Sensitivity and specificity of the question "do you have any concerns regarding your mouth related to undergoing surgery?" for predicting perioperative oral health problems in patients with primary esophageal and lung cancer: a retrospective observational study.

BACKGROUND: Perioperative oral management contributes to the prevention of dental/systemic complications. However, a professional dental checkup before surgery is generally not performed and relies on the patient's answer to a simple question by medical professionals other than dentists: "Do you have any concerns regarding your mouth related to undergoing surgery?" Here, we evaluated the sensitivity and specificity of this question for predicting perioperative oral health problems in patients with primary esophageal and primary lung cancer. METHODS: We performed an oral cavity check in all patients before scheduled surgery for primary esophageal and lung cancer. A total of 183 patients were enrolled (M, 112; F, 71; 24-88 years, median, 69 years), consisting of 61 with primary esophageal cancer (M, 46; F, 15; 24-85 years, median, 69 years) and 122 with primary lung cancer (M, 66; F; 56; 33-88 years, median, 69 years). All subjects provided a response to this question, and an oral cavity check was performed by dentists. The sensitivity and specificity of this question for detecting oral health problems were evaluated retrospectively. RESULTS: Overall sensitivity and specificity for detecting oral health problems were 0.263 and 0.898, respectively. There were no significant differences by sex or disease (primary esophageal or lung cancer). CONCLUSION: This simple question has low sensitivity but high specificity for detecting oral health problems. Although challenging to detect surgical patients with oral health problems by simply asking questions, the results indicated that patients with oral complaints are more likely to have problems during surgery.

Expanding on the professional role of dental hygienists as key managers of medical-dental and hospital-dental clinic collaboration in a local Japanese hospital without a dentistry department: From a questionnaire survey after a web seminar.

INTRODUCTION: Perioperative oral management (POM) was introduced into the Japanese universal health insurance system in 2012. Collaboration with dental clinics is important for hospitals without a dentistry department. A dental hygienist newly assigned as a member of the patient flow management centre led a seminar to promote collaboration via the web. This study represents the first step to explore the possible role of the hospital-based dental hygienist in the field of regional medical-dental cooperation of POM by assessing their willingness to participate in providing this type of care by a survey. METHODS: The rate of attendees' satisfaction and the current problems of the collaboration for POM were evaluated through a questionnaire survey after the web seminar. RESULTS: All respondents reported satisfaction with the web seminar although it was the first experience of an online seminar for half of the respondents. All hospital dentists, but only 47.8% of dentists working at clinics, had participated in POM. Dental hygienist tended to show greater desire to participate in POM than dentists. All respondents appreciated the role played by the dental hygienist as a key manager of medical-dental collaboration between the hospital and local clinics. CONCLUSION: The hospital-based dental hygienist can play a role in planning and management of web seminars for POM, to raise awareness and promote regional medical-dental cooperation of POM.

J-SUPPORT research policy for oral mucositis associated with cancer treatment.

BACKGROUND: Oral mucositis is one of the main areas of research in supportive and palliative care of cancer patients. However, the methodology of prospective clinical trials on oral mucositis has not been established, despite its uniqueness. Here, we propose a novel research policy on oral mucositis, including an implementable set of recommendations for researchers conducting clinical trials. METHODS: The first draft was developed by an expert panel of six specialists from the Japanese Supportive, Palliative, and Psychosocial Care Study Group. A provisional draft was developed after review by the following medical societies: the Japanese Association of Supportive Care in Cancer, the Japanese Association of Oral Supportive Care in Cancer, the Japanese Cancer Association, and the receipt of public comments. RESULTS: The research policy on oral mucositis mainly consists of the following components: (i) definition of oral mucositis; (ii) characteristics of oral mucositis; (iii) characteristics of oral mucositis research; (iv) target population for oral mucositis research; (v) endpoints and assessment measures in oral mucositis; (vi) eligibility criteria; (vii) research design; (viii) minimally recommended intervention in oral mucositis research as a supplement. The final policy (Ver1.0) was completed on August 16, 2021. CONCLUSIONS: This policy may serve as a significant reference for planning and conducting clinical trials for the management of oral mucositis.

Patients scheduled to undergo esophageal surgery should have the highest priority for perioperative oral management triage: a cross-sectional study.

