[Postoperative risk of bleeding after removal of third molars in healthy patients - a prospective observational clinical study]. / Nabloedingsrisico na verwijdering derde molaar bij gezonde patiënten; een prospectief observationeel klinisch onderzoek.

Removal of third molars in healthy patients is considered a procedure with a low risk of bleeding. However, exactly how low the incidence of postoperative bleeding is remains unclear due to the heterogeneity of available studies. To determine the exact postoperative risk of bleeding after the removal of third molars in healthy patients, a prospective observational multicentre study was conducted. A total of 1,035 patients with complete follow-up was included. Of these, 329 patients reported subsequent bleeding, but did not consult their attending physician. A total of 15 patients visited the hospital, 8 of whom required minimally invasive (re)treatment. No hospitalizations were necessary. There was a large difference between the incidence of postoperative bleeding reported by patients and postoperative bleeding requiring clinical examination and/or treatment. To reduce this difference in future, patients should be given detailed information about what degree of postoperative bleeding is considered normal after removal of a third molar.

[Dental aspects of Marfan syndrome]. / Tandheelkundige aspecten van het syndroom van Marfan.

Marfan syndrome is characterized by several (severe) medical disorders, the most important of which is aortic dilatation. Treatment of these disorders has consequences for oral care, in particular with regard to endocarditis prophylaxis and the use of anticoagulation. Furthermore, several orofacial anomalies of Marfan syndrome relevant to dental care are described in the literature. These anomalies may affect different areas within the spectrum of dental care, ranging from orthodontics to periodontology. Within these areas, Marfan syndrome is associated with a characteristic countenance and the prevalence of temporomandibular dysfunction, caries, endodontic anomalies and periodontitis. Medical-dental interaction with patients with Marfan syndrome should also be taken into consideration.

[Antithrombotics: backgrounds with haemostasis and antithrombotic therapy]. / Antitrombotica: achtergronden bij stolling en antistolling.

The clinical guidelines on antithrombotics, published by the Dutch Institute of Expertise for Oral Healthcare, give advice on policy to be followed in cases of dental procedures involving bleeding. The guidelines allow room for professional assessment of bleeding risks, for which background knowledge about haemostasis, thrombosis and antithrombotic processes is necessary. Normal haemostasis can be divided in several steps: vasoconstriction, primary haemostasis by aggregation of thrombocytes, and secondary haemostasis by the formation of fibrin out of coagulation factors. In the case of thrombosis, a blood clot forms inside a blood vessel, causing obstruction of blood flow to the underlying tissue. Various antithrombotics are prescribed for the prevention and treatment of thrombosis. Thrombocyte aggregation inhibitors only have an effect on primary haemostasis. Vitamin K antagonists influence secondary haemostasis by lowering the production of several coagulation factors. The direct oral anticoagulants have an immediate effect on an activated coagulation factor, and are currently prescribed in large quantities [in the Netherlands]. Low-molecular-weight heparin also inhibits activated coagulation factors, but is not used for long-term antithrombotic therapy since it is administrated subcutaneously.

[Using the new clinical guidelines on antithrombotics in the dental practice]. / Toepassen van nieuwe richtlijn 'Antitrombotica' in de mondzorgpraktijk.

A 64-year-old man has deep caries in tooth 37 without acute pain; extraction is indicated, however. According to his list of medications, he takes the antithrombotics apixaban and clopidogrel. Or: a 78-year-old woman has upper and lower dentures that don't function well, and she experiences retention problems. Implant-bearing upper and lower dentures on 4 and 2 implants, respectively, are indicated. The patient takes acenocoumarol and reports that the clotting time value of her blood (INR) sometimes fluctuates. The clinical guidelines 'Dental procedures in patients using antithrombotic medication', which recently appeared, offer oral healthcare providers recommendations for reducing the risk of bleeding while observing the risk of thrombosis. These guidelines by the Dutch Institute of Expertise for Oral Healthcare replace the previous guidelines from 2012. The recommendations are up to date with current practice in the Netherlands and take into account all antithrombotics patients may currently use in an outpatient setting. Furthermore, the responsibilities of the oral healthcare providers and the agreements with thrombosis services are formalised in these guidelines.

[Education and the dentist in 2025. Three educational programmes in dentistry in the Netherlands: three kinds of dentist?] / Serie: Onderwijs en de tandarts anno 2025. Drie opleidingen tandheelkunde in Nederland: drie soorten tandartsen?

