants rinsed for 60s twice daily with 20ml of their allocated mouthwash, after morning and evening meals. On Day 0 and 60, before eating and oral hygiene and at least 60 minutes after drinking, unstimulated saliva was collected. Samples underwent mRNA analysis. Study endpoints were changes in Log Salivary Viral Load.ResultAfter adjusting for baseline differences, the reduction in viral load was significantly greater for the test group, all p-values

SignificanceConvolutional neural networks (CNNs) show the potential for automated classification of different cancer lesions. However, their lack of interpretability and explainability makes CNNs less than understandable. Furthermore, CNNs may incorrectly concentrate on other areas surrounding the salient object, rather than the network's attention focusing directly on the object to be recognized, as the network has no incentive to focus solely on the correct subjects to be detected. This inhibits the reliability of CNNs, especially for biomedical applications.AimDevelop a deep learning training approach that could provide understandability to its predictions and directly guide the network to concentrate its attention and accurately delineate cancerous regions of the image.ApproachWe utilized Selvaraju et al.'s gradient-weighted class activation mapping to inject interpretability and explainability into CNNs. We adopted a two-stage training process with data augmentation techniques and Li et al.'s guided attention inference network (GAIN) to train images captured using our customized mobile oral screening devices. The GAIN architecture consists of three streams of network training: classification stream, attention mining stream, and bounding box stream. By adopting the GAIN training architecture, we jointly optimized the classification and segmentation accuracy of our CNN by treating these attention maps as reliable priors to develop attention maps with more complete and accurate segmentation.ResultsThe network's attention map will help us to actively understand what the network is focusing on and looking at during its decision-making process. The results also show that the proposed method could guide the trained neural network to highlight and focus its attention on the correct lesion areas in the images when making a decision, rather than focusing its attention on relevant yet incorrect regions.ConclusionsWe demonstrate the effectiveness of our approach for more interpretable and reliable oral potentially malignant lesion and malignant lesion classification.

In medical imaging, deep learning-based solutions have achieved state-of-the-art performance. However, reliability restricts the integration of deep learning into practical medical workflows since conventional deep learning frameworks cannot quantitatively assess model uncertainty. In this work, we propose to address this shortcoming by utilizing a Bayesian deep network capable of estimating uncertainty to assess oral cancer image classification reliability. We evaluate the model using a large intraoral cheek mucosa image dataset captured using our customized device from high-risk population to show that meaningful uncertainty information can be produced. In addition, our experiments show improved accuracy by uncertainty-informed referral. The accuracy of retained data reaches roughly 90% when referring either 10% of all cases or referring cases whose uncertainty value is greater than 0.3. The performance can be further improved by referring more patients. The experiments show the model is capable of identifying difficult cases needing further inspection.

SignificanceEarly detection of oral cancer is vital for high-risk patients, and machine learning-based automatic classification is ideal for disease screening. However, current datasets collected from high-risk populations are unbalanced and often have detrimental effects on the performance of classification.AimTo reduce the class bias caused by data imbalance.ApproachWe collected 3851 polarized white light cheek mucosa images using our customized oral cancer screening device. We use weight balancing, data augmentation, undersampling, focal loss, and ensemble methods to improve the neural network performance of oral cancer image classification with the imbalanced multi-class datasets captured from high-risk populations during oral cancer screening in low-resource settings.ResultsBy applying both data-level and algorithm-level approaches to the deep learning training process, the performance of the minority classes, which were difficult to distinguish at the beginning, has been improved. The accuracy of "premalignancy" class is also increased, which is ideal for screening applications.ConclusionsExperimental results show that the class bias induced by imbalanced oral cancer image datasets could be reduced using both data- and algorithm-level methods. Our study may provide an important basis for helping understand the influence of unbalanced datasets on oral cancer deep learning classifiers and how to mitigate.