OBJECTIVES: An increasing number of patients visiting the dental office have a growing need for perioperative oral management (POM) to prevent postoperative complications. Therefore, it is necessary to determine which patients should receive preferential POM. This study investigated the dental status of patients scheduled to undergo surgery and addressed the priority for POM. METHODS: This retrospective study included a total of 150 patients who were scheduled to undergo surgery at the Department of Respiratory Surgery (DRS), Department of Neurological Surgery (DNS), Department of Gynecological Surgery (DGS), Department of Breast and Endocrine Surgery (DBES), and Department of Esophageal Surgery (DES) managed by the Perioperative Management Center of Okayama University Hospital. We compared the general and dental status of patients among the five groups. RESULTS: The DES group had significantly fewer teeth than the DBES group (p = 0.012), more severe periodontitis than both the DBES (p = 0.005) and DNS groups (p = 0.020), and poorer molar occlusal support status than both the DBES (p = 0.002) and DGS groups (p = 0.041). The DES group exhibited a significantly higher median age (p = 0.002), a higher ratio of males (p < 0.001), a higher prevalence of malignant tumors (p < 0.001), and higher proportions of smokers (p < 0.001) and drinkers (p < 0.001) than the other groups. CONCLUSION: Patients who underwent surgery at the DES had more dental problems than other surgery patients. Accordingly, these patients should be given the highest priority for POM triage.

Early intervention of the perioperative multidisciplinary team approach decreases the adverse events during neoadjuvant chemotherapy for esophageal cancer patients.

BACKGROUND: Multidisciplinary team (MDT) approach has become a standard for perioperative patient care, including in esophageal cancer. In our institution, the Perioperative Management Center (PERiO) has been doing an MDT approach for patients undergoing esophageal cancer surgery since 2009. On the other hand, neoadjuvant therapy has also been becoming standard for many malignancies, including esophageal cancer. In Japan, neoadjuvant chemotherapy (NAC) for esophageal cancer is standard now. However, there have been no reports about when is the best time to start the MDT approach for patients with neoadjuvant therapy. In this study, the best start time for the MDT approach for esophageal cancer patients with NAC was examined from the perspective of adverse events during chemotherapy and perioperative period. METHODS: All cases underwent thoracoscopic esophagectomy in the prone position (TEPP) after NAC. The PERiO Intervention group that started before NAC (n = 100) was compared with the PERiO Intervention group that started after NAC (n = 77). Eventually, 54 paired cases were matched by propensity score matching. RESULTS: The adverse event rate during chemotherapy, especially oral complications, was significantly decreased in the PERiO Intervention started before the NAC group (P = 0.007). Furthermore, weight loss during the period from chemotherapy to surgery was significantly reduced in the group that started before NAC (P = 0.033). CONCLUSION: The MDT approach should be started before NAC in patients undergoing esophageal cancer surgery to prevent adverse events during chemotherapy and provide safe perioperative conditions.

A cost-minimization analysis of measures against metallic dental restorations for head and neck radiotherapy.

The aim of this study was to compare the estimated public medical care cost of measures to address metallic dental restorations (MDRs) for head and neck radiotherapy using high-energy mega-voltage X-rays. This was considered a first step to clarify which MDR measure was more cost-effective. We estimated the medical care cost of radiotherapy for two representative MDR measures: (i) with MDR removal or (ii) without MDR removal (non-MDR removal) using magnetic resonance imaging and a spacer. A total of 5520 patients received head and neck radiation therapy in 2018. The mean number of MDRs per person was 4.1 dental crowns and 1.3 dental bridges. The mean cost per person was estimated to be 121 720 yen for MDR removal and 54 940 yen for non-MDR removal. Therefore, the difference in total public medical care cost between MDR removal and non-MDR removal was estimated to be 303 268 800 yen. Our results suggested that non-MDR removal would be more cost-effective than MDR removal for head and neck radiotherapy. In the future, a national survey and cost-effectiveness analysis via a multicenter study are necessary; these investigations should include various outcomes such as the rate of local control, status of oral mucositis, frequency of hospital visits and efforts of the medical professionals.

Systematic review of growth factors and cytokines for the management of oral mucositis in cancer patients and clinical practice guidelines.

PURPOSE: To update the clinical practice guidelines for the use of growth factors and cytokines for the prevention and/or treatment of oral mucositis (OM). METHODS: A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: recommendation, suggestion, and no guideline possible. RESULTS: A total of 15 new papers were identified within the scope of this section and were merged with 51 papers that were reviewed in the previous guidelines update. Of these, 14, 5, 13, 2, and 1 were randomized controlled trials about KGF-1, G-CSF, GM-CSF, EGF, and erythropoietin, respectively. For the remaining agents there were no new RCTs. The previous recommendation for intravenous KGF-1 in patients undergoing autologous hematopoietic stem cell transplantation (HSCT) conditioned with high-dose chemotherapy and TBI-based regimens is confirmed. The previous suggestion against the use of topical GM-CSF for the prevention of OM in the setting of high-dose chemotherapy followed by autologous or allogeneic stem cell transplantation remains unchanged. CONCLUSIONS: Of the growth factors and cytokines studied for the management of OM, the evidence supports a recommendation in favor of KGF-1 and a suggestion against GM-CSF in certain clinical settings.

