Unveiling denture-induced oral lesions: A comprehensive study on classification and pain assessment.

BACKGROUND: Denture-induced oral Lesions (DIOLs) often manifests shortly after the placement or adjustment of new or realigned dentures, frequently resulting in severe pain and discomfort. OBJECTIVES: This study aimed to classify DIOLs placing a particular emphasis on assessing the associated pain. METHODS: A prospective case study was conducted involving 126 patients who were fitted with a total of 193 dentures of various types at the Hadassah School of Dental Medicine. All patients underwent comprehensive intra-oral examinations within 1-8 weeks following denture delivery, completed symptom questionnaires and had their medical records reviewed. Key variables documented included age, gender, overall health status, denture type, and a detailed description of the DIOLs. The description encompassed factors such as lesion location, shape, colour, size, border characteristics, ulcerative appearance, membrane coverage, 3D morphology (elevated, immersed and flat) and patient-reported Verbal Pain Score (VPS) when touching the DIOLs, when wearing the denture, and when not wearing the denture. RESULTS: Notably, 25.4% of denture wearers required no adjustments, while 14.4% necessitated more than three revisions. A majority (71.8%) of DIOLs cases were associated with mandibular complete dentures, primarily situated on the alveolar ridge. The mean VPS indicated a pain intensity of 7 ± 2.1, with temporary dentures in both jaws causing the most discomfort. Implant-supported overdentures were particularly painful when placed in the mandible. Additionally, VPS scores were higher among older individuals and those with prior prosthetic experiences. A significant correlation was observed between pain intensity and presence of chronic health condition (0.036). CONCLUSIONS: This study revealed distinct characteristics of DIOLs and highlighted the multifactorial nature of pain experienced following the development of DIOLs. Insights into the influence of patient and denture characteristics on DIOLs and pain intensity can guide healthcare professionals in optimising patient comfort and satisfaction.

Delayed CTP-Derived Deep Venous Outflow: A Novel Predictor of Striatocapsular Infarction after M1 Thrombectomy.

BACKGROUND AND PURPOSE: Isolated striatocapsular infarction occurs commonly in patients with ischemic stroke following M1 thrombectomy. We aimed to explore the correlation between CTP-derived parameters of deep venous outflow at presentation and subsequent striatocapsular infarction in a retrospective cohort of such patients. MATERIALS AND METHODS: TTP and peak enhancement were measured on CTP-derived time-attenuation curves of the internal cerebral and thalamostriate veins bilaterally. The difference in TTP (ΔTTP) and the relative decrease in venous enhancement between the ischemic and normal sides were calculated. NCCT performed 24 (SD, 12) hours postthrombectomy was used to determine tissue fate in the caudate head, caudate body, lentiform nucleus, and internal capsule. Striatocapsular ischemia (striatocapsular infarction-positive) was defined as infarction and striatocapsular injury as either infarction, contrast enhancement, or hemorrhagic transformation in ≥1 of these regions. A striatocapsular ischemia score was calculated (0 = no ischemic region, 1 = 1 ischemic region, 2 = ≥2 ischemic regions). RESULTS: One hundred sixteen patients were included in the analysis. Sixty-one patients had striatocapsular infarction (striatocapsular infarction-positive). The mean thalamostriate ΔTTP was 1.95 (SD, 1.9) seconds for patients positive for striatocapsular infarction and 0.79 (SD, 2.1) for patients negative for it (P = .010). Results were similar for striatocapsular injury. The mean thalamostriate ΔTTP was 0.79 (SD, 2.1), 1.68 (SD, 1.4), and 2.05 (SD, 2) for striatocapsular infarction scores of 0, 1, and 2, respectively (P = .030). CONCLUSIONS: CTP-derived thalamostriate ΔTTP is an excellent surrogate marker for striatocapsular infarction in patients post-M1 thrombectomy. The novel approach of extracting venous outflow parameters from CTP has numerous potential applications and should be further explored.

Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy.

BACKGROUND AND PURPOSE: The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS: We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS: The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients. CONCLUSIONS: Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.

Computed Tomography Perfusion-Based Decision Making for Acute Ischemic Stroke-Missing the Mismatch.