In the context of the series on education and the dentist in 2025, the directors of education and training at the 3 dentistry programmes in the Netherlands were asked about the kind of dentist they are training. If, after all, the head of a dental practice is looking for a new colleague and has 3 candidates, each from a different faculty, what can he expect of each of them and are there differences in the 'kind of dentist' they are? In the spring of 2019, Geerling Langenbach and Corine Visscher of the ACTA (Academic Centre for Dentistry Amsterdam), Nico Creugers and Ohlin Cremers of the Radboud University in Nijmegen and Luc van der Sluis and Berdien Kooistra-Akse of the Rijksuniversiteit Groningen were interviewed one after another by Denise van Diermen, guest editor of the series 'Education and the dentist in 2025'.

[Can dental students and dental care providers in the Netherlands effectively and safely prescribe drugs?] / Serie: Onderwijs en de tandarts anno 2025. Kunnen tandheelkunde­studenten en mondzorgverleners in Nederland effectief en veilig geneesmiddelen voorschrijven?

Dentists and dental specialists are qualified to prescribe drugs. In this study, we assessed and compared the pharmacotherapeutic knowledge and skills of final year dental students, dentists and dental specialists in the Netherlands. In 2017, a random sample of these three groups was invited to complete an assessment. The knowledge assessment comprised 40 multiple choice questions covering often prescribed drugs. The skills assessment comprised three patient cases for which participants had to write a treatment plan. For the knowledge assessment, the response rates were 26 (20%) dental students, 28 (8%) dentists and 19 (19%) dental specialists, and for the skills assessment the response rates were 14 (11%) dental students, eight (2%) dentists, and eight (8%) dental specialists. On average, all three groups had inadequate knowledge scores (smaller 80%) and only a small proportion (smaller 30%) of their treatment plans was assessed as correct. These results suggest that dental students, dentists and dental specialists lack prescribing competence, which could be caused by poor pharmacotherapy education during under- and postgraduate dental training.

[Series: Education and the dentist in 2025. An interfaculty National Progress Test for Dentistry as future method of testing?] / Serie: Onderwijs en de tandarts anno 2025. Een interfacultaire Landelijke Voortgangstoets Tandheelkunde als toekomstige toetsmethode?

The interuniversity Progress Test in Medicine is a measuring instrument consisting of about 200 test items, to measure the development of medical students' knowledge during their studies. The Progress Test consists of 4 tests per academic year. Future versions of the Progress Test will likely be based on computerised administration of the test. One of the main goals of the Progress Test is to counter the so-called 'learningto-the-test' effect. Additional benefits are that students and teachers get detailed feedback about command of knowledge and where omissions in knowledge or the curriculum exist at multiple institutions. A Progress Test for dental education in the Netherlands can easily be conceived because the goals of the Progress Test fit well with the common framework (Raamplan Tandheelkunde) shared among the current three dental programmes. The current 'Overalltoets' (general test) of ACTA (academic centre for dentistry Amsterdam) could form a foundation for starting a Progress Test for dental education.

[The medical-dental interactions scanner: an Electronic Health Record-integrated quality and safety module for medical-dental interactions]. / De MTI-scanner: een EPD-geïntegreerde kwaliteits- en veiligheidsmodule voor medisch tandheelkundige interacties.

Dental professionals will be confronted more frequently with medically compromised patients due to an increasing life expectancy in Western countries. The patients' systemic diseases and medication usage can both have consequences for oral health and dental treatment. It is often impossible to have all medical-dental interactions handy in the dental practice. To support the dental professional in providing safe healthcare, a tool has been developed. The medical-dental interactions scanner supports both patients and dental professionals in taking a patient's medical history and linking that information to the available literature. By that means, it is possible for the caregiver to provide patient-specific recommendations concerning possible adverse effects of medicaments,intra-oral manifestations of systemic diseases and measures to prevent medical emergencies.

Survey response of oral and maxillofacial surgeons on invasive procedures in patients using antithrombotic medication.

The aim was to evaluate the management strategies of Dutch oral and maxillofacial surgeons when performing invasive dental or oral surgery in patients using oral antithrombotic medication (OAM). In November 2009 a survey was mailed to all 213 members of the Dutch Society for Oral and Maxillofacial Surgery. A response rate of 57% was achieved with 79 surveys returned through mail and 38 surveys answered through the Internet. The results show that many different treatment strategies are advocated by Dutch oral and maxillofacial surgeons, regarding preferred international normalised ratio (INR) value and continuation or discontinuation of OAM prior to invasive dental or oral surgery. The risk of bleeding during or after an invasive dental procedure was overestimated. A need for a practice guideline on this topic was expressed by 73% of respondents.