Abstract Background Expatriates are a distinct population at unique risk for health problems related to their travel exposure. Methods We analyzed GeoSentinel data comparing ill returned expatriates with other travelers for demographics, travel characteristics, and proportionate morbidity (PM) for travel-related illness. Results Our study included 2,883 expatriates and 11,910 non-expatriates who visited GeoSentinel clinics ill after travel. Expatriates were more likely to be male, do volunteer work, be long-stay travelers (>6 months), and have sought pre-travel advice. Compared to non-expatriates, expatriates returning from Africa had higher proportionate morbidity (PM) for malaria, filariasis, schistosomiasis, and hepatitis E; expatriates from the Asia-Pacific region had higher PM for strongyloidiasis, depression, and anxiety; expatriates returning from Latin America had higher PM for mononucleosis and ingestion-related infections (giardiasis, brucellosis). Expatriates returning from all three regions had higher PM for latent TB, amebiasis, and gastrointestinal infections (other than acute diarrhea) compared to non-expatriates. When the data were stratified by travel reason, business expatriates had higher PM for febrile systemic illness (malaria and dengue) and vaccine-preventable infections (hepatitis A), and volunteer expatriates had higher PM for parasitic infections. Expatriates overall had higher adjusted odds ratios for latent TB and lower odds ratios for acute diarrhea and dermatologic illness. Conclusions Ill returned expatriates differ from other travelers in travel characteristics and proportionate morbidity for specific diseases, based on the region of exposure and travel reason. They are more likely to present with more serious illness.

Abstract Background There is an urgent need to protect children against dengue since this age group is particularly sensitive to the disease. Since dengue vectors are active mainly during the day, a potential target for control should be schools where children spend a considerable amount of their day. School uniforms are the cultural norm in most developing countries, worn throughout the day. We hypothesise that insecticide-treated school uniforms will reduce the incidence of dengue infection in school-aged children. Our objective is to determine the impact of impregnated school uniforms on dengue incidence. Methods A randomised controlled trial will be conducted in eastern Thailand in a group of schools with approximately 2,000 students aged 7–18 years. Pre-fabricated school uniforms will be commercially treated to ensure consistent, high-quality insecticide impregnation with permethrin. A double-blind, randomised, crossover trial at the school level will cover two dengue transmission seasons. Discussion Practical issues and plans concerning intervention implementation, evaluation, analysing and interpreting the data, and possible policy implications arising from the trial are discussed. Trial registration clinicaltrial.gov. Registration number: NCT01563640

Abstract Background The Timor-Leste Ministry of Health has recently finalized the National Malaria Control Strategy for 2010-2020. A key component of this roadmap is to provide universal national coverage with long-lasting insecticide-treated nets (LLINs) in support of achieving the primary goal of reducing both morbidity and mortality from malaria by 30% in the first three years, followed by a further reduction of 20% by end of the programme cycle in 2020 1. The strategic plan calls for this target to be supported by a comprehensive information, education and communication (IEC) programme; however, there is limited prior research into household and personal usage patterns to assist in the creation of targeted, effective, and socio-culturally specific behaviour change materials. Methods Nine separate focus group discussions (FGDs) were carried out in Dili, Manatuto, and Covalima districts, Democratic Republic of Timor-Leste, in July 2010. These focus groups primarily explored themes of perceived malaria risk, causes of malaria, net usage patterns within families, barriers to correct and consistent usage, and the daily experience of users (both male and female) in households with at least one net. Comprehensive qualitative analysis utilized open source analysis software. Results The primary determinants of net usage were a widespread perception that nets could or should only be used by pregnant women and young children, and the availability of sufficient sleeping space under a limited number of nets within households. Both nuisance biting and disease prevention were commonly cited as primary motivations for usage, while seasonality was not a significant factor. Long-term net durability and ease of hanging were seen as key attributes in net design preference. Very frequent washing cycles were common, potentially degrading net effectiveness. Finally, extensive re-purposing of nets (fishing, protecting crops) was both reported and observed, and may significantly decrease availability of nighttime sleeping space for all family members if distributed nets do not remain within the household. Conclusions Emphasizing that net usage is acceptable and important for all family members regardless of age or gender, and addressing the complex behavioural economics of alternative net usages could have significant impacts on malaria control efforts in Timor-Leste, as the country's programmes make progress towards universal net coverage.