The emerging use of mechanical thrombectomy for acute ischemic stroke treatment focuses on the importance of patient selection. Computed tomography perfusion (CTP) is one of widely used techniques. However, the accuracy and reliability of this modality is in debate among vascular neurologists. We present a case of an 80-year-old man admitted because of acute ischemic stroke. CT angiography demonstrated left proximal M2 occlusion. As CTP demonstrated signs of large ischemic core with no significant penumbra, mechanical thrombectomy was not performed following tPA administration. Twenty-four hours after thrombolysis, the patient was neurologically intact. Both non-contrast CT and magnetic resonance imaging (MRI) demonstrated small stroke involving the left caudate. Differences between CTP and MRI diffuse-weighted imaging were previously described. However, in the presented case, these differences were brought to extreme, precluding endovascular treatment. In our opinion, this case emphasizes why CTP should not be used for patient exclusion among patients in the early time frame for intervention. Such patients should be evaluated by MRI or by clinical-radiological mismatch only. CTP may have a role in selecting patients for endovascular intervention in borderline circumstances such as prolonged time window, wake-up stroke, etc.

[The influence of military underwater activity on the oral cavity].

The military dentists who serve in the navy, treat divers, among other patients. Divers are being exposed to a changing, unique environment on a regular basis. The aim of this article is to review latest literature on the different effects of scuba diving on the diver's head, face and oral regions and to emphasize methods of disease prevention, diagnostic tools and treatment guidelines. The review focuses on diving barotrauma (pressure- induced injury related to an air space) as well as scuba diving mouthpiece-related oral conditions, which include facial, jaw pain and headaches, decompression sickness and mouthpiece-related herpes infection. Each condition is described by its effect on the oral cavity and in particular the teeth.

Mechanisms of post-radiation injury: cerebral microinfarction not a significant factor.

Post-radiation leukoencephalopathy is characterized by cognitive impairment and white matter alternations on imaging. Cerebral small vessel disease (SVD) is one of several suggested etiologies. Cerebral microinfarction (CMI) is a recently described marker of SVD. We sought to examine the rate of CMI as a biomarker of ongoing ischemia among patients who underwent brain radiotherapy (RT). 110 patients treated with RT for primary or metastatic brain tumors were enrolled. A total of 685 brain MRI tests performed 1-108 months post-radiation were examined. The annual incidence of CMI was calculated. Only 2 definite CMI were found (2/685, 0.3 %). The calculated annual incidence of CMI was 0.11. This incidence is similar to the normal population, and lower than the reported incidence in patients with intracerebral hemorrhage or cognitive impairment. CMI incidence in patients treated with brain RT is similar to the general population. This finding suggests that post-radiation leukoencephalopathy and cognitive impairment are not due to active SVD solely but rather secondary to other causes such as inflammation, metabolic or direct cell damage.

Symptomatogenic acute cervical artery dissection following dental procedure - Case series.

INTRODUCTION: Cervical artery dissection (CAD) is an important cause of ischemic stroke which may occur following minor traumatic neck manipulations or hyperextension. This paper describes four cases of CAD secondary to dental procedures. CASES: Four patients were admitted to the neurology department due to various neurological deficits, which developed subsequently to dental procedure. CT angiography demonstrated CAD in all patients. No predisposing background disease or other neck manipulations were found. DISCUSSION: We describe four cases of dental procedure induced CAD. Since dental procedures are very common, CAD incidence may be higher than recognized. High clinical suspicion is crucial for promoting vascular imaging and diagnosis, especially among patients with non-neurologically symptomatic CAD. We suggest avoiding prolonged neck hyperextension during dental procedures, especially under general anesthesia, in order to prevent this rare but dramatic complication.

Dental implants in patients at high risk for infective endocarditis: a preliminary study.

The safety of dental implant placement in patients at high risk for infective endocarditis (IE) has never been shown. The outcome of osseointegrated implants in patients with artificial heart valves or with a history of an infected valve is not known. In this article we describe our experience of dental implant placement in patients at high risk for IE. A retrospective study was conducted on patients at high risk for IE who underwent dental implant placement. All the patients received prophylactic antibiotic treatment before the surgical procedure, in accordance with the relevant American Heart Association guidelines. A total 13 patients underwent 16 surgical procedures for the placement of 57 dental implants over a period of 17 years. Within the follow-up period, no case of IE was reported. Two implants failed before exposure in one patient, one patient suffered from mitral valve thrombosis 14 days after the dental procedure, and another patient suffered a stroke 6 months following treatment. Despite the limitation of the small group of patients and the known low incidence of IE, dental implants may be regarded as a legitimate procedure for patients at high risk for IE.

[Dental treatment and anti-thrombotic therapy. Part II: the era of new anti-thrombotic drugs].

Surgical intra-oral treatment for patients under antithrombotic therapy presents a challenge for the dental team. Within the last few years evidence based systematic reviews established new clinical guidelines for wide groups of patients which need to use antithrombotic treatment. The expected increase in use of antithrombotic treatment forced the pharmaceutical industry to provide new treatments. The former anticoagulant and anti-platelets aggregation groups of drugs were limited to small variety of medication. The search for the new treatments with ideal properties led to newly invented groups of drugs. In this article we will describe the new advancements in anti-thrombotic treatments. The article will summarize the limited knowledge of surgical management of patients under the new anti-thrombotic medications and the recommended approach for oral surgical procedures.

