Iris Publishers- Open access Journal of Online Journal of Dentistry & Oral Health | Method of Diagnosis and Treatment of Impacted Teeth on the Upper Jaw

 

Authored by MA Postnikov*,

Abstract

Aim: The aim is to increase the effectiveness of diagnosis and comprehensive treatment of patients with impacted incisors and canines on the maxilla.

Objectives: To develop and propose a new technique for determining the topography of impacted teeth (incisors and canines) on the maxilla, using the highly informative data of cone-beam computed tomography; to apply a new method of diagnosis in the planning of comprehensive orthodontic treatment of patients with impacted teeth; to introduce this method into the clinical practice of orthodontist.

Materials and methods: To obtain a three-dimensional image, the X-ray device “Planmeca Pro Max 3D Mid” with «Planmeca Romexis»-the software for saving, viewing and changing images was used. To build and conduct measurements on the image the program “Dolphin Imaging” (3D Surgery and Ceph Tracing) (USA) was used. A computed tomogram of patient was used to determine the levels of location of impacted teeth and angles of their longitudinal axes inclination in three mutually perpendicular planes according to the proposed technique.

Results and summary: A technique of determining the spatial location of the frontal impacted teeth on the maxilla was developed and introduced into practice of the orthodontist, using data from cone-beam computed tomography. The proposed method allows to determine the level of location and degree of its inclination, that is very important for planning comprehensive orthodontic and surgical treatment of patients with impacted teeth.

Keywords: Impacted teeth; Diagnosis; Orthopantomography; Cone beam computed tomography; Comprehensive orthodontic treatment

Relevance

Diagnosis and treatment of patients with impaction of permanent teeth is one of the urgent problems of modern dentistry due to morphological, functional and aesthetic changes that occur in case of absence of a tooth in the dentition, which leads to violation of the social adaptation of the individual. Today, tooth impaction is a fairly common anomaly of the maxillofacial system: for 100 children seeking orthodontic care, 15-20 have malocclusion complicated by the impaction of one or more teeth (Budkova TS, Zhigurt Yu I, Khoroshilkina FI, 1997). The front teeth of the upper jaw are more often impacted: Central incisors and canines-61.6% (Stepanov GV, 2008).

In classical cases of treatment of patients with impacted teeth, traditional orthodontic treatment should be chosen [1,2,3]. However, in cases when the impacted tooth has an anomaly of location, improper inclination or unfavorable individual anatomical features, undoubtedly, combined surgical and orthodontic treatment is preferable [2,4,5]. It is here that the determination of the exact location of the retained tooth is especially important. When teething is delayed, X-ray examination methods are fundamental both in the diagnosis and in the treatment planning.

There are some methods of determining the location levels of impacted anterior teeth. The most common and generally accepted is the method proposed by Yu I Zhigurt [6]. The study of the impacted teeth location conducts using orthopantomogram of jaws, where 4 levels of location the impacted upper incisors and canines are determined. At the orthopantomogram we draw a median line, which coincides with the median plane. Then, 2 horizontal lines are drawn perpendicular to the median plane: one-through the point of the prostion, the second-through the point of the anterior nasal spine. The vertical distance between these lines is divided into 4 equal parts and horizontal lines are drawn through the obtained points. The first level of tooth location is between the two lower lines, the fourth is between the two upper lines, the second and third are in the middle [6].

Method of Yu I Zhigurt [6] can also be used to measure the angle of inclination of the impacted teeth: the mid-sagittal plane is drawn on the orthopantomogram through the middle of the vomer and the anterior nasal spine. Then we draw a horizontal plane perpendicularly to level of incisal surface of the permanent central incisors of the upper jaw. Angles of inclination of the longitudinal axes of impacted teeth located in the anterior part of the dentition (upper internal angles) are determined relative to this plane. Three degrees of inclination of the longitudinal axes of the impacted teeth were determined: 1 degree-up to 105°, 2 degree-105-120°, 3 degree-more than 120° [6].

Despite the popularity among orthodontists, this method has a number of significant drawbacks. It is impossible to reliably determine the position and placement of the elements of the upper and lower jaw at the orthopantomogram, including teeth, since the anatomical structures are deformed due to the layering them on each other. It was also established that the true vertical and horizontal linear dimensions of teeth and jaws are significantly distorted at the orthopantomogram. As a result, it becomes impossible to determine the overall magnification of the image. In addition, at the orthopantomogram we perform a slice at a certain depth, therefore, the image of impacted teeth located not in the center of the alveolar bone can be either enlarged or reduced (Khoroshilkina F Ya, 2006). All of the above allows us to say that this method is not sufficiently informative and does not allow us to accurately assess the location of impacted tooth in the jaw [7].