Efficacy of Oral Care Provided by Interprofessional Collaboration for a Patient with Esophageal Cancer Associated with Post-polio Syndrome during Neoadjuvant Chemotherapy.

Preoperative oral care is helpful to prevent postoperative complications in patients who are undergoing esophagectomy. Here, we report the case of an 81-year-old Japanese man with an upper limb disability caused by post-polio syndrome who was receiving neoadjuvant chemotherapy for esophageal cancer. He had poor oral health status and developed oral complications as a side effect of chemotherapy. He could not brush his teeth by himself. However, infection control by oral care provided by an interprofessional collaboration successfully improved his oral hygiene, and his follow-up involved no severe complications. Interprofessional collaboration is useful especially for patients with upper limb disability.

Unusual oral mucosal microbiota after hematopoietic cell transplantation with glycopeptide antibiotics: potential association with pathophysiology of oral mucositis.

Severe oral mucositis occurs frequently in patients receiving hematopoietic stem cell transplantation (HCT). Oral mucosal bacteria can be associated with progression of oral mucositis, and systemic infection may occur via ulcerative oral mucositis. However, little information is available regarding the oral microbiota after HCT. Here, PCR-denaturing gradient gel electrophoresis (DGGE) was performed to characterize the oral mucosal microbiota, which can be affected by antibiotics, before and after HCT. Sixty reduced-intensity HCT patients were enrolled. Three patients with the least antibiotic use (quinolone prophylaxis and/or ß-lactam monotherapy group) and three patients with the most antibiotic use (ß-lactam-glycopeptide combination therapy group) were selected. Bacterial DNA samples obtained from the oral mucosa before and after HCT were subjected to PCR-DGGE. The trajectory of oral mucositis was evaluated. The oral mucosal microbiota in the ß-lactam-glycopeptide combination therapy group was different from that in the quinolone prophylaxis and/or ß-lactam monotherapy group, and Staphylococcus spp. and Enterococcus spp. were identified. Lautropia mirabilis was dominant in one patient. Ulcerative oral mucositis was observed only in the ß-lactam-glycopeptide combination therapy group. In conclusion, especially with the use of strong antibiotics, such as glycopeptides, the oral mucosal microbiota differed completely from that under normal conditions and consisted of Staphylococcus spp., Enterococcus spp., and unexpectedly L. mirabilis. The normal oral microbiota consists not only of bacteria, but these unexpected bacteria could be involved in the pathophysiology as well as systemic infection via oral mucositis. Our results can be used as the basis for future studies in larger patient populations.

Replacing zoledronic acid with denosumab is a risk factor for developing osteonecrosis of the jaw.

OBJECTIVE: Intravenous zoledronic acid (ZA) is often replaced with subcutaneous denosumab in patients with bone metastatic cancer. Despite their different pharmacologic mechanisms of action, both denosumab and ZA are effective in bone metastasis but cause osteonecrosis of the jaw (ONJ) as a side effect. ZA persists in the body almost indefinitely, whereas denosumab does not persist for long periods. This study evaluated the risks of developing ONJ when replacing ZA with denosumab. STUDY DESIGN: In total, 161 Japanese patients administered ZA for bone metastatic cancer were enrolled in this single-center, retrospective, observational study. The risk of developing ONJ was evaluated by logistic regression analysis using the following factors: age, gender, cancer type, angiogenesis inhibitors, steroids, and replacement of ZA with denosumab. RESULTS: Seventeen patients (10.6%) developed ONJ. Multiple regression analysis indicated a significant difference in rate of ONJ associated with replacement of ZA with denosumab (odds ratio = 3.81; 95% confidence interval 1.04-13.97; P = .043). CONCLUSIONS: Replacing ZA with denosumab is a risk factor for the development of ONJ. Both binding of bisphosphonate to bone and receptor activator of nuclear factor-κ B ligand inhibition could additively increase the risk of ONJ. We bring the replacement of ZA with denosumab to the attention of clinical oncologists.

Prevalence of oral health-related conditions that could trigger accidents for patients with moderate-to-severe dementia.