Levels of sirolimus in saliva and blood following mouthwash application.

OBJECTIVES: Sirolimus (rapamycin) is a mammalian target of rapamycin (mTOR) inhibitor with antiproliferative activity. Its systemic administration is currently evaluated for the management of squamous cell carcinoma and various oral disorders. Topical oral application can enhance availability, efficacy and improve safety and compliance. Our objective was to evaluate the release profile and the safety of a sirolimus mouthwash. SUBJECTS AND METHODS: A sirolimus mouthwash (0.05 mg ml(-1) ) was applied to ten healthy male volunteers. Saliva and blood samples were taken after rinsing. Mass spectrometry and chemiluminescent microparticle immunoassay were used to determine saliva and blood levels of sirolimus. A topical oral release profile measurement and safety evaluation were performed. RESULTS: After rinsing with the mouthwash, a classic immediate release profile was noted in the oral cavity. Extremely high initial sirolimus levels rapidly declined over a 4-hour period. Systemic exposure was limited, with a maximum level significantly lower than therapeutic doses, and safety was confirmed. CONCLUSIONS: A single rinse with sirolimus mouthwash leads to high transient levels of the drug in the saliva. Although levels were variable, a therapeutic concentration was achieved topically along with minimal systemic absorption. These results broaden the potential clinical use of oral topical rapalogs.

[Dental treatment and anti-thrombotic therapy. Part 1: clinical guideline].

The modern dental treatment plan opens a variety of new surgical rehabilitating treatments. Dental implants, socket preservation peri-apical endodontic surgery and alveolar bone augmentation were introduced to dentistry within the last three decades. The common characteristics of all these treatments are the surgical technique involving soft as well as heard tissue. Within the last decade various new anti-thrombotic indications for treatments of patients at risk for thrombotic events and a new armamentarium of anti-thrombotics techniques were introduced. Both medical improvements confront the dental health providers with the problem of surgical treatment with the threat of bleeding. The treatment approach is based on a tradeoff between major bleeding versus a catastrophic thrombotic event. The magnitude of bleeding risk is a summation of the antithrombotic treatment and the extant of surgical treatment. In this article we will summarize the clinical guidelines of dental treatment for patients under anti-thrombotic treatment.

[Root canal treatments in a patient with florid cemento-osseous dysplasia].

This article follows the comprehensive dental treatment of a patient who presented with multi periapical radiolucencies on a complete set of periapical radiographs. All the affected teeth were treated and root canal fillings were performed. None of the periapical radiolucencies showed any evidence of a healing process. On a later stage, the lesions have been diagnosed as florid cemento-osseous dysplasia. (In this article the correct diagnosis and treatment will be discussed).

[Antibiotic prophylaxis for the prevention of infective endocarditis--new guidelines of the American Heart Association].

Within the last twelve month both the working party of the British Society for Antimicrobial Chemotherapy and the American Heart Association have changed their attitude towards antibiotic prophylaxis for the prevention of infective endocarditis dramatically. The major change is the exclusion of the groups of patients formerly known as the "low and medium" risk groups from the new treatment group. A brief summary of the American as well as the British recommendations for adults and children is reported.

[Dental treatment for patients with myasthenis gravis].

Myasthenia gravis is an autoimmune disease, characterized by weakness of the skeletal muscles, which increases during action. The nature of the disease influences the mode of dental treatment. Careful treatment planning prevents over-activity of the muscles. The bulbar appearance of the disease, affects the chewing muscles, thus, it is important to avoid aspiration of foods or other particles from the mouth. Infections may exacerbate the symptoms of Myasthenia gravis, therefore the dentist must eliminate oral focal infections and avoid using medicines that might worsen the disease.

[Emergencies evolving from local anesthesia].

