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Concept: Mouth

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BACKGROUND: The pattern of protein intake following exercise may impact whole-body protein turnover and net protein retention. We determined the effects of different protein feeding strategies on protein metabolism in resistance-trained young men. METHODS: Participants were randomly assigned to ingest either 80g of whey protein as 8x10g every 1.5h (PULSE; n=8), 4x20g every 3h (intermediate, INT; n=7), or 2x40g every 6h (BOLUS; n=8) after an acute bout of bilateral knee extension exercise (4x10 repetitions at 80% maximal strength). Whole-body protein turnover (Q), synthesis (S), breakdown (B), and net balance (NB) were measured throughout 12h of recovery by a bolus ingestion of [15N]glycine with urinary [15N]ammonia enrichment as the collected end-product. RESULTS: PULSE Q rates were greater than BOLUS (~19%, P<0.05) with a trend towards being greater than INT (~9%, P=0.08). Rates of S were 32% and 19% greater and rates of B were 51% and 57% greater for PULSE as compared to INT and BOLUS, respectively (P<0.05), with no difference between INT and BOLUS. There were no statistical differences in NB between groups (P=0.23); however, magnitude-based inferential statistics revealed likely small (mean effect+/-90%CI; 0.59+/-0.87) and moderate (0.80+/-0.91) increases in NB for PULSE and INT compared to BOLUS and possible small increase (0.42+/-1.00) for INT vs. PULSE. CONCLUSION: We conclude that the pattern of ingested protein, and not only the total daily amount, can impact whole-body protein metabolism. Individuals aiming to maximize NB would likely benefit from repeated ingestion of moderate amounts of protein (~20g) at regular intervals (~3h) throughout the day.

Concepts: Metabolism, Nutrition, Eating, Ingestion, Coprophagia, Digestive system, Mouth, Whey protein

173

Nonsyndromic orofacial clefts are common birth defects with multifactorial etiology. The most common type is cleft lip, which occurs with or without cleft palate (nsCLP and nsCLO, respectively). Although genetic components play an important role in nsCLP, the genetic factors that predispose to palate involvement are largely unknown. In this study, we carried out a meta-analysis on genetic and clinical data from three large cohorts and identified strong association between a region on chromosome 15q13 and nsCLP (P = 8.13×10-14 for rs1258763; relative risk (RR): 1.46, 95% confidence interval (CI): 1.32-1.61)) but not nsCLO (P = 0.27; RR: 1.09 (0.94-1.27)). The 5 kb region of strongest association maps downstream of Gremlin-1 (GREM1), which encodes a secreted antagonist of the BMP4 pathway. We show during mouse embryogenesis, Grem1 is expressed in the developing lip and soft palate but not in the hard palate. This is consistent with genotype-phenotype correlations between rs1258763 and a specific nsCLP subphenotype, since a more than two-fold increase in risk was observed in patients displaying clefts of both the lip and soft palate but who had an intact hard palate (RR: 3.76, CI: 1.47-9.61, Pdiff<0.05). While we did not find lip or palate defects in Grem1-deficient mice, wild type embryonic palatal shelves developed divergent shapes when cultured in the presence of ectopic Grem1 protein (P = 0.0014). The present study identified a non-coding region at 15q13 as the second, genome-wide significant locus specific for nsCLP, after 13q31. Moreover, our data suggest that the closely located GREM1 gene contributes to a rare clinical nsCLP entity. This entity specifically involves abnormalities of the lip and soft palate, which develop at different time-points and in separate anatomical regions.

Concepts: Gene, Genetics, Mouth, Cleft lip and palate, PHF8, Palatine uvula, Soft palate, Cleft

35

There have been significant changes in the understanding of the role of carbohydrates during endurance exercise in recent years, which allows for more specific and more personalized advice with regard to carbohydrate ingestion during exercise. The new proposed guidelines take into account the duration (and intensity) of exercise and advice is not restricted to the amount of carbohydrate; it also gives direction with respect to the type of carbohydrate. Studies have shown that during exercise lasting approximately 1 h in duration, a mouth rinse or small amounts of carbohydrate can result in a performance benefit. A single carbohydrate source can be oxidized at rates up to approximately 60 g/h and this is the recommendation for exercise that is more prolonged (2-3 h). For ultra-endurance events, the recommendation is higher at approximately 90 g/h. Carbohydrate ingested at such high ingestion rates must be a multiple transportable carbohydrates to allow high oxidation rates and prevent the accumulation of carbohydrate in the intestine. The source of the carbohydrate may be a liquid, semisolid, or solid, and the recommendations may need to be adjusted downward when the absolute exercise intensity is low and thus carbohydrate oxidation rates are also low. Carbohydrate intake advice is independent of body weight as well as training status. Therefore, although these guidelines apply to most athletes, they are highly dependent on the type and duration of activity. These new guidelines may replace the generic existing guidelines for carbohydrate intake during endurance exercise.