BackgroundCompliance to periodontal maintenance therapy (PMT) is essential for long-term periodontal health. Between PMT visits, patients must maintain good oral hygiene. A dentifrice with demonstrable clinical benefits for use between PMT visits would be highly desirable. The aim of this clinical study was to investigate the effect of a novel dental gel on probing depths (PD) and inflammation when used as a home care dentifrice in Stage I and II periodontitis patients.MethodsThis double-blind clinical study randomized 65 subjects with Stage I and II periodontitis to the novel dental gel containing 2.6% EDTA, and a commercially available anti-gingivitis dentifrice with 0.454% stannous fluoride. Primary endpoint was PD at 6 months for those sites with baseline PD ≥ 4 mm and secondary endpoints included whole mouth mean scores of modified gingival index (MGI), modified sulcus bleeding index (mSBI) and plaque index (PI). No SRP was performed at baseline.ResultsSubjects using the novel dentifrice showed significant PD reductions of 1.18 mm (from 4.27 mm at baseline to 3.09 mm at 6 months) compared to 0.93 mm (from 4.23 mm at baseline to 3.30 mm at 6 months) shown for those using the positive control dentifrice. Difference between treatments at 6 months was 0.21 mm with P-value = 0.0126. Significant improvements in MGI (P = 0.0000), mSBI (P = 0.0000), and PI (P = 0.0102) were also observed in 6 months.ConclusionThe novel dentifrice showed significant reductions in PD and gingival inflammation over 6 months solely as a home care dentifrice without baseline SRP in Stage I and II periodontitis maintenance patients.

Non-invasive strategies that can identify oral malignant and dysplastic oral potentially-malignant lesions (OPML) are necessary in cancer screening and long-term surveillance. Optical coherence tomography (OCT) can be a rapid, real time and non-invasive imaging method for frequent patient surveillance. Here, we report the validation of a portable, robust OCT device in 232 patients (lesions: 347) in different clinical settings. The device deployed with algorithm-based automated diagnosis, showed efficacy in delineation of oral benign and normal (n = 151), OPML (n = 121), and malignant lesions (n = 75) in community and tertiary care settings. This study showed that OCT images analyzed by automated image processing algorithm could distinguish the dysplastic-OPML and malignant lesions with a sensitivity of 95% and 93%, respectively. Furthermore, we explored the ability of multiple (n = 14) artificial neural network (ANN) based feature extraction techniques for delineation high grade-OPML (moderate/severe dysplasia). The support vector machine (SVM) model built over ANN, delineated high-grade dysplasia with sensitivity of 83%, which in turn, can be employed to triage patients for tertiary care. The study provides evidence towards the utility of the robust and low-cost OCT instrument as a point-of-care device in resource-constrained settings and the potential clinical application of device in screening and surveillance of oral cancer.

Abstract Background Individual strategies in pandemic preparedness plans may not reduce the impact of an influenza pandemic. Methods We searched modeling publications through PubMed and associated references from 1990 to 30 September 2009. Inclusion criteria were modeling papers quantifying the effectiveness of combination strategies, both pharmaceutical and non-pharmaceutical. Results Nineteen modeling papers on combination strategies were selected. Four studies examined combination strategies on a global scale, 14 on single countries, and one on a small community. Stochastic individual-based modeling was used in nine studies, stochastic meta-population modeling in five, and deterministic compartmental modeling in another five. As part of combination strategies, vaccination was explored in eight studies, antiviral prophylaxis and/or treatment in 16, area or household quarantine in eight, case isolation in six, social distancing measures in 10 and air travel restriction in six studies. Two studies suggested a high probability of successful influenza epicenter containment with combination strategies under favorable conditions. During a pandemic, combination strategies delayed spread, reduced overall number of cases, and delayed and reduced peak attack rate more than individual strategies. Combination strategies remained effective at high reproductive numbers compared with single strategy. Global cooperative strategies, including redistribution of antiviral drugs, were effective in reducing the global impact and attack rates of pandemic influenza. Conclusion Combination strategies increase the effectiveness of individual strategies. They include pharmaceutical (antiviral agents, antibiotics and vaccines) and non-pharmaceutical interventions (case isolation, quarantine, personal hygiene measures, social distancing and travel restriction). Local epidemiological and modeling studies are needed to validate efficacy and feasibility.

SignificanceOral cancer is among the most common cancers globally, especially in low- and middle-income countries. Early detection is the most effective way to reduce the mortality rate. Deep learning-based cancer image classification models usually need to be hosted on a computing server. However, internet connection is unreliable for screening in low-resource settings.AimTo develop a mobile-based dual-mode image classification method and customized Android application for point-of-care oral cancer detection.ApproachThe dataset used in our study was captured among 5025 patients with our customized dual-modality mobile oral screening devices. We trained an efficient network MobileNet with focal loss and converted the model into TensorFlow Lite format. The finalized lite format model is ∼16.3  MB and ideal for smartphone platform operation. We have developed an Android smartphone application in an easy-to-use format that implements the mobile-based dual-modality image classification approach to distinguish oral potentially malignant and malignant images from normal/benign images.ResultsWe investigated the accuracy and running speed on a cost-effective smartphone computing platform. It takes ∼300  ms to process one image pair with the Moto G5 Android smartphone. We tested the proposed method on a standalone dataset and achieved 81% accuracy for distinguishing normal/benign lesions from clinically suspicious lesions, using a gold standard of clinical impression based on the review of images by oral specialists.ConclusionsOur study demonstrates the effectiveness of a mobile-based approach for oral cancer screening in low-resource settings.

