Estimating the direct costs of oral cancer in Spain: a retrospective hospital data analysis.

BACKGROUND: Studies on the costs incurred from cancer in Spain are scarce and have focused on the most prevalent types such as colorectal, breast, and lung cancer. The aim of this study was to calculate the direct costs associated with the diagnostic, treatment and follow-up procedures for oral cancer in Spain. MATERIAL AND METHODS: Applying a bottom-up approach, we retrospectively analyzed the medical records of a cohort of 200 patients with oral cancer (C00-C10), diagnosed and treated in Spain between 2015 and 2017. For each patient, we collected their age, sex, degree of medical impairment (American Society of Anesthesiologists [ASA] classification), tumor extent (TNM classification), relapses and survival during the first 2 years of follow-up. The final calculation of the costs is expressed in absolute values in euros as the percentage of the gross domestic product per capita and in international dollars (I$). RESULTS: The total cost per patient rose to €16,620 (IQR, €13,726; I$11,634), and the total direct cost at the national level was €136,084,560 (I$95,259,192). The mean cost for oral cancer represented 65.1% of the gross domestic product per capita. The costs for the diagnostic and therapeutic procedures were determined by the ASA grade, tumor size, lymph node infiltration and presence of metastases. CONCLUSIONS: The direct costs for oral cancer are considerable compared with other types of cancer. In terms of gross domestic product, the costs were similar to those of countries neighboring Spain, such as Italy and Greece. The main determinants of this economic burden were the patient's degree of medical impairment and tumor extent.

The impact of COVID-19 on access to dental care for people with disabilities: a global survey during the COVID-19 first wave lockdown.

BACKGROUND: It is unclear what immediate impact the COVID-19 pandemic has had on delivery of oral healthcare to people with disabilities worldwide. AIM: To report the international impact of COVID-19 lockdown on oral healthcare provision for people with disabilities before, during and after the first lockdown (March to July 2020). MATERIAL AND METHODS: Cross-sectional online self-administered survey of dentists who treat people with disabilities completed 10th to 31st of July 2020. Responses allowed comparison from before, during and immediately after the first wave lockdowns of the COVID-19 pandemic. Data were analysed using McNemar's test to compare reported practice before to during lockdown, and before to after lockdown. RESULTS: Four-hundred-thirty-six respondents from across global regions reported a significant reduction from before to during and from before to after lockdown regarding: the proportion of dentists treating people with all types of disability (p <0.001) and the number of patients with disabilities seen per week (p<0.0001). The proportion reporting no availability of any pharmacological supports rose from 22% pre-lockdown to 61% during lockdown (p < 0.001) and a persistent 44% after lockdown (p < 0.001). An increase in teledentistry was observed. CONCLUSIONS: During the first COVID-19 lockdown, there was a significant negative impact on the delivery of dental care to people with disabilities. Oral healthcare access was significantly restricted for people with disabilities with access to sedation and general anaesthesia particularly affected. There is now an increased need to ensure that no-one is left behind in new and existing services as they emerge post-pandemic.

Intravenous amoxicillin/clavulanate for the prevention of bacteraemia following dental procedures: a randomized clinical trial.

OBJECTIVES: Although controversy exists regarding the efficacy of antibiotic prophylaxis for patients at risk of infective endocarditis, expert committees continue to publish recommendations for antibiotic prophylaxis regimens. This study aimed to evaluate the efficacy of four antimicrobial regimens for the prevention of bacteraemia following dental extractions. METHODS: The study population included 266 adults requiring dental extractions who were randomly assigned to the following five groups: control (no prophylaxis); 1000/200 mg of amoxicillin/clavulanate intravenously; 2 g of amoxicillin by mouth; 600 mg of clindamycin by mouth; and 600 mg of azithromycin by mouth. Venous blood samples were collected from each patient at baseline and at 30 s, 15 min and 1 h after dental extractions. Samples were inoculated into BACTEC Plus culture bottles and processed in the BACTEC 9240. Conventional microbiological techniques were used for subcultures and further identification of the isolated bacteria. The trial was registered at ClinicalTrials.gov with ID number NCT02115776. RESULTS: The incidence of bacteraemia in the control, amoxicillin/clavulanate, amoxicillin, clindamycin and azithromycin groups was: 96%, 0%, 50%, 87% and 81%, respectively, at 30 s; 65%, 0%, 10%, 65% and 49% at 15 min; and 18%, 0%, 4%, 19% and 18% at 1 h. Streptococci were the most frequently identified bacteria. The percentage of positive blood cultures at 30 s post-extraction was lower in the amoxicillin/clavulanate group than in the amoxicillin group (P < 0.001). The incidence of bacteraemia in the clindamycin group was similar to that in the control group. CONCLUSIONS: Bacteraemia following dental extractions was undetectable with amoxicillin/clavulanate prophylaxis. Alternative antimicrobial regimens should be sought for patients allergic to the ß-lactams.