Aim of study

increase the efficiency of diagnostics and comprehensive treatment of patients with impacted teeth by creating a new method of determining the location of impacted maxillary incisors and canines, using cone beam computed tomography.

Materials and Methods of Study

The development of method of diagnosis and comprehensive treatment of patients with impacted maxillary incisors and canines was carried out at the department of postgraduate dentistry of Samara state medical university. 12 computed tomograms of 6 patients with impacted maxillary teeth were obtained and studied. Each patient corresponded to 2 three-dimensional images, one of which was used to study the level of location, and the second oneto determine the angle of inclination of the tooth longitudinal axis.

We used x-ray unit «Planmeca ProMax 3DMid» for cone-beam computed tomography. We used computer graphics software «Planmeca Romexis» to work with the x-ray images. After performing a CBCT in the area of the impacted tooth, an X-ray image was obtained in three planes: coronary-left upper corner, axial-left lower corner, sagittal-right upper corner, and volumetric imageright lower corner, which allows you to determine the current orientation X, Y and Z planes and current image scale. There is a toolbar on the right. A rectangular coordinate system was displayed in the window of each slice, with the help of which the parameters of the impacted tooth and its location in the jaw were measured [8].

We used the 3D module of the Dolphin Imaging computer program (USA) to determine the level of location of the impacted teeth and to take measurements on the obtained image. The method we have proposed includes determining the location of levels of the impacted maxillary frontal teeth (incisors, canines) according to cone beam computed tomography. We draw two horizontal lines on the patient’s CT scan: one through the points of Spina nasalis anterior (Sna) and Spina nasalis posterior (Snp), and the second through the apical basis of the upper jaw. We divide the vertical distance between these lines into three equal parts and draw horizontal lines through the resulting points. The first level of tooth location is between two lower lines, the third is between two upper lines, the second is in the middle (Figure 1).

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Iris Publishers- Open access Journal of Online Journal of Dentistry & Oral Health | Emergency Room Utilization for Dental Treatment: the Socioeconomic Impact of Utilizing Emergency Rooms to Treat Non-Traumatic Dental Issues

 

Authored by Darlene G O’Brien*

Introduction

This paper reviews published articles that examine the impact of the utilization of hospital-based emergency room departments, in the United States (U.S.), to treat non-traumatic dental issues. Research has shown that oral health not only has an impact on one’s systemic health but also on quality of life and economic productivity [1-3]. Most dental conditions such as dental caries, pulpal lesions or periodontal conditions can be treated routinely in a private practice or a clinic-based setting. If left untreated, these conditions can develop into more serious conditions and could even result in death [4]. Studies have shown that the usage of emergency rooms (ERs) for non-traumatic dental care has continued to increase since 2001 [5-8]. Although the Affordable Care Act (ACA) has increased access to care for some populations, disparities remain.

In addition, oral health disparities are on the rise in this country, when it comes to minorities, the poor and populations, who lack health insurance or have a greater rate of dental disease [9]. An understanding of the causes behind this increase of ER usage and its effects is crucial in the development of initiatives to improve access to care, promote preventative care and avoid the use of valuable hospital resources for nonemergency dental treatment. This paper explores the disparities in access to dental care that has led to the increase of ER usage, the impact of these disparities on our population, as well as, the economic impact on the U.S. healthcare system from the use of ERs for the treatment of non-traumatic dental issues.

Literature Review

In a qualitative study by Gift et al. [1] the results from a National Health Interview Survey were analyzed and it was found that in 1989, 164 million hours of work were missed by employed participants as a result of dental visits or issues. Females, blacks and adults aged 17-24 missed the greatest amount of time. Those who lacked dental insurance, were less educated and had a lower income were more likely to have missed work. Those in higher social classes making more money lost significantly less work hours than service workers. Nationwide, 51million hours of school were also missed, as a result of dental visits or oral problems. The most school hours were missed by females, Hispanics, participants with lower income and those without dental insurance.

In addition, a total of 41 million restricted activity days were reported for all ages nationwide with the more disadvantaged socioeconomic groups, participants lacking dental insurance and those with less than 12 years education having the most restricted activity days. Gift et al. noted that this study indicates the burden of lost work/wages, school and activity is higher in populations with low economic status and lack of insurance. Gift et al. [1], MacDougall [2] noted that a lack of dental care for people living in poverty may lead to a lower rate of employability related to missing teeth or dental deformities resulting in a further need for public assistance. Several of the studies reviewed showed a correlation between Medicaid recipients or those who lacked dental insurance and an increase in ER usage to treat non-traumatic dental problems. In a national study conducted from 2008-2010, data was collected from the Nationwide Emergency Department Sample. It was found that almost 71% of all ER visits, involving dental related issues, were from people living in low income areas. In addition, 40.5% of these visits were made involved patients without any dental insurance and an additional 30% were covered by Medicaid [9].