Oral cancer (OC) is the sixth most commonly reported malignant disease globally, with high rates of disease-related morbidity and mortality due to advanced loco-regional stage at diagnosis. Early detection and prompt treatment offer the best outcomes to patients, yet the majority of OC lesions are detected at late stages with 45% survival rate for 2 years. The primary cause of poor OC outcomes is unavailable or ineffective screening and surveillance at the local point-of-care level, leading to delays in specialist referral and subsequent treatment. Lack of adequate awareness of OC among the public and professionals, and barriers to accessing health care services in a timely manner also contribute to delayed diagnosis. As image analysis and diagnostic technologies are evolving, various artificial intelligence (AI) approaches, specific algorithms and predictive models are beginning to have a considerable impact in improving diagnostic accuracy for OC. AI based technologies combined with intraoral photographic images or optical imaging methods are under investigation for automated detection and classification of OC. These new methods and technologies have great potential to improve outcomes, especially in low-resource settings. Such approaches can be used to predict oral cancer risk as an adjunct to population screening by providing real-time risk assessment. The objective of this study is to (1) provide an overview of components of delayed OC diagnosis and (2) evaluate novel AI based approaches with respect to their utility and implications for improving oral cancer detection.

Background: Dental instrumentation with hand-held devices is associated with discomfort, fatigue and musculoskeletal diseases or repetitive stress injuries. The goal of this in vivo study was to determine the effect of an ergonomic handle sheath on muscle work, comfort and fatigue associated with (a) piezoelectric scaling by hygienists with and without musculoskeletal disorders (MSDs), and (b) dental cavity preparation by healthy dentists using a dental micromotor. Materials and Methods: Two groups of ten hygienists each tested the piezoelectric scaler. Hygienists in Group 1 had no MSDs, while those in Group 2 had been diagnosed with MSDs. Additionally, ten dentists with no MSDs used a dental micromotor to prepare four standardized cavities. Time-based work in four muscles, comfort and fatigue were recorded in the presence and absence of an add-on soft, insulating handle sheath. Data were analyzed using a repeated measures analysis of variance model with Tukey’s post-hoc test. Results: Comfort, fatigue and muscle work were significantly better for both devices when the sheath was used. While hygienists with MSDs used more muscle work to complete the set scaling task, and the sheath-related reduction in work was somewhat greater, these MSD-related differences did not quite reach significance. Conclusions: The results of this pilot study show that the ergonomic performance of an ultrasonic scaler and a dental micromotor may be improved by the use of an ergonomic handle sheath.

(1) Background: Musculoskeletal disorders (MSDs), discomfort, fatigue, pain, and other acute and chronic work-related injuries are common among dental clinicians. Hand instruments constitute a primary risk factor for these conditions. The overall goal of this study was to compare in dental hygienists with healthy hands, and in those with MSDs, the effect of three different handle designs on instrumentation-related muscle work, comfort, fatigue, and quality of tactile feedback. (2) Methods: Clinicians tested three periodontal curettes: one with a novel adaptive silicone handle, another with a rigid resin handle, and the third with a rigid silicone handle. Ten hygienists—five with MSDs and five without—each scaled three typodonts using the three different curettes. Statistical analysis was performed using a General Linear Model (GLIM) and Tukey’s post hoc test, and a significance level of p < 0.05 was implemented. (3) Results: On average, mean comfort and fatigue across all instruments were significantly worse in testers with MSDs, who also expended significantly more work to complete the same task. In all testers, a novel adaptive handle design was associated with significantly reduced total muscle work and post-instrumentation fatigue, as well as better comfort than conventional rigid handle designs. (4) Conclusions: An adaptive curette handle design demonstrated significantly better ergonomic outcomes than conventional rigid curette handle designs. Hygienists with MSDs expend significantly more muscle work during dental instrumentation.