Evaluation of two commercial nucleic acid amplification kits for detecting Mycobacterium tuberculosis in saliva samples.

OBJECTIVE: The objective of this study was to evaluate the efficacy of two commercial nucleic acid amplification techniques to identify Mycobacterium tuberculosis in saliva. SUBJECTS AND METHODS: Fifty-two participants were recruited, 32 patients with a clinical and microbiological diagnosis of pulmonary tuberculosis and 20 healthy volunteers as controls. Three sputum samples were collected from each participant and were examined by direct bacilloscopy, cultured in liquid and solid media, and processed using the Mycobacterium tuberculosis direct (MTD) test for rRNA detection. One saliva sample was collected from each participant using conventional methods and was examined by direct bacilloscopy, cultured, and processed using the MTD test for rRNA detection and the FluoroType Mycobacterium tuberculosis assay for DNA detection. RESULTS: In saliva samples, the sensitivity, specificity, and positive and negative predictive values of the MTD test were 71.8%, 95%, 95.8%, and 67.8%, respectively. The values obtained with the FluoroType assay were 56.2%, 90%, 90%, and 56.2%, respectively. CONCLUSIONS: Our results indicate that when a sufficient volume of sputum cannot be obtained, saliva could be an alternative biological sample for the rapid diagnosis of pulmonary tuberculosis using commercial nucleic acid amplification techniques.

Infective endocarditis prophylaxis.

Antibiotic prophylaxis for infective endocarditis continues to be administered empirically, although its indications are ever more restrictive. Some expert committees have even suggested that antibiotic prophylaxis is unnecessary, rekindling the controversy between those who defend the scientific evidence and those working in clinical practice; in any case, this proposal will facilitate the undertaking of prospective placebo-controlled trials, so necessary to resolve this issue. In the meantime, the most prudent approach is to adopt the recommendations proposed by the expert committees in each country.

Antiretroviral therapy: effects on orofacial health and health care.

This study summarizes the adverse effects of antiretroviral therapy (ART) agents against HIV on orofacial health and health care. Current antiretroviral agents fall mainly into three major classes: nucleoside reverse-transcriptase inhibitors (NRTIs), non-nucleoside reverse-transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) - now with the new classes of fusion inhibitors, entry inhibitors--CCR5 co-receptor antagonists and HIV integrase strand transfer inhibitors. Many of the ART agents can have adverse orofacial effects, or can give rise to allergies or drug interactions--the optimum anti-HIV drug has yet to be found. There are few orofacial adverse effects that characterize a particular ART class, but erythema multiforme (EM), ulcers and xerostomia may be associated with reverse-transcriptase inhibitors (RTI); parotid lipomatosis, taste disturbance, xerostomia and perioral paraesthesia mainly related to PIs. Facial lipoatrophy is a common adverse effect of NRTIs; EM is more frequently associated with NNRTIs. Thus, although most of the more recent ART drugs and combinations of them show improved safety profiles, some may give rise to orofacial adverse effects, and may affect oral health care.

Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay?

Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimize diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a 'scheduling delay' in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices. The access to and the kind of healthcare system in a particular country are also relevant in this context, particularly the referral system. The design of a simple, clear, fail-safe, fast-track referral scheme for those suspected with cancer may diminish greatly the length of the delay. Moreover, there is a need for future investigations, which are methodologically adequate, that consider cultural and geographical aspects and use patient survival as the final outcome, that are able to recognize the agents/factors responsible for diagnostic delay by patients as well as healthcare providers and those attributable to the healthcare systems.

Efficacy of fluoroquinolones against pathogenic oral bacteria.

This article reviews the characteristics of the main fluoroquinolones used in dentistry (ciprofloxacin, levofloxacin and moxifloxacin), including pharmacokinetic/ pharmacodynamic parameters, susceptibility profiles of oral bacteria and clinical trials on their efficacy in dental practice. It seems that some of these antibiotics might represent a safe alternative in patients with allergy, intolerance, or lack of response to beta-lactams.

Stomatology and odontology: perspectives of Spanish professors and senior lecturers in dentistry.

