An international survey of oral medicine practice: proceedings from the 5th World Workshop in Oral Medicine.

OBJECTIVES: (i) To define the current state of oral medicine clinical practice internationally, and (ii) to make recommendations for future modeling of the practice of oral medicine. MATERIALS AND METHODS: A survey was designed by an international panel of oral medicine experts to assess the current state of oral medicine practice internationally. The survey was sent to oral medicine experts across the world, and responses were electronically stored and analyzed using descriptive statistics. RESULTS: Two hundred respondents completed the survey representing 40 countries from six continents. The two most common settings for an oral medicine practice were in a hospital and a dental school. More than 88% of respondents considered management of oral mucosal disease, salivary dysfunction, oral manifestations of systemic diseases, and facial pain in the definition of oral medicine. CONCLUSIONS: (i) Oral medicine clinicians diagnose and manage a wide variety of orofacial conditions; (ii) There are significant differences in the definition of oral medicine clinical practice from country to country; (iii) India has the largest expansion of oral medicine services as defined by escalating numbers of clinicians within the specialty as compared with other countries; (iv) oral medicine practitioners have a wide range of professional responsibilities.

CO2 laser in oral graft-versus-host disease: a pilot study.

This paper is the first to report the benefits of CO2 laser treatment for pain control in severe oral chronic graft-versus-host disease (GVHD). A CO2 laser device was used during 17 treatment sessions in four patients. The CO2 laser was applied over the mucosal lesions using 1 W for 2-3 s/1 mm(2). This treatment resulted in a consistent and significant decrease in pain, measured using a standard visual analogue scale. These results suggest that the CO2 laser can be used for the alleviation of pain in oral chronic GVHD.

[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.

[The potential dangers of endocrinal disorders].

The symptoms of most endocrine system diseases are usually clearly recognizable and most of the times are accompanied by a rich medical history. Many general practitioners are reluctant to treat such cases and prefer to refer these patients to specialists who are trained in management of the medically compromised thus increasing the chances of dental treatment without complications. However, sometimes endocrinal diseases develop slowly and their clinical manifestations are hidden or subclinical in nature. In these cases, neither the patient nor the dentist are aware of the condition and there is the potential of life threatening, emergency situations in what at first seem as simple, straightforward dental procedures. Therefore, the dentist must be able to recognize the clinical problem, differentiate between the different symptoms and initiate the proper management protocol. The most unstable endocrinal disorders that should be treated with great care are diabetes mellitus, mainly hypoglycemia, hyperthyroidism and adrenal insufficiency. The general practitioner dentist can treat patients suffering from these disorders providing the disease is well controlled and balanced and that the dental treatment is not very traumatic.

[Legal and ethical considerations of emergencies in the dental office].

The dentist has the ethical and legal responsibility to anticipate emergency situations in correlation with the patient's medical status. He has the obligation to do all in his power to prevent emergencies from happening and to be prepared to manage any emergency that might occur. This article also discusses the importance of monitoring and documentation.

Ultraviolet B irradiation: a new therapeutic concept for the management of oral manifestations of graft-versus-host disease.

Ultraviolet irradiation inhibits the proliferative responses of lymphoid cells to mitogens and alloantigens by inactivation of T lymphocytes and antigen-presenting cells. Its immunosuppressive capacity led to the introduction of UV irradiation into clinical practice for the treatment of dermatologic manifestations of chronic graft-versus-host disease. The cumulative experience with psoralen-UV-A rays in the treatment of cutaneous and oral graft-versus-host disease was the incentive for the application of oral UV-B rays in 2 patients with oral graft-versus-host disease signs and symptoms after allogeneic marrow transplantation. Intraoral UV-B irradiation (0.02 mJ/cm(2)) was administered 2 or 3 times per week on an ambulatory basis; the dose was increased by 0. 02 mJ/cm(2) every fourth session. Both patients responded early and satisfactorily, displaying only minimal side effects at a relatively low cumulative dose. Intraoral UV-B proved a valuable modality in the treatment of resistant chronic oral graft-versus-host disease.

Systemic absorption of lidocaine after topical application for the treatment of oral mucositis in bone marrow transplantation patients.

This paper evaluates lidocaine absorption via oral mucosa following its topical application for symptomatic treatment of bone marrow transplantation (BMT)-induced oral mucositis. Five patients with high-grade oral mucositis after allogeneic BMT were entered consecutively into the study. Five healthy individuals served as controls. All 10 participants rinsed their mouth with 5 ml of a 2% lidocaine solution for 1 min, after which they expectorated the liquid. Blood samples were drawn at 1, 5, 10, 20, 30 and 60 min after rinsing and centrifuged. Plasma lidocaine levels were measured by fluorescence polarization immunoassay. In the BMT patients, plasma lidocaine levels were lower than the therapeutic range of this drug (0.2 microg/ml vs 1.5-5.5 microg/ml), while in the controls no detectable lidocaine levels were noted. The data from this preliminary study indicate that lidocaine prescribed as an anesthetic mouthwash in BMT patients with oral mucositis results in minor systemic absorption of the drug.

Bleeding tendency: a practical approach in dentistry.