In a three-year pediatric study by Hom et al. [6], data was collected from 110 hospitals in North Carolina. Medicaid was the source of payment 62 % of the time, making it the most common form of reimbursement, in this study, each year [6]. In a 2010 study, Davis et al. [10] looked at data from seven hospitals in the Minneapolis-St. Paul metropolitan area in Minnesota. They also found that the majority of the participants in the study, who utilized the ER for non-traumatic dental issues were on public assistance, such as Medicaid or SCHIP. However, a substantial amount of visits was also coded as self-pay indicating that patients lacked dental insurance. The majority of patients utilizing the ER to treat nontraumatic dental issues were between the ages of 20 and 50. It was noted that these results reflected similar results from other studies [10]. An increase in utilization of the ER to treat nontraumatic dental problems was also seen in a 2010 New Hampshire study. Data was analyzed from the New Hampshire Emergency Department Hospital Discharge and it was found that 15-44-yearold persons were the most likely to seek dental treatment in the ER and self- pay was indicated as the major primary payer [5].

Concern about the lack of definitive care received by patients seeking non-traumatic dental care in the ER was mentioned in multiple studies that were reviewed. In the study by Anderson et al. [5], it was noted that the hospitals were not sufficiently equipped to treat non traumatic dental issues, nor did they have the staff to provide definitive dental care. The study indicated that this was an inappropriate use of hospital resources and patients who were treated in an ER setting would not necessarily receive follow up care. Without follow up treatment, the condition would likely become more serious since dental conditions are not typically selflimiting. Anderson et al. [5], Davis et al. [10] found that about 20% of the participants had between 2-11 dental related visits to the ER. Although they couldn’t determine if the patients were returning for the same dental problem, they felt this was a result of the inability of the ER to provide definitive care. Patients needed to return to the ER due to the lack of follow treatment after the initial visit or a progression of untreated underlying dental disease [10].

In a 2015 study by Okunseri et al. [7], data was analyzed from the National Hospital Ambulatory Medical Care Survey for 2007- 2010. This is a survey of emergency and outpatient departments in hospitals throughout the 50 states. The focus of this study was to determine the rate of prescription of opiods for patients who present in the ER for non-traumatic dental issues. This study found that 50.3 percent of the patients, who presented with non-traumatic dental issues, were given an opiod prescription. The authors noted their concern that this was because ERs cannot provide routine dental care and provide definitive dental care for someone who presents with a toothache and is in need of an extraction or endodontic treatment to relieve the pain. Rather, the patient is treated with palliative care and typically receives an antibiotic and painkillers. Okusari et al. [7], Sun et al. [8] conducted a mixed-methods study, which included both quantitative and qualitative components that reflected similar sentiments.

In the quantitative portion of this study, ER claims data were obtained from 45 Oregon hospitals as well as the Oregon All Payer All Claims file. All ER visits in 2010 were included. A total of 15,081 patients were seen for non-traumatic dental issues and dental problems were the 12th most common ER diagnosis category. The study found that dental procedures were rarely performed and opoid analgesics were dispensed to 56 % of the patients. In addition, it was found that more than 25 % of these patients had more than 1 ER dental visit and 21 % had 2-4 ER dental visits. In the qualitative portion of this study, 17 ER dental visitors were interviewed. Participants indicated that they were unable to pay for treatment at a dental office and so they sought treatment at the ER instead. Frustration was expressed over the lack of definitive care provided at the ER and that they were then referred back to a dentist for treatment they couldn’t afford, leading to a vicious cycle. ER department providers and community dentists were also interviewed. They were in agreement that the care provided in ERs is palliative. Concern was expressed over the return visits to the ER and repeat prescriptions for pain medication [8].