The curricula of dental faculties in many countries of the European Union can be described as odontological. The faculties of some of the countries who have become and are becoming members of the European Community have traditionally educated dentists in the stomatological tradition. In 1987, the Spanish dental education system initiated movement from the stomatological model to the odontological. Both models have their respective strengths and weaknesses. This study surveyed professors and senior lecturers in Spain's public dental faculties to assess their perspectives on 10 items related to the tension between the odontological and the stomatological approach to preparing dentists. Amongst other things, the results of the study indicate that the respondents believe the odontological model, with its emphasis on strengthening technical qualifications, may not prepare individuals for dental practice better than the stomatology tradition; and that the odontological model results in the loss of the strength of the stomatological model, that is, the strong foundation in clinical medicine. The suggestion is advanced that European dental educators consider revising the odontology curriculum to strengthen the education of dental students in clinical medicine. A curriculum in which dental and medical students share the first 3 years of study could accomplish this. It is further suggested that subsequent years in the curriculum be flexible enough for students to earn degrees in both dentistry and medicine, if desired. Such an approach is not inconsistent with the accepted profile and competencies of the European dentist.

Efficacy of antibiotic prophylactic regimens for the prevention of bacterial endocarditis of oral origin.

Despite the controversy about the risk of individuals developing bacterial endocarditis of oral origin, numerous Expert Committees in different countries continue to publish prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures. In this paper, we analyze the efficacy of antibiotic prophylaxis in the prevention of bacteremia following dental manipulations and in the prevention of bacterial endocarditis (in both animal models and human studies). Antibiotic prophylaxis guidelines remain consensus-based, and there is scientific evidence of the efficacy of amoxicillin in the prevention of bacteremia following dental procedures, although the results reported do not confirm the efficacy of other recommended antibiotics. The majority of studies on experimental models of bacterial endocarditis have verified the efficacy of antibiotics administered after the induction of bacteremia, confirming the efficacy of antibiotic prophylaxis in later stages in the development of bacterial endocarditis. There is no scientific evidence that prophylaxis with penicillin is effective in reducing bacterial endocarditis secondary to dental procedures in patients considered to be "at risk". It has been suggested that there is a high risk of severe allergic reactions secondary to prophylactically administered penicillins, but, in reality, very few cases have been reported in the literature. It has been demonstrated that antibiotic prophylaxis could contribute to the development of bacterial resistance, but only after the administration of several consecutive doses. Future research on bacterial endocarditis prophylactic protocols should involve the re-evaluation of the time and route of administration of antibiotic prophylaxis, and a search for alternative antimicrobials.

"Scheduling delay" in oral cancer diagnosis: a new protagonist.

Diagnostic delays in oral cancer have been classified as "patient delay" and "delay by the clinicians". However, the influence of the accessibility (scheduling delay) to the health care system in oral cancer diagnosis has not been studied before. To assess scheduling delay, a descriptive, cross-sectional study was designed. This study was based upon role-play telephone conversations with two standardised patients (lingual ulceration-SP1 and patient seeking fixed prosthodontics-SP2). that followed a structured script. The variables considered in the study were days to go until the arranged appointment, professional degree of the contacted person and referral to other provider of care. The scheduling delay for SP1 reached a median value of 1 day, and for SP2 was 6 days. When the professional degree (receptionist vs GDP) of the person arranging the appointment for the patient with lingual ulceration was considered, the scheduling delay was significantly shorter when the appointment was fixed by the GDP (X approximately i-X approximately j=4.5; 95%CI=-7.48,-1.51). GDPs gave priority to the patients with lingual ulcerations over those demanding fixed bridgework (X approximately i-X approximately j=6.48; 95%CI=-9.46,-3.50). The GDPs showed a high level of awareness of the oral cancer, however, educational interventions seem to be necessary for dental surgery receptionists.

Detection of HCV RNA in saliva of patients with hepatitis C virus infection by using a highly sensitive test.

Hepatitis C virus (HCV) is transmitted primarily by direct percutaneous exposures to blood. Since HCV RNA has been found in saliva, it has been suggested that saliva might also be a source of infection. HCV RNA in saliva from plasma HCV RNA positive patients was tested by a highly sensitive PCR method. HCV RNA was detected in 32 out of 61 saliva specimens (52.4%). No correlation was found between the presence of HCV in saliva and age, sex, identified risk factors for HCV infection, time lapsed since the diagnosis, transaminases and alkaline phosphatase values and stimulated salivary flow. A statistically significant relation between plasma HCV RNA viral load and saliva HCV RNA detection was observed (P<0.001). In conclusion, HCV RNA is often present in saliva of HCV infected patients, with plasma viral load being the only known predictable factor. Further studies on salivary HCV RNA are needed.