The dental profession faces the problems of exaggerated bleeding on a daily basis. The hemostatic, as well as the fibrinolytic processes are better understood today, and the dentist should be familiar with them. The activation of coagulation factors and their clinical expression in the circulation are both described. The most frequently used blood coagulation tests are explained. Antithrombotic medications are frequently used and their implications in dentistry are accentuated. Protocols of prevention and treatment of exaggerated bleeding following dental procedures are included. Among them, the transfusion of clotting factors and the administration of antifibrinolytic medications (tranexamic acid) are recommended for both congenital or acquired bleeding tendencies.

Thalidomide-induced perioral neuropathy.

Thalidomide was administered as a therapeutic agent for chronic graft-versus-host disease after allogeneic peripheral blood stem cell transplantation in a patient with breast cancer. Although side effects of thalidomide have been described earlier, this is the first instance of perioral neuropathy associated with thalidomide treatment. Awareness of this specific side effect may contribute to early diagnosis and appropriate treatment.

The use of tretinoin as oral mucositis prophylaxis in bone marrow transplantation patients: a preliminary study.

OBJECTIVE: The examination of prophylactic efficacy of tretinoin on oral mucositis, post bone marrow transplantation (BMT). PATIENTS AND METHODS: The study population consisted of 11 patients undergoing BMT. Six tretinoin topically-treated patients (0.25 mg daily of 0.1% tretinoin cream) were matched with five non-treated control patients comparing mucositis severity, duration and analgetic (morphine) requirements. Concomitant follow-up included conditioning parameters associated with mucositis and engraftment. RESULTS: The mean of oral mucositis peak scores was significantly lower in the tretinoin-treated patients vs the non-treated patients (score 1.5 vs 3.6; P < 0.02). In the majority of cases the duration of the most severe phase of oral mucositis was shorter in the tretinoin-treated group as compared with the control. Only one patient in the experimental group required morphine analgesics compared with four patients in the control group. CONCLUSIONS: This preliminary study indicates that the severity of oral mucositis, both objective and subjective, in BMT patients may be reduced by 0.1% topical tretinoin cream, 0.25 mg, administered daily from the beginning of the BMT conditioning regimen until marrow engraftment.

Pulmonary edema: a complication following dental treatment under general anesthesia.

This article describes pulmonary edema in two young, physically healthy individuals following routine intensive dental treatment under general anesthesia. The etiology, diagnosis, prognosis, and treatment are discussed. This paper demonstrates that young, healthy patients may develop pulmonary edema in the perianesthesia period or even during anesthesia itself. Obstructive events, which occur especially in the post extubation period, may trigger this condition, as may other well-known phenomena. Early diagnosis and intensive treatment are mandatory in order to effectively resolve the situation.

Dental health care workers at risk.

Healthy DHCWs do not seem to be at significantly higher risk for occupationally acquired diseases when compared with other HCWs. Special attention should be paid to DHCWs who are more susceptible to diseases potentially transmitted in a dental setting. These DHCWs include pregnant women, due to their immunologic changes, and the developing fetus; DHCWs; those with habits such as excessive intake of alcohol; DHCWs following splenectomy, radiotherapy, and long-term corticosteroid therapy; and DHCWs suffering from diseases that have an impact on the first and secondary defense against infections, such as diabetes mellitus, chronic renal failure, sickle cell anemia, leukemia, lymphoma, or HIV.

Salivary immunoglobulins in recipients of bone marrow grafts. III. A longitudinal follow-up of CMV specific antibodies.

Cytomegalovirus (CMV) infection is a major complication of BMT. The oral cavity is a common route for CMV infection, whose protection is provided by salivary anti-CMV antibodies. We developed an ELISA assay for the detection of CMV-specific antibodies in parotid saliva. Saliva of patients receiving BMT from CMV-positive donors was transiently reconstituted with IgG and IgA anti-CMV antibodies shortly after transplantation. The concentration of these antibodies gradually decreased during the 2 months after transplantation and increased again around day 80. A remarkable rise in the salivary concentrations of IgG and IgM anti-CMV was observed shortly after i.v. administration of Sandoglobulin. These results demonstrate, for the first time accurate monitoring of CMV-specific antibodies in saliva using a quantitative ELISA assay. The study suggests that secretion of CMV-specific antibodies in saliva of immunocompromised patients can be reconstituted by donor-derived B and plasma cells transferred with the BM or by i.v. administration of pooled Ig.

A longitudinal follow-up of salivary secretion in bone marrow transplant patients.

Salivary gland dysfunction is a common sequela of the bone marrow transplantation procedure. We determined the effect of different bone marrow transplantation protocols on parotid salivary flow rate. Salivary secretion was substantially reduced during conditioning of all the recipients. A gradual flow rate reconstitution could be detected as soon as a few days after the bone marrow transplantation. Eight patients conditioned with total lymph node irradiation and chemotherapy or chemotherapy alone displayed earlier and complete recovery of saliva secretions 2 to 5 months after the grafting. Recovery was delayed and incomplete when total body irradiation was added to the conditioning regimen (seven patients). Six of these patients also developed graft-versus-host disease. The results suggest that total body irradiation induces irreversible damage to the parotid glands resulting in profound xerostomia followed by opportunistic infections. Chemotherapy with or without total lymph node irradiation does not induce such damage.