Local anesthesia is without doubt the most frequently used drug in dentistry and in medicine. In spite of records of safety set by using these drugs, there is evidence to adverse reactions ranging from 2.5%-11%. Most of the reactions originate from the autonomic system. A recent, well-planned study indicates that adverse reactions are highly correlated to the medical status of the patient: the higher the medical risk, the greater the chance to experience an adverse reaction. This study also found that adverse reactions highly correlated to the concentration of adrenalin. Another recent study found a direct relationship between adverse reactions and the level of anxiety experienced by the patient and to the dental procedure. Most of the reactions in this study occurred either immediately at injection time and within 2 hours following the injection. Since the beginning of last century, vasoconstrictors have been added to local anesthesia solutions in order to reduce toxicity and prologue activity of the LA. However, today it is commonly agreed that this addition to local anesthesia should not be administered to cardiac patients especially those suffering from refractory dysrhythmias, angina pectoris, post myocardial infarction (6 months) and uncontrolled hypertension. Other contraindications to vasoconstrictors are endocrine disorders such as hyperthyroidism, hyperfunction of the medullary adrenal (pheochromocytoma) and uncontrolled diabetes mellitus. Cross reactivity of local anesthetic solutions can occur with MAO inhibitors, non specific beta adrenergic blockers, tricyclic antidepressants, phenothiazides and cocaine abusers. Noradrenaline added to local anesthetics as a vasoconstrictor has been described as a trigger to a great increase in blood pressure and therefore has been forbidden for use in many countries. This paper describes 4 cases of severe complications following the injections of local anesthesia of which three ended in fatality.

[Syncope in the dental environment].

Syncope or Fainting is, by far, the most common emergency situation in the dental practice. Syncope is defined as an abrupt, transient, short term loss of consciousness and postural tone, followed by spontaneous and complete recovery. The pathophysiology of syncope consists of a sudden cessation or decrease in cerebral perfusion. Differential diagnosis of these medical conditions is of paramount importance in uncovering unrecognized systemic diseases. The dental team plays an important role in the process of establishing the correct diagnosis by its ability to recognize and document all the clinical symptoms and signs evident at the time of fainting. The dental surgeon is expected to be familiar with the various etiologies of syncope and should be able to differentiate between them. This article provides the essentials of the diagnostic procedure and an approach to the evaluation of the unconscious patient.

[Respiratory distress].

Dental treatment is usually conducted in the oral cavity and in very close proximity to the upper respiratory airway. The possibility of unintentionally compromising this airway is high in the dental environment. The accumulation of fluid (water or blood) near to the upper respiratory airway or the loosening of teeth fragmentations and fallen dental instruments can occur. Also, some of the drugs prescribed in the dental practice are central nervous system depressants and some are direct respiratory drive depressors. For this reason, awareness of the respiratory status of the dental patient is of paramount importance. This article focuses on several of the more common causes of respiratory distress, including airway obstruction, hyperventilation, asthma, bronchospasm, pulmonary edema, pulmonary embolism and cardiac insufficiency. The common denominator to all these conditions described here is that in most instances the patient is conscious. Therefore, on the one hand, valuable information can be retrieved from the patient making diagnosis easier than when the patient is unconscious. On the other hand, the conscious patient is under extreme apprehension and stress under such situations. Respiratory depression which occurs during conscious sedation or following narcotic analgesic medication will not be dealt with in this article. Advanced pain and anxiety control techniques such as conscious sedation and general anesthesia should be confined only to operators who undergo special extended training.

[Chest pains in the dental environment].

Chest pain does not necessarily indicate cardiac disease. The most common causes of acute chest pain encountered in dental situations include hyperventilation, pulmonary embolism, angina pectoris and myocardial infarction. Stress and fear often cause rapid breathing or hyperventilation. This usually occurs in young adults and although the hyperventilating patient often complains of chest pain, this is rarely a manifestation of cardiac disease. Pulmonary embolism usually indicates the occlusion of a pulmonary artery causing severe chest pain. The primary clinical manifestation of angina pectoris is chest pain. Although most instances of anginal pain are easily terminated, the dentist must always consider the possibility that the supposed anginal attack is actually a sign of acute myocardial infarction (AMI). AMI is a clinical syndrome caused by a deficient coronary arterial blood supply to a region of myocardium that results in cellular death. There is a high incidence of mortality among AMI with death often occurring within 2 hours of the onset of signs and symptoms. The initial clinical manifestations of all types of chest pain can be similar. Therefore the dentist must develop proficiency in constituting a differential diagnosis and an efficient management protocol. As in most medical situations prevention is the most powerful tool. However, if chest pains do occur, measures such as airway management, oxygen supplementation, coronary artery dilation, analgesis and in extreme cases, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.

[Allergy-related emergencies].

Allergic reactions can develop to any of the drugs or materials commonly used in dentistry. They exhibit a broad range of clinical signs and symptoms ranging from mild, delayed reactions to immediate and life-threatening reactions developing within seconds. Allergies usually manifest themselves in reactions that are related to histamine release in one of three ways: skin reactions, respiratory problems and anaphylaxis. Anaphylaxis is the most critical allergic reaction in the dental environment. Measures such as airway management, oxygen supplementation, antihistamine, adrenaline and corticosteroid medication, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.