Late detection and specialist referral result in poor oral cancer outcomes globally. High-risk LRMU populations usually do not have access to oral medicine specialists, a specialty of dentistry, whose expertise includes the identification, treatment, and management of oral cancers. To overcome this access barrier, there is an urgent need for novel, low-cost tele-health approaches to expand specialist access to low-resource, remote and underserved individuals. The goal of this study was to compare the diagnostic accuracy of remote versus in-person specialist visits using a novel, low-cost telehealth platform consisting of a smartphone-based, remote intraoral camera and custom software application. A total of 189 subjects with suspicious oral lesions requiring biopsy (per the standard of care) were recruited and consented. Each subject was examined, and risk factors were recorded twice: once by an on-site specialist, and again by an offsite specialist. A novel, low-cost, smartphone-based intraoral camera paired with a custom software application were utilized to perform synchronous remote video/still imaging and risk factor assessment by the off-site specialist. Biopsies were performed at a later date following specialist recommendations. The study’s results indicated that on-site specialist diagnosis showed high sensitivity (94%) and moderate specificity (72%) when compared to histological diagnosis, which did not significantly differ from the accuracy of remote specialist telediagnosis (sensitivity: 95%; specificity: 84%). These preliminary findings suggest that remote specialist visits utilizing a novel, low-cost, smartphone-based telehealth tool may improve specialist access for low-resource, remote and underserved individuals with suspicious oral lesions.

Vaccines against dengue virus Dengue fever, a widespread arboviral infection caused by four distinct serotypes of the dengue virus (DENV1-4), continues to be a substantial public health concern in numerous [...], Dengue fever, caused by four distinct serotypes of the dengue virus (DENV1-4), poses a public health concern for much of the world. The NIH&apos;s Laboratory of Infectious Diseases at the National Institute of Allergy and Infectious Diseases (NIAID) has developed a series of single-dose, live-attenuated tetravalent DENV vaccines, including TV005. However, phase III trials require a lengthy three-to-five year follow-up. In contrast, controlled human infection models (CHIMs) offer a faster means to assess vaccine efficacy for any of the four serotypes. In this issue of the JCI, Pierce, Durbin, and colleagues conducted a CHIM study with attenuated DENV2 and DENV3 challenge viruses in individuals six months after vaccination with TV005. The TV005 vaccine was well tolerated and effectively protected all vaccinated individuals from viremia and rash during challenges with DENV2 or DENV3. Notably, vaccine recipients also showed serotype-specific efficacy. While long-term studies are still needed, these findings represent an important step in providing protection against dengue virus.

Early diagnosis is the most important determinant of oral and oropharyngeal squamous cell carcinoma (OPSCC) outcomes, yet most of these cancers are detected late, when outcomes are poor. Typically, nonspecialists such as dentists screen for oral cancer risk, and then they refer high-risk patients to specialists for biopsy-based diagnosis. Because the clinical appearance of oral mucosal lesions is not an adequate indicator of their diagnosis, status, or risk level, this initial triage process is inaccurate, with poor sensitivity and specificity. The objective of this study is to provide an overview of emerging optical imaging modalities and novel artificial intelligence-based approaches, as well as to evaluate their individual and combined utility and implications for improving oral cancer detection and outcomes. The principles of image-based approaches to detecting oral cancer are placed within the context of clinical needs and parameters. A brief overview of artificial intelligence approaches and algorithms is presented, and studies that use these 2 approaches singly and together are cited and evaluated. In recent years, a range of novel imaging modalities has been investigated for their applicability to improving oral cancer outcomes, yet none of them have found widespread adoption or significantly affected clinical practice or outcomes. Artificial intelligence approaches are beginning to have considerable impact in improving diagnostic accuracy in some fields of medicine, but to date, only limited studies apply to oral cancer. These studies demonstrate that artificial intelligence approaches combined with imaging can have considerable impact on oral cancer outcomes, with applications ranging from low-cost screening with smartphone-based probes to algorithm-guided detection of oral lesion heterogeneity and margins using optical coherence tomography. Combined imaging and artificial intelligence approaches can improve oral cancer outcomes through improved detection and diagnosis.

Objective:Overall aim of this prospective, randomized, positive controlled, double-blind in vivo study was to identify the effects of a test dental gel containing 2.6% edathamil with an added carrier and permeability enhancer vs. a positive control dentifrice on periodontal health measures in patients with Stage II and III periodontitis. Methods:In this prospective double-blinded, randomized study, 33 subjects were randomly assigned in a 1:1 ratio to brushing their teeth with either the test gel (LivFresh®, Livionex Dental Gel, Los Gatos, CA 95030) or the positive control toothpaste (Crest ProHealth®, P&G, Cincinnati, OH 45202).Full-mouth gingival index, modified sulcus bleeding index, and periodontal pocket probing depths were recorded for all teeth at baseline, and on days 90 and 180.Subjects brushed with the study material twice a day. Results:The test dental gel reduced gingival inflammation and bleeding, as well as periodontal pocket probing depths significantly more than a control dentifrice. Conclusions:In this pilot study in subjects with Stage II and III periodontitis, a test dental gel was found to improve gingival inflammation and bleeding, as well as periodontal pocket depths significantly better than a control dentifrice.