The cost effectiveness of using the ER to treat non-traumatic dental issues was raised in some of the studies reviewed. Singhal et al. [3] conducted an interrupted time series study with controlled variables. The target population was people 21 or older, who were enrolled in Medicaid, during 2006-2011. The objective of the study was to examine the impact of the elimination of dental coverage for adults on Medicaid, in California. During this time period, 113,309 Medicaid adult enrollees visited the ER for dental problems. After the elimination of Medicaid adult dental benefits, there was 32.3 % increase in ER dental visits by this group. As a result, this increased the average that California Medicaid program spent by an additional 1.25 million for ER visits. Although this represents a 66-million-dollar savings for the state, the authors noted that the additional ER costs did not represent a resolution to the dental problem which would likely incur more costs. In addition, costs of hospital admissions, physician visits, loss of productivity and quality of life should be considered [3]. A PEW Trust study found that the average cost of a Medicaid enrollee’s inpatient hospital care for the treatment of dental issue far exceeds what it would cost for preventative treatment received in a dental office by nearly ten times. MacDougall [2], Davis et al [10] found that the cumulative charges by 5 Minnesota hospitals in a one-year period equaled 4,743,519 dollars. The authors noted that many of these charges were associated with visits that were avoidable or a result of incomplete treatment and a lack of follow up care resulting in repeat ER visits [10].

Strengths and Limitations of the Literature

The majority of the research reviewed involved a retrospective analysis of data collected from multiple databases which means that causality could not be proven. Sun et al. [8] provided us some insight into causality but the cohort, for the qualitative portion of their study was small. The data collected from ERs was helpful in establishing the reasons for ER visits, but it usually involved dental diagnoses codes that were entered by ER physicians. Since “unspecified teeth and supporting structures” tended to be the most common diagnosis in all of the studies, which analyzed these codes, this leaves open the possibility of misclassification bias. Several of the studies, that were reviewed, looked at ER visits on a statewide level and therefore cannot be used to predict nationwide trends. However, when comparing these studies, they all tended to have similar results and conclusions, indicating national trends and strengthening the validity of their findings.

The full scope of the economic impact on this country is unclear. The costs of treatment from all nontraditional venues that are used to treat non-traumatic dental issues must be taken into consideration along with the impact on productivity and the quality of life. In Addition, further research needs to be done on this topic to determine specific barriers that result in the use of the ER for dental care as well as to establish the success or lack of success of interventions.

US Healthcare System Implications

The US government needs to consider the implications of the access to care issue in this country and take further action to reduce barriers to oral healthcare. Because oral health is an integral part of systemic health, barriers to care have the potential to affect the quality of life and economic productivity of US citizens. Additionally, usage of the ER for non-emergency dental treatment is a costing millions per year and is not an efficient utilization of a hospital’s resources. Preventative programs should be at the heart of any initiative taken. Dental disease is largely preventable and should not escalate into an urgent care issue. School based programs are key and certainly, at risk populations should be targeted. Increasing dental knowledge regarding the importance of oral health, preventative care and how to access care is particularly important in at risk populations. I believe it would be helpful for hospitals to pair with dental schools, as an externship site, to include dental professionals on hospital staff. Unfortunately, this could be difficult for some hospitals due to their geographic location. All hospitals should develop a relationship with local dental clinics or other dental resources so that patients can be referred for more definitive treatment. It would also be helpful for emergency room staff to be familiar with their state’s Medicaid coverage in order to facilitate the referral of patients to receive definitive dental treatment. Medicaid benefits for adults should be expanded nationwide but provider availability must be addressed. Reimbursement for Medicaid providers should be increased to address the access to care issue due to limited providers. Finally, if legislation that supports the role of midlevel dental providers is implemented in every state, it would increase access to care by increasing dental providers that except Medicaid and providing more financially feasible treatment for the uninsured.

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Iris Publishers- Open access Journal of Online Journal of Cardiology Research & Reports | Can Hypercholesterolemia Alter Euroscore II Predictivity in Smokers?

 

Authored by Tania Leme da Rocha Martinez*

Abstract

Although EUROSCORE II is a strong predictor of mortality, it is not completely exact. The literature presents several examples in which this parameter collaborates, but does not provide conclusive predictability. From a database of 950 adult patients and of both sexes from an Intensive Care Unit of a large tertiary hospital, smokers were selected, classified according to exposure levels, in a number of 81 in total. A regression was then performed using a linear model of least squares. Controlled variables: gender, age, diabetes, hypertension, body mass index and primary or secondary prevention. Formula EUROSCORE II in smoking patients presented associations with cholesterol and hypertension levels, which, according to statistical analysis, were not confounding factors.

Keywords: EUROSCORE II; Risk models; Mortality; Cardiac surgery; Cholesterol; Diabetes; Hypertension; Smokers

Introduction

The explanation of the value of EUROSCORE II to the patient at the time of his surgical indication meets an ethical need for bilateral decision-making in the patient doctor relationship. This procedure opens the opportunity for greater effectiveness of awareness regarding the control of modifiable cardiovascular risk factors. The justification for this conduct can be evaluated based on statistical estimates of Intensive Care Unit databases.