[Considerations with respect to the use of corticosteroids in dentoalveolar surgical treatments]. / Beschouwingen over het gebruik van corticosteroïden in de dentoalveolaire chirurgie.

Corticosteroids are used incidentally in dentoalveolar surgical treatments to reduce possible postsurgical problems. Natural corticosteroids are produced in the adrenal cortex. Synthetic corticosteroids are known to have anti-inflammatory effects when they are administered in doses exceeding the normal physiological amounts which the body produces. Several contraindications and side effects are known. Administration of corticosteroids for dentoalveolar surgical treatments shows a reduction of edema and pain. When using corticosteroids, the risk of infections is not known to be higher than usual and the risk of adverse effects is minimal. According to the literature, there is no clear recommendation to use corticosteroids as a standard for dentoalveolar surgical treatments.

[Dental procedures for patients using oral anticoagulation: new insights]. / Bloedige ingrepen bij patiënten met antitrombotica: nieuwe inzichten.

What treatment is appropriate for a patient who has to undergo an invasive dental procedure if that patient is using medication that influences the blood coagulation system? Should the medication be stopped before the invasive procedure, with the risk of complications involving re-thrombosis? Or should the procedure be carried out without adjusting the medication? What is the risk of bleeding complications? Recent studies appear to indicate that temporarily stopping medication is in many cases unnecessary and can even harm the patient. In recent decades dentists have received a great number of diverse recommendations. In this article recent research in this field is summarized and evaluated. The authors advocate the development of evidence-based clinical guidelines.

[Carotid calcification on a panoramic radiograph: what to do?]. / Een opaciteit in de hals op het orthopantomogram: wat te doen?

A 71-year-old man is discussed in whom the oral and maxillofacial surgeon observed, by chance, a radiopacity on the panoramic radiograph that was highly suggestive of a calcification at the bifurcation of the internal and external carotid artery. While, on the basis of international literature, various treatments are advanced with respect to the importance of vascular investigation and possible surgical removal of significant calcification, at present the view in The Netherlands is that the family doctor has the responsibility to assess whether such patient should be referred for further evaluation by the neurologist or vascular surgeon. The same applies to the possible indication for prescription of antitrombotics.

[Transient paresis after mandibular block anaesthesia]. / Parese na mandibulaire blokanesthesie.

Mandibular block anaesthesia is frequently used in dentistry. The technique is more susceptible to failure than local anaesthesia by infiltration. Two cases of patients who were afflicted by transient paresis of (branches of) the facial and vagus nerves after mandibular block anaesthesia have been analysed. With reference to both these cases advice is given on how to react in case of a misdirected mandibular block anaesthesia.

[The importance of adequate medical history taking in dentistry]. / Het belang van een goede medische anamnese.

A patient's medical history is a vital part of his or her dental history and increases the dentist's awareness of diseases and medication which might interfere with the patient's dental treatment. This article describes the essential characteristics of a solid medical history, according to the Dutch Guidelines for Dental Education published in 1997. In future the importance of patients' medical histories will increase along with the number of medically complex patients who visit the dental general practice.

[Postoperative course after uncomplicated tooth extractions in adults. Experiences in a university mouth disease and jaw surgery clinic]. / Het beloop na ongecompliceerde extracties bij volwassenen. Ervaringen in een universiteitskliniek mondziekten en kaakchirurgie.

The records of 68 adult patients, referred to a Department of Oral and Maxillofacial Surgery for extraction of one or more teeth, have been studied with regard to the complexity of the treatment and the postoperative course. In 11 patients surgical removal had to be performed, while in the remaining 57 patients treatment consisted of simple extractions. Forty-six patients of these 57 patients returned a questionnaire about postoperative problems and use of analgesics. These patients were divided into two groups, one consisting of 17 healthy patients without any medical disorder and/or use of drugs, and a second consisting of 29 medically compromised patients. The postoperative course did not differ between both groups. Four patients (1 healthy, 3 medically compromised) experienced postoperative complaints during more than 6 days. Remarkably, the number of patients who experienced pain but did not use analgesics was considerably higher in the healthy group (29%) compared with the medically compromised group (7%). On the other hand, medically compromised patients more often experienced pain in spite of the use of analgesics (52%) than healthy patients (41%). No differences in wound healing after simple tooth extractions were observed between healthy and medically compromised patients.