OBJECTIVE: This study was performed to determine the prevalence of oral health conditions unnoticed by doctors and ward staff that may increase risk of incidents and/or accidents in hospitalised patients with moderate-severe dementia. BACKGROUND DATA DISCUSSING THE PRESENT STATUS OF THE FIELD: Dementia patients may not recognise risks in the mouth, such as tooth mobility or ill-fitting dental prostheses and/or dentures. In addition to the risk of choking, injury by sharp edges of collapsed teeth or prosthodontics could pose risks. However, many previous publications were limited to case reports or series. MATERIALS AND METHODS: Ninety-two consecutive hospitalised dementia patients (M: 52, F: 40, median age: 82.5 years, range: 62-99 years, from 2011 to 2014), referred for dentistry for dysphagia rehabilitation, were enrolled in this study. Participants referred for dental treatment with dental problems detected by ward staff were excluded. All participants had a Global Clinical Dementia Rating Score >2. Their dental records were evaluated retrospectively for issues that may cause incidents and/or accidents. RESULTS: Problems in the mouth, for example tooth stumps, dental caries, and ill-fitting dentures, were detected in 51.1% of participants (47/92). Furthermore, 23.9% (22/92) showed risk factors that could lead to incidents and/or accidents, for example falling out of teeth and/or prosthodontics or injury by sharp edges of teeth and/or prosthodontics. CONCLUSIONS: Hospitalised moderate-severe dementia patients had a high prevalence of oral health conditions unnoticed by doctors and ward staff that may increase risk of incidents and/or accidents.

Perioperative Management Center (PERIO) for Neurosurgical Patients.

Perioperative management is critical for positive neurosurgical outcomes. In order to maintain safe and authentic perioperative management, a perioperative management center (PERIO) was introduced to patients of our Neurosurgery Department beginning in June 2014. PERIO involves a multidisciplinary team consisting of anesthesiologists, dentists/dental hygienists/technicians, nurses, physical therapists, pharmacists, and nutritionists. After neurosurgeons decide on the course of surgery, a preoperative evaluation consisting of blood sampling, electrocardiogram, chest X-ray, and lung function test was performed. The patients then visited the PERIO clinic 7-14 days before surgery. One or two days before surgery, the patients without particular issues enter the hospital and receive a mouth cleaning one day before surgery. After surgery, postoperative support involving eating/swallowing evaluation, rehabilitation, and pain control is provided. The differences in duration from admission to surgery, cancellation of surgery, and postoperative complications between PERIO and non-PERIO groups were examined. Eighty-five patients were enrolled in the PERIO group and 131 patients in the non-PERIO group. The duration from admission to surgery was significantly decreased in the PERIO group (3.6 ± 0.3 days), compared to that in the non-PERIO group (4.7 ± 0.2 days). There was one cancelled surgery in the PERIO group and six in the non-PERIO group. Postoperative complications and the overall hospital stay did not differ between the two groups. The PERIO system decreased the duration from admission to surgery, and it is useful in providing high-quality medical service, although the system should be improved so as not to increase the burden on medical staff.

Incidence and Risk Factors of Osteonecrosis of the Jaw in Advanced Cancer Patients after Treatment with Zoledronic Acid or Denosumab: A Retrospective Cohort Study.

Zoledronic acid and denosumab are two antiresorptive drugs currently in use for treating osteoporosis. They have different mechanisms of action, but both have been shown to delay the onset of skeletal-related events in patients with advanced cancer. However, medication-related osteonecrosis of the jaw (MRONJ) has been reported in cancer patients treated with zoledronic acid or denosumab. We studied 155 patients with several types of advanced cancer who were treated with zoledronic acid or denosumab in our hospital during the period from April 2010 through March 2013. Thirteen of these 155 patients (8.4%) developed MRONJ. MRONJ development was significantly associated with the number of zoledronic acid or denosumab infusions (p<0.001) and the duration of zoledronic acid or denosumab therapy (p<0.001). Logistic regression analysis showed that diabetes [odds ratio (OR)=6.699, 95% confidence interval (CI), 1.435-31.277, p=0.016], anemia [OR=14.559, 95% CI, 2.161-98.069, p=0.006], and pus discharge [OR=6.491, 95% CI, 1.514-27.835, p=0.012] significantly increased the risk of developing MRONJ. However, the risk of MRONJ was significantly lower [OR=0.137, 95% CI, 0.020-0.944, p=0.043] when patients received periodical dentistry maintenance. Diabetes, anemia, and pus discharge may also play roles in its development. These findings suggest that the active inclusion of dentistry maintenance in bisphosphonate or denosumab treatment of cancer patients can reduce MRONJ development.

Detection of Identical Isolates of Enterococcus faecalis from the Blood and Oral Mucosa in a Patient with Infective Endocarditis.