Concepts: Photosynthesis, Nutrition, Obesity, Eating, Digestive system, Mouth, Carbohydrate

30

Improving oral health is a leading population health goal; however, curricula preparing health professionals have a dearth of oral health content and clinical experiences. We detail an educational and clinical innovation transitioning the traditional head, ears, eyes, nose, and throat (HEENT) examination to the addition of the teeth, gums, mucosa, tongue, and palate examination (HEENOT) for assessment, diagnosis, and treatment of oral-systemic health. Many New York University nursing, dental, and medical faculty and students have been exposed to interprofessional oral health HEENOT classroom, simulation, and clinical experiences. This was associated with increased dental-primary care referrals. This innovation has potential to build interprofessional oral health workforce capacity that addresses a significant public health issue, increases oral health care access, and improves oral-systemic health across the lifespan. (Am J Public Health. Published online ahead of print January 20, 2015: e1-e5. doi:10.2105/AJPH.2014.302495).

Concepts: Health care, Health economics, Medicine, Public health, Health, Mouth, Population health, Dentistry

28

The early treatment of Class III malocclusion with a protraction facemask can produce forward movement of the maxilla but is generally associated with posterior rotation of the mandible and dentoalveolar compensations. This article shows the dental and skeletal effects of intermaxillary elastics applied to temporary anchorage devices in the treatment of maxillary deficient Class III patients.

Concepts: Mouth, Maxilla, Dental anatomy, Sanskrit, Bones of the head and neck, Dental consonant

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Some fruits and their anthocyanin-rich extracts have been reported to exhibit chemopreventive activity in the oral cavity. Insights regarding oral metabolism of anthocyanins remain limited. Anthocyanin-rich extracts from blueberry, chokeberry, black raspberry, red grape, and strawberry were incubated ex vivo with human saliva from 14 healthy subjects. All anthocyanins were partially degraded in saliva. Degradation of chokeberry anthocyanins in saliva was temperature dependent and decreased by heating saliva to 80 °C and after removal of cells. Glycosides of delphinidin and petunidin were more susceptible to degradation than those of cyanidin, pelargonidin, peonidin and malvidin in both intact and artificial saliva. Stability of di- and tri-saccharide conjugates of anthocyanidins slightly, but significantly, exceeded that of monosaccharide compounds. Ex vivo degradation of anthocyanins in saliva was significantly decreased after oral rinsing with antibacterial chlorhexidine. These results suggest that anthocyanin degradation in the mouth is structure-dependent and largely mediated by oral microbiota.

Concepts: Mouth, Fruit, Anthocyanin, Raspberry, Rubus occidentalis, Anthocyanidin, Petunidin, Anthocyanidins

28

Sturge-Weber syndrome is a nonhereditary congenital condition characterized by leptomeningeal and facial skin angiomatous malformation following the trigeminal nerve path. The intraoral angiomatosis are presented in 40% of cases and results in an important periodontal alteration, increasing the risk of bleeding during dental procedures. A 43-year-old male patient presented with port wine stain on the right side of the face, the entire hard and soft palates, the alveolar ridge, and buccal mucosa, and had an excessive accumulation of calcified masses in both supragingival and subgingival sites, with swelling and generalized inflammation throughout the gingiva and alveolar mucosa. He reported not having sanitized the area for years for fear of bleeding. Periodontal management, to remove calculus and to control gingivitis initiated in the supragingival region and gradually reaching the subgingival region to control oral microbiota, was performed with mild bleeding. The redness of the staining greatly diminished with time and the extreme halitosis of the patient also improved sharply leading to a dramatic improvement in quality of life. Ambulatory care is a feasible alternative for periodontal management that within safety limits for bleeding risks reduces the operational cost.