Euroscore II

1. Program for evaluation of operative risk in patients who will undergo cardiac surgery.

2. Parameters analyzed:

a) Age; gender (male or female); Creatinine clearance (> 85, between 51 and 85, < 51, dialysis patient; extracardiac arteriopathy, mobility deficit; previous cardiac surgery;

b) Chronic lung disease; endocarditis in activity; critical preoperative status; insulin-dependent diabetes; NYHA classification; class IV angina; ejection fraction (< 21, between 21 and 30; between 31 and 50, > 50); recent myocardial infarction; systolic pressure (<31, between 31 and 55, > 55); urgency (whether elective, urgent, emerging or desperate); thoracic aortic surgery; nature of the intervention (1 isolated revascularization, > 2 revascularizations, revascularization and valve surgery or left ventricle aneurysm) [1-6].

Objective

To study the possible effect of hypercholesterolemia and other modifiable major risk factors in patients already with one of them, in this case smoking, on the value of Euroscore II.

Methods

From a database of 950 adult patients and of both sexes of an Intensive Care Unit of a large tertiary hospital, smokers were selected, classified according to exposure levels, in number of 81 in total. A regression was then performed using a linear model of least squares to estimate the effects of hypercholesterolemia on EUROSCORE II, controlling for a series of variables such as gender, age, diabetes, hypertension, body mass index and primary or secondary prevention.

Results and Discussion

The data indicated by the regression had a significant effect on THE EUROSCORE II of the following variables, in the order of significance: hypercholesterolemia has, on average, and controlling by the other variables, 7.5 more than EUROSCORE II. That is, approximately 30% more on average. Hypertension also presented a variation of 3.69 points, equivalent to 14%. The only significant differences in EUROSCORE II when controlled by the other variables were in relation to gender (men have a EUROSCORE 3.54 lower than women), age (an increase of 0.27 Euroscore II for each year more of life). The other variables were not significant at a level of 0.05, even when considering the types of exposure to smoking [7,8].

Conclusion

There is a deleterious effect that can be added to the smokers EUROSCORE II values by the concomitance of Hypercholesterolemia or by Hypertension.

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Iris Publishers- Open access Journal of Online Journal of Cardiology Research & Reports | Hypotensive Potential of Desmodium Adscendens on Cardiovascular Functions

 

Authored by Seriki SA*

Abstract

Background: Desmodium adscendens is one of the medicinal herbs used in the management of some medical conditions in recent times. The current study investigates the effects of aqueous leave extract of Desmodium adscendens on the serum levels of Sodium, Chloride, Potassium, and Bicarbonate ions, and the implication on cardiovascular function in healthy wistar rats.

Method: Twenty-four (24) wistar rats grouped into four (n=6) were used for the research. Group 1 served as control, while Groups 2, 3, and 4 were treated orally with low, median and high doses of the extract of D adscendens for four weeks, after which blood was collected separately from each group and the serum level of the electrolyte determined by appropriate methods and comparison made with the control group and among the groups.

Results: There was significant decrease (P < 0.05) in serum concentration of Sodium, Chloride and Bicarbonate ions, and significant increase in Potassium ion concentration.

Conclusions: The significant decrease in serum concentration of Na+, Cl-, HCO3- and significant decrease indicate that the extract has the potential to lower blood pressure, and that may be attributed to the active phytochemical constituents present in the leave. Therefore D. adscendens leaf has beneficial hypotensive potential on cardiovascular functions.

Keywords: Serum electrolytes; Hypotensive potentials; Cardiovascular function; Desmodium adscendens

Introduction

Traditional Medicines have over time given alternatives to conventional and orthodox medicines in the treatment of many conditions at more affordable rates, especially to poor rural populace in developing nations. They are also readily available to the larger population living in the rural settlements [1].

Desmodium adscendens

Desmodium adscendens is one among such useful medicinal plants that have recently gained the attention of many researchers. Previous studies have revealed Desmodium adscendens that has been traditionally used by the locals in managing medical conditions such as: muscle cramp, tendon, spinal pain, bronchitis, epilepsy and some central nervous system disorders, among many others [2]. The herb is of the Family - “Fabaceae”; and genus - Desmodium. It is often described in English as Beggar- lice or Tick Clover [2].