The detection of infective endocarditis (IE) of oral origin has been previously discussed. However, there are few reports confirming this infection using molecular biological techniques. We herein describe the case of a 67-year-old man who developed IE. Blood culture samples and strains obtained from the gingival and buccal mucosa showed 100% identity to Enterococcus faecalis JCM 5803 on sequencing of 16S rRNA gene fragments. A random amplification of polymorphic DNA (RAPD) analysis showed the same pattern for these samples, thus confirming the identity of E. faecalis isolates in the blood and oral mucosa. Our observations provide novel information regarding the level of identity between IE pathogens and oral bacteria.

Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT).

PURPOSE: Hematology-oncology patients undergoing chemotherapy and hematopoietic stem cell transplantation (HSCT) recipients are at risk for oral complications which may cause significant morbidity and a potential risk of mortality. This emphasizes the importance of basic oral care prior to, during and following chemotherapy/HSCT. While scientific evidence is available to support some of the clinical practices used to manage the oral complications, expert opinion is needed to shape the current optimal protocols. METHODS: This position paper was developed by members of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT) in attempt to provide guidance to the health care providers managing these patient populations. RESULTS: The protocol on basic oral care outlined in this position paper is presented based on the following principles: prevention of infections, pain control, maintaining oral function, the interplay with managing oral complications of cancer treatment and improving quality of life. CONCLUSION: Using these fundamental elements, we developed a protocol to assist the health care provider and present a practical approach for basic oral care. Research is warranted to provide robust scientific evidence and to enhance this clinical protocol.

Management of lacerated and swollen tongue after convulsive seizure with a mouth protector: interprofessional collaboration including dentists in intensive care.

We encountered a 74-year-old male patient with tongue laceration after convulsive seizures under intensive care. The tongue showed severe swelling, and the right ventral surface had been lacerated by his isolated and pointed right lower canine. Our university hospital has established a perioperative management center, and is promoting interprofessional collaboration, including dentists, in perioperative management. Dentists collaborating in the perioperative management center took dental impressions, with the support of anesthesiologists who opened the patient's jaw under propofol sedation, to produce a mouth protector. By raising the patient's bite, the completed mouth protector prevented the isolated tooth from contacting the tongue and protected the lacerated wound. Use of the mouth protector prevented the lacerated tongue from coming into contact with the pointed tooth, and the tongue healed gradually. These findings underscore that interprofessional collaboration including dentists can improve the quality of medical care.

Distribution of oral mucosal bacteria with mecA in patients undergoing hematopoietic cell transplantation.

PURPOSE: We recently reported frequent detection of antibiotic-resistant bacteria on the oral mucosa during the period of hematopoietic cell transplantation (HCT) and suggested an association between oral mucositis and antibiotic-resistant bacterial infection. Methicillin-resistant Staphylococcus spp. were frequently detected, and the oral cavity may be a reservoir of the gene mediating methicillin resistance, mecA. Here, we examined the frequency of mecA carriers in patients undergoing HCT. METHODS: Fifty-nine patients (male (M) = 37, female (F) = 22, 47.3 ± 11.0 years) receiving HCT were enrolled in this study. Buccal swab samples were obtained four times from day -7 to day +20 (once/week), and mecA was detected by PCR. Fifty-two subjects without systemic disease, who completed dental treatment, especially periodontal treatment (M = 21, F = 31, 55.4 ± 14.2 years), were also enrolled as controls and checked for mecA on the oral mucosa. RESULTS: Seventy-six percent (45/59) of the HCT patients carried mecA at least once in the study period (days -7 to +20), while no control subjects had mecA. The frequency of mecA carriers was 19.2 % from days -7 to -1, while it was significantly increased on days +7 to +13 and +14 to +20, with frequencies of 60.9 and 63.2 %, respectively (P < 0.01, ANOVA). CONCLUSIONS: mecA was detected in oral mucosa of patients undergoing HCT. The high detection frequency of staphylococci resistant to penicillin and beta-lactams in our recent report was supported.

Occlusion and weight change in a patient after esophagectomy: success derived from restoration of occlusal support.

Occlusal support may be an important factor affecting nutritional support after major surgery. This report presents a patient who gained body weight after receiving a new prosthesis. The patient was an 82-year-old man with thoracic esophageal carcinoma. He did not have occlusal support because of multiple caries lesions. His body weight slowly increased after surgery, but almost stopped in the period of 54 to 68 days after surgery. After treatment with dentures (day 72 postsurgery), body weight gain was observed again, although his medical treatment had not changed. An appropriate prosthesis could contribute to perioperative nutrition support and may lead to earlier recovery after surgery.