Short-term efficacy and safety of pravastatin in 72 children with familial hypercholesterolemia.

The safety, tolerability, and efficacy of a 12-wk treatment with pravastatin, 5, 10, and 20 mg/d, was evaluated in 72 children with heterozygous familial hypercholesterolemia (FH) in a double-blind, randomized and placebo-controlled study. The results show that pravastatin was well tolerated and that adverse events were mild and equally distributed among the three treatment groups. Plasma total and LDL cholesterol levels were significantly reduced in all pravastatin treatment groups, in comparison with the control group; -24.6% (-28.1 to 21.0) and -32.9% (-37.0 to -28.6), for mean change and 95% confidence interval, respectively. In four children plasma LDL cholesterol levels were reduced within normal limits for sex and age. HDL cholesterol increased in the pravastatin 20-mg group, +10.8% (+3.4 to +18.8), whereas plasma apo B100 and very LDL (VLDL) cholesterol levels were reduced within all pravastatin-treated groups -26.8% (-31.2 [corrected] to -21.7) and -24.5% (-35.0 to -12.3). These data show that short-term pravastatin treatment of children with FH is safe and effective, although long-term dose titration studies with 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors need to be performed, to reduce plasma LDL cholesterol levels below a predefined level. The results of these studies have to be awaited before new treatment strategies are to be considered in these children.

Origin and migration of an Afrikaner founder mutation FHAfrikaner-2 (V408M) causing familial hypercholesterolemia.

Of the three major Afrikaner founder mutations, responsible for more than 95% of Familial Hypercholesterolemia cases among South African Afrikaners, one mutation called V408M or FHAfrikaner-2 was identified in the Netherlands. Subsequent analysis of a group of Canadian patients of Dutch origin with Familial Hypercholesterolemia revealed the presence of this mutation in western Canada. The founder of the Canadian family, suffering from Familial Hypercholesterolemia caused by V408M, was traced back to Andijk, a small village in the northwestern part of the Netherlands, a region from where the first settlers to South Africa departed in the 17th and 18th century. Further genealogical investigation demonstrated that the mutation must have been introduced in the Netherlands by an individual from northern Germany. Haplotype analysis resulted in the identification of the common haplotypes TaqI-, StuI+, AvaII+, NcoI+ in Canadian as well as Dutch patients with V408M. The results of this study further support the hypothesis that Dutch settlers introduced this Afrikaner founder mutation in the Afrikaner population in South Africa. After a recombinational event in the mutated gene, the mutation was also introduced in western Canada.

[How much feedback is provided by the 'feedback post'? Four years of medical information provision to dental practitioners]. / Hoeveel feedback geeft de 'Feedback Post'? Vier jaar medische informatieverstrekking aan praktiserende tandartsen.

This article describes the 'Feedback Post AZIG', an institute to which dentists can turn for advice on medical questions. The frequency as well as the content of these questions, posed between 1991 and 1994, are considered. Dentist clearly have a need for medical feedback and this need increases every year. Given the expected increase of the number of medically compromised patients in the dental practice, the importance of both medical training to dentists and feedback possibilities should not be underestimated.

Recurrent pancreatitis and chylomicronemia in an extended Dutch kindred is caused by a Gly154-->Ser substitution in lipoprotein lipase.

We report the molecular basis of familial chylomicronemia and recurrent pancreatitis in five members of a large Dutch family. All patients had normal plasma hepatic lipase and apoC-II levels, but absent lipoprotein lipase (LPL) catalytic activity and low LPL mass in postheparin plasma. The mutation in the LPL gene was characterized as a G715-->A substitution in the last nucleotide of exon 4, resulting in a substitution of Ser for Gly154. PCR amplification of exons 4 + 5 from the patients' mRNA, followed by direct sequencing, revealed normal splicing of intron 4. The mutation creates a BfaI restriction site that allows rapid screening of family members for the mutation. Reproduction of this mutation in LPL-cDNA by site-directed mutagenesis, followed by transient expression in COS-B cells, revealed production of a catalytically inactive enzyme. The Gly154-->Ser substitution appears in a conserved beta-sheet region, in close proximity to Asp156, which is part of the catalytic triad. These studies show that changes to residues close to Asp156 can have profound effects on catalytic activity of LPL.