Oral cancer is a growing health issue in low- and middle-income countries due to betel quid, tobacco, and alcohol use and in younger populations of middle- and high-income communities due to the prevalence of human papillomavirus. The described point-of-care, smartphone-based intraoral probe enables autofluorescence imaging and polarized white light imaging in a compact geometry through the use of a USB-connected camera module. The small size and flexible imaging head improves on previous intraoral probe designs and allows imaging the cheek pockets, tonsils, and base of tongue, the areas of greatest risk for both causes of oral cancer. Cloud-based remote specialist and convolutional neural network clinical diagnosis allow for both remote community and home use. The device is characterized and preliminary field-testing data are shared.

The tetravalent dengue vaccine CYD-TDV (Dengvaxia) is the first licensed vaccine against dengue, but recent findings indicate an elevated risk of severe disease among vaccinees without prior dengue virus (DENV) exposure. The World Health Organization currently recommends CYD-TDV only for individuals with serological confirmation of past DENV exposure. Our objective was to evaluate the potential health impact and cost-effectiveness of vaccination following serological screening. To do so, we used an agent-based model to simulate DENV transmission with and without vaccination over a 10-year timeframe. Across a range of values for the proportion of vaccinees with prior DENV exposure, we projected the proportion of symptomatic and hospitalized cases averted as a function of the sensitivity and specificity of serological screening. Scenarios about the cost-effectiveness of screening and vaccination were chosen to be representative of Brazil and the Philippines. We found that public health impact depended primarily on sensitivity in high-transmission settings and on specificity in low-transmission settings. Cost-effectiveness could be achievable from the perspective of a public payer provided that sensitivity and the value of a disability-adjusted life-year were both high, but only in high-transmission settings. Requirements for reducing relative risk and achieving cost-effectiveness from an individual perspective were more restricted, due to the fact that those who test negative pay for screening but receive no benefit. Our results predict that cost-effectiveness could be achieved only in high-transmission areas of dengue-endemic countries with a relatively high per capita GDP, such as Panamá (13,680 USD), Brazil (8,649 USD), México (8,201 USD), or Thailand (5,807 USD). In conclusion, vaccination with CYD-TDV following serological screening could have a positive impact in some high-transmission settings, provided that screening is highly specific (to minimize individual harm), at least moderately sensitive (to maximize population benefit), and sufficiently inexpensive (depending on the setting).

ObjectivesSurgical margin status is a significant determinant of treatment outcome in oral cancer. Negative surgical margins can decrease the loco-regional recurrence by five-fold. The current standard of care of intraoperative clinical examination supplemented by histological frozen section, can result in a risk of positive margins from 5 to 17 percent. In this study, we attempted to assess the utility of intraoperative optical coherence tomography (OCT) imaging with automated diagnostic algorithm to improve on the current method of clinical evaluation of surgical margin in oral cancer.Materials and methodsWe have used a modified handheld OCT device with automated algorithm based diagnostic platform for imaging. Intraoperatively, images of 125 sites were captured from multiple zones around the tumor of oral cancer patients (n = 14) and compared with the clinical and pathologic diagnosis.ResultsOCT showed sensitivity and specificity of 100%, equivalent to histological diagnosis (kappa, ĸ = 0.922), in detection of malignancy within tumor and tumor margin areas. In comparison, for dysplastic lesions, OCT-based detection showed a sensitivity of 92.5% and specificity of 68.8% and a moderate concordance with histopathology diagnosis (ĸ = 0.59). Additionally, the OCT scores could significantly differentiate squamous cell carcinoma (SCC) from dysplastic lesions (mild/moderate/severe; p ≤ 0.005) as well as the latter from the non-dysplastic lesions (p ≤ 0.05).ConclusionThe current challenges associated with clinical examination-based margin assessment could be improved with intra-operative OCT imaging. OCT is capable of identifying microscopic tumor at the surgical margins and demonstrated the feasibility of mapping of field cancerization around the tumor.