Serum electrolytes

Serum electrolytes are salts and minerals, such as sodium, potassium, chloride calcium and bicarbonate, which are found in the blood, and conduct electrical impulses in the body. They could be higher or lower than the normal level it should be in the blood, sometimes resulting in serious health conditions. An electrolyte test can help determine whether or not an electrolyte imbalance exists in the body. It is among the most commonly used laboratory tests for assessment of a patient’s clinical conditions and disease states, because electrolyte balance in the body is essential for normal functioning of cells & organs [1]. Electrolyte disorders are common complications frequently seen in patients with heart failure, seizures, and coma. They occur when serum electrolytes concentrations are either too high or too low. Their concentrations need to be balanced for the body to function properly [3]. The imbalance may result from pathological alterations leading to stimulation of the renin-angiotensin-aldosterone system (RAAS), sympathoadrenergic stimulation, a neurohormonal activation, and sometimes, cardiac glycosides or ACE inhibitors [3].

Sodium ion

The most available cation in the extracellular fluid is sodium. It plays a very important role in regulating water balance in the body. Its normal serum level ranges from 130 to 145 mmol/L. Antidiuretic hormone (ADH), also known as arginine vasopressin is a non-peptide hormone that regulates renal handling of free water. Alteration of the amount of water reabsorbed by the kidney has an important effect on serum sodium concentration. ADH is secreted by the neurons in the supra-optic and paraventricular nuclei of the hypothalamus, and its release is stimulated by hypovolemia, thirst, increased serum osmolality, and angiotensin II [4]. In the renin-angiotensin-aldosterone system, renin from the juxtaglomerumar apparatus of the kidney catalyzes the conversion of angiotensinogen in the liver to angiotensin I, which is further converted to angiotensin II (in the lungs) by Angiotensin converting Enzyme (ACE) [5]. Angiotensin II, which is a vasoconstrictor enhances optimal perfusion pressure to end organs, especially when plasma volume is decreased. It also induces the release of aldosterone, ADH and cortisol. Aldosterone is a hormone released from the adrenal cortex of the kidneys with mineralocorticoidal actions, which affects the distal tubular reabsorption and retention of sodium rather than water [6].

Potassium ions

Potassium represents an important ion of the human body. About 98% of the body’s potassium pool is present in the intracellular compartment, leading to a steep potassium concentration gradient across cellular membranes, indicating why potassium is particularly important to maintain the cellular membrane potential. It regulates the heartbeat and function of muscles. Normal serum potassium level = 3.5-5.0 m Eq/L. Potassium, along with sodium is involved with regulation of water and acid-base balance in blood and tissue [7]. In mammals, the osmotic pressure and water distribution maintenance is the primary function of electrolytes like sodium and potassium. In addition, they play a role in maintenance of pH, in oxidation reduction reactions, in heart muscle functioning and as co-factors for enzymes [6]. The body has two mechanisms to restore potassium balance when the serum potassium level goes up: by shifting the plasma potassium into cells, and by renal elimination [8].

Chloride ion

The chloride ion is the principal extracellular anion in humans with a concentration of about 95-110 mmol/L. It is passively absorbed from the upper small intestine and primarily regulated by the renal proximal tubules, where it is exchanged for bicarbonate ions. and passively follows sodium and water through during renal tubular reabsorption by the nephron [8]. Homeostatic mechanisms indirectly regulate Chloride ion through changes in sodium and bicarbonate. Being an anion, Sodium will balance out positive charges in the extracellular fluid, and by passively following sodium, it helps to maintain extracellular osmolality.

Bicarbonate ion

Bicarbonate ion is an intermediate form in the deprotonation of carbonic acid. It is a polyatomic anion with the chemical formula HCO3-. It serves a crucial biochemical role in the physiological pH buffering system [8]. Bicarbonate (HCO−3) is a vital component of the pH buffering system [9] of the human body (maintaining acid– base homeostasis). 70%–75% of CO2 in the body is converted into carbonic acid (H2CO3CO), which is the conjugate acid of HCO−3 and can quickly turn into it.

With carbonic acid as the central intermediate species, bicarbonate, in conjunction with water, hydrogen ions, and carbon dioxide – forms the buffering system, which is maintained at the volatile equilibrium [9] required to provide prompt resistance to pH changes in both the acidic and basic directions. This is especially important for protecting tissues of the central nervous system, where pH changes too far outside of the normal range in either direction could prove disastrous. A higher serum bicarbonate concentration is associated with higher left ventricular mass, higher aortic pulse pressure and a higher risk of heart failure among nonusers of diuretics [10].