Concepts: Mouth, Gingiva, Periodontitis, Port-wine stain, Sturge-Weber syndrome, Frederick Parkes Weber, William Allen Sturge, Phakomatoses

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OBJECTIVE: To compare lingual and buccal mucosa graft urethroplasty for anterior urethral stricture with respect to intraoperative, postoperative parameters and urethroplasty outcome. METHODS: From January 2011 to December 2011, a total of 30 patients with anterior urethral stricture whereas group 2 underwent dorsal onlay buccal mucosa graft urethroplasty. Patients were evaluated for postoperative, tongue protrusion, oral opening, and difficulty in speech and swallowing pain score. Surgical outcome was evaluated with pre- and postoperative work-up involving retrograde urethrogram, uroflow and urethroscopy. RESULTS: Mean age, stricture length and overall pain score were comparable in two groups. All the patients were mostly pain free by postoperative day 7. Group 1 patients had significant difficulty in speech and delayed return to normal diet as compared with group 2. The group 2 patients had a significant reduction in oral opening for the first week after surgery. In group 1, approximately 20% patients (with bilateral lingual grafts and stricture length >7 cm) complained of a change in speech character with restricted tongue movement in the long term, whereas there was no significant long-term morbidity in group 2. At mean follow up of 14.5 months, urethroplasty outcome was comparable in the two groups with one failure in group 1, and two failures in group 2. CONCLUSION: Lingual mucosa graft urethroplasty provides outcomes equivalent to those of buccal mucosa graft urethroplasty. Postoperative morbidity and long-term change in speech make it a second choice for strictures >7 cm, only for cases where buccal mucosa graft is unavailable.

Concepts: Mouth, Term, Urethral stricture, Tongue, Lingual nerve, Buccal mucosa, Urethroplasty

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OBJECTIVE: The mechanism for tooth extraction induced residual alveolar ridge reduction (RRR) during adolescence is poorly understood. This study investigated the alveolar bone morphology, growth, resorption and functional loading at normal and extraction sites using an adolescent pig model. DESIGN: Sixteen 3-month-old pigs were divided into two groups - immediate post-extraction (IE) and 6-week post-extraction (SE). The IE group received an extraction of one deciduous mandibular molar, immediately followed by a final experiment to record masseter muscle EMGs and strains from the buccal surface of the extraction and contralateral non-extraction sites during function (mastication). The SE group was given the same tooth extraction, then kept for 6 weeks before the same final functional recording as the IE group. Both groups also received baseline (pre-extraction) EMGs and fluorescent vital stains 10 and 3 days before the final functional recording. Immediately after the final functional recording, animals were euthanized and alveolar bone specimens from extraction and contralateral non-extraction sites were collected and used to analyse alveolar bone morphology, apposition and resorption based on fluorescent and hematoxylin and eosin stained histological sections. RESULTS: At control sites (IE-extraction, IE-non-extraction and SE-non-extraction), the alveolar ridges grew gingivally and buccally. Bone formation characterized the buccal surface and lingual bundle bone, whereas resorption characterized the lingual surface and buccal bundle bone. The SE-extraction sites showed three major alterations: convergence of the buccal and lingual gingival crests, loss of apposition on the lingual bundle bone, and decelerated growth at the entire buccal surface. These alterations likely resulted from redirected crestal growth as part of the socket healing process, loss of tongue pressure to the lingual side of the teeth which normally provides mechanical stimulation for dental arch expansion, and masticatory underloading during the initial post-extraction period, respectively. CONCLUSIONS: These data indicate that the initial phase of RRR in adolescents is a product of modified growth, not resorption, possibly because of decreased mechanical stimulation at the extraction site.

Concepts: Mouth, Anatomy, Adolescence, Teeth, Mandibular nerve, Tongue, Dental anatomy, Dental alveolus

26

Mouth rinsing with a CHO solution has been suggested to improve short (<1 h) endurance performance through central effect. We examined the effects of mouth rinsing with a CHO solution on running time to exhaustion on a treadmill. Six well-trained subjects ran to exhaustion at 85% VO2max , on three separate occasions. Subjects received either an 8% CHO solution or a placebo (PLA) every 15 min to mouth rinse (MR) or a 6% CHO solution to ingest (ING). Treatments were assigned in a randomized, counterbalanced fashion, with the mouth-rinsing treatments double-blinded. Blood samples were taken to assess glucose (Glu) and lactate (Lac), as well as the perceived exertion (RPE). Gas exchange and heart rate (HR) were collected during all trials. Subjects ran longer (P = 0·038) in both the MR (2583 ± 686 s) and ING (2625 ± 804 s) trials, compared to PLA (1935 ± 809 s), covering a greater distance (MR 9685 ± 3511·62 m; ING 9855 ± 4118·62; PLA 7295 ± 3727 m). RER was significantly higher in both ING and MR versus PLA. No difference among trials was observed for other metabolic or cardiovascular variables (VO2 , Lac, Glu, HR), nor for RPE. Endurance capacity, based on time to exhaustion on a treadmill, was improved when either mouth rinsing or ingesting a CHO solution, compared to PLA.

Concepts: Ingestion, Mouth, Exercise physiology, VO2 max, Physical fitness