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Iris Publishers- Open access Journal of Online Journal of Complementary & Alternative Medicine | The Health Implications of Plastic Bioaccumulation and The Potential to Enhance Biotransformation Using Herbal Medicine and Nutritional Supplements

Authored by Carina Harkin*

Abstract

Plastic is ubiquitous with recent studies having highlighted that plastic is in bottled and tap water and food products including honey, sugar and beer. 3-10 tonnes are estimated to fall on Paris per year. Plastic has recently been shown to be a vector for heavy metal contamination and to cross the blood–brain barrier (BBB). Global concern regarding the health implications is mounting, with the World Health Organisation (WHO) having conducted a risk assessment review of plastics. Whilst knowledge gaps exist, we remain to eat, drink and inhale plastic without knowing what harm it is potentially causing. This paper discusses the scale of global microplastic contamination, the sources and routes of microplastic contamination including inhaling and ingesting plastics, and the potential health implications of plastic bioaccumulation. Research into biotransformation is new and evolving. This paper looks at how plastic is bio transformed and the potential pharmacognostical approaches that have the potential to maximize plastic biotransformation. This paper discusses what is known about how plastic is bio transformed by Phase I cytochrome P450 enzyme group modification and Phase II glutathione, sulphation, glucuronidation and glycine conjugation pathways, and the importance of supporting endogenous antioxidants to assist plastic biotransformation. The paper specifically discusses what is known about how ingested plastics including phthalates and bisphenol A (BPA), and inhaled plastics, including dioxins and furans are bio transformed by these processes and what herbal medicine and nutritional supplementation may maximise plastic biotransformation and address plastic bioaccumulation.

Keywords: Plastic bioaccumulation; Plastic biotransformation; Microplastic; Nano plastic; Microplastics in drinking-water; Microplastic exposure and impacts on human health; Complementary and alternative medicine (CAM); Herbal medicine; Nutritional Supplements; Pharmacognosy

Keywords: Acetyl-Coa: Acetyl Coenzyme A; ALS: Amyotrophic Lateral Sclerosis; ADHD: Attention Deficit Hyperactivity Disorder; BPA: Bisphenol A; BBB: Blood-Brain Barrier; CDG: Caclium D-Glucarate; CAT: Catalase; CDC: Centers For Disease Control And Prevention; CD: Cluster Of Differentiation; CAM: Complementary And Alternative Medicine; Cuzn-SOD: Copper-Zinc SOD; CYP450: Cytochrome P450; DDT: Dichlorodiphenyltrichloroethane; DINP: Diisononyl Phthalate; DIDP: Diisodecyl Phthalate; EDCS: Endocrine Disrupting Chemicals; FSAI: Food Safety Authority Of Ireland; GSH: Glutathione; GPX: Glutathione Peroxidase; GR: Glutathione Reductase; GST: Glutathione S-Transferase; GST Family: Glutathione S-Transferases; GMIT: Galway-Mayo Institute Of Technology; GNRH: Gonadotropin-Releasing Hormone; HSE: Health Service Executive; HPA: Hypothalamic-Pituitary Axis; LGBTQI: Lesbian, Gay, Bisexual, Transgender, Queer Or Questioning And Intersex; BZIP: Leucine Zipper; Mn-SOD: Manganese SOD; MFO: Mixed-Function Oxidase Enzyme; NAC: N-Acetylcysteine; NHANES: National Health And Nutrition Examination Survey; NATS: N-Terminal Acetyltransferases; NDDS: Neurodevelopmental Disorders; NDGS: Neurodegenerative Diseases; NRF2: Nuclear Factor-Erythroid-2-Related Factor 2; PCOS: Polycystic Ovary Syndrome; POPS: Persistent Organic Pollutants; PTS: Persistent Toxic Substances; PAHS: Polycyclic Aromatic Hydrocarbons; PCBS: Polychlorinated Biphenyls; PETE: Polyethylene Terephthalate; SAM-E: S-Adenosyl-L-Methionine; SFN: Sulforaphane; SOD: Superoxide Dismutase; TCR: T-Cell Receptor; TCDD: Tetrachlorodibenzo-P-Dioxin; TEQ: Toxic Equivalent; T2D: Type 2 Diabetes; US: United States; UDP: Uridine Diphosphate; UDPGA: Uridine Diphsphate Glucuronic Acid; UGT: UDP-Glucuronosyltransferase; WHO: World Health Organisation

Background

Plastic is a crude oil product a non-renewable energy source [1]

The largest global consumer of oil is the United States (US) military, consuming 100 million barrels of oil per year [2]. Despite overwhelming evidence of carbon-fuelled climate change and billions in subsidies for alternative technologies, global oil consumption will reach 100 million barrels per day, more than twice what it was 50 years ago, with no sign of abating [3]. The US alone uses 330 million barrels of oil per year in plastics production alone, [4] three times the US military use.

The scale of microplastic contamination is staggering

An estimated 8 million tons of plastic enters our oceans each year. Microplastics are omnipresent in marine waters, from deep ocean sediments to polar icecaps [5].

Microplastics contain and absorb toxic chemicals

Microplastics are a vector for heavy metal contamination from the marine environment [6,7]. Microplastics attract harmful pathogenic bacteria in sewage and contain and absorb toxic chemicals. More than 50 persistent organic pollutants (POPs), specifically polychlorinated biphenyls (PCBs) and polycyclic aromatic hydrocarbons (PAHs) are found in the five most common types of plastic [8]. POPs are also called persistent toxic substances (PTS) [9].

Plastic in Tap Water Globally

Billions of people are drinking water contaminated by plastic particles with 83% of samples found to be polluted. The US had highest contamination rate, at 94%, with plastic fibres found in tap water at Congress buildings, ironically the US EPA headquarters and Trump Tower in New York. Lebanon and India had next highest rates. European nations including UK, Germany and France had lowest contamination rate at 72%. The average number of fibres found in each 500ml sample ranged from 4.8 in the US to 1.9 in Europe [10,11]. An Irish study (June 2017) found microplastic contamination in a handful of tap water and well samples “We don’t know what the health impact is and we should follow the precautionary principle so we can find out what the real risks are,” said Dr Anne Marie Mahon at the Galway-Mayo Institute of Technology (GMIT) [12]

Plastic in Bottled Water Globally

The Orb study (Orb Media U.S-based non-profit journalism organisation) tested 259 bottles from 19 locations in 9 countries across 11 different brands were found to contain on average 325 plastic pieces for every liter of water. Scientists used Nile red dye to fluoresce plastic particles in the water, developed by Dr Andrew Mayes, University of East Anglia scientist. Nestlé Pure Life was worst offender; concentrations as high as 10,000 plastic pieces per liter. Of 259 bottles tested, only 17 were plastic free [13]. The contamination is said to be partially coming from packaging and/ or bottling process [14]. The most common plastic fragment was polypropylene plastic used to make bottle caps. Polypropylene is number 5 in triangle and considered safe. The study was not published in a journal, nor has been peer reviewed. A second unrelated Story of Stuff Study examined 19 bottled water brands in the US, also found plastic microfibers were widespread. Plastic fibers in bottled water brands are twice as high as those found in tap water [15]. See (Appendix) for brands Orb Media and Story of Stuff tested.

Plastic Water Bottles

Plastic water bottles are made from polyethylene terephthalate (PETE recycling code 1). This symbol is normally also found in soft drinks. PETE does not contain BPA/Phthalates, but studies find the endocrine disrupting chemical (EDC) antimony, a toxic phthalate ‘plasticiser’ used to make plastics flexible, leaches from PET bottles placed in heat for prolonged periods (16). Reusable plastic drinking water bottles are or more generally now, were made from polycarbonate (recycling code 7). Polycarbonate is made of BPA [17]. Investigations show in some cases, BPA-free PETE containers might leach of estrogen like chemicals [18].

Sources of Environmental Microplastic

Washing acrylic, polyester and nylon

Plastic derived, acrylic, polyester and nylon persist in the environment. Synthetic clothing that ends up in landfill soaks through the land, into the water table and into our drinking water. Alternatively, it ends up in our sea and evaporates into our clouds and back into our drinking water. One truck load of used clothes goes to landfill every second. One truckload of plastic enters the sea every second. By 2050 scientists estimate there will be more plastic in the sea than fish [19]. Acrylics are by far the worst offender. When acrylics are washed in washing machines, the average load of household washing shed 750,000 microplastics per wash, 5 times more than polyester-cotton. When drying synthetics, we are venting microplastic straight into the atmosphere [20, 21].

Burning plastics

Burring plastics releases endocrine disrupting cancer causing dioxins and furans the most toxic chemicals known to humankind [22].

Human sludge

A 2017 study for the Environmental Protection Agency (EPA) co-written by Dr Anne Marie Mahon from the Marine from the Freshwater Research Centre, Galway-Mayo Institute of Technology (GMIT) identified sludge spreading and the washing of plastic by the recycling industry as significant sources of environmental microplastics. It estimated that at least a billion microplastic particles are spread on Irish farmland each year (not all farms acquire and spread sludge) [23].

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