Intra-alveolar granulocytic sarcoma developing after tooth extraction.

Granulocytic sarcoma (GS) is a malignant tumour composed of poorly differentiated myeloid cells forming in an extramedullary site. It is generally associated with acute leukaemia, particularly the myelocytic type. Its appearance in patients with chronic myeloid leukaemia is exceptional. GS can appear in multiple locations with the oral cavity being rarely involved. A mandibular GS detected in a patient with chronic myeloid leukaemia 10 days after a tooth extraction is reported. The pathogenesis (by metastatic cells or migration through the Haversian canals) of the tumour is discussed.

Regression of AIDS-related Kaposi's sarcoma following ritonavir therapy.

This paper describes a case report of an HIV-infected patient with mucocutaneous Kaposi's sarcoma (KS) with oral involvement, which presented complete clinical resolution of lesions on antiretroviral treatment with ritonavir, an HIV-1 protease inhibitor. Although it has still not been demonstrated that ritonavir has a specific antiviral action against HHV-8, a gamma herpesvirus probably involved in KS aetiopathogenesis, it has been proven that it reduces the HIV load significantly. This affects certain growth factors of KS, such as Tat protein and cytokines, and favours recovery of immune function, which correlates with protection against AIDS-defining conditions.

Thalidomide for the treatment of acquired immunodeficiency syndrome-associated refractory oral ulcers.

A case of severe, oral, not otherwise specified ulcers in a human immunodeficiency virus-infected patient is described. The lesions did not respond to acyclovir, prednisone, pentoxifylline, or foscarnet sodium therapy. Dramatic clinical improvement and progressive ulcer healing were observed after starting oral thalidomide therapy. Clinicians should be aware of the usefulness of thalidomide for the treatment of acquired immunodeficiency syndrome-associated not otherwise specified ulcerations.

An update on infective endocarditis of dental origin.

OBJECTIVES: The aim of this study was to analyse the prevalence of dental treatment and oral infections related to the development of infective endocarditis (IE). METHODS: A retrospective study of 103 cases of IE diagnosed from 1997 to 1999 was conducted in Galicia, Spain. RESULTS: According to the Duke's endocarditis criteria (1994), 87 cases (84.5%) were considered definite IE. A presumed oral portal of entry was recorded in 12 patients (13.7%). Oral infections were held responsible in six cases while the remaining six had received dental treatment in the previous three months (three tooth extractions, one scaling, one cleaning, one fillings). In eight cases of IE (66.6%) typical oral pathogenic microflora was identified, with Streptococcus viridans being the most frequent. In four patients no previous cardiac disease was recorded. CONCLUSIONS: These results suggest that prevalence and characteristics of IE cases of dental origin did not change significantly in the last decades. The need for increased oral hygiene and improved dental care should be emphasized on preventing IE of dental origin. Continued education of physicians and dentists on the importance of the knowledge of current prophylactic protocols should also be considered.

Bacterial endocarditis of oral etiology in an elderly population.

The aim of this study was to analyze the prevalence and characteristics of bacterial endocarditis (BE) of oral origin in a group of elderly people. A retrospective study of 115 BE clinical records was performed, focusing on the demographic and predisposing features, as well as on the analytical and clinical variables. Twenty-two of the 115 cases were excluded as they were detected in intravenous drug users. Of the remaining 93 cases, 54.8% were diagnosed in patients older than 60 years of age (group A) and 45.2% in patients younger than 60 years (group B). There were 16 cases (17.2%) of oral origin; 4 BE cases mainly associated with tooth extractions were found in group A and 12 BE (most of them related with odontogenic abscesses) in group B. Within group A, 1 patient (25%) had not an underlying cardiac condition versus 5 cases (41.6%) in group B. Even though the prevalence of BE of oral origin in patients older than 60 is low, the high frequency of cardiopathies, poor oral health and high number of dental procedures shown by the old population makes them a risk group for BE of oral origin.

Fluconazole response patterns in HIV-infected patients with oropharyngeal candidiasis.

A prospective study to assess the efficacy of fluconazole in oropharyngeal candidiasis in patients with HIV was conducted. A cohort of 30 HIV-positive persons with clinical and microbiologic confirmed oropharyngeal candidiasis (Candida albicans > 1000 CFU/ml) received fluconazole 100 mg daily for 7 days. In vitro antifungal susceptibility tests demonstrated a lack of fluconazole resistances. Cultures of mouth swabs were performed at the end of therapy and 2 weeks later. There was a clinical and microbiologic cure in 26 patients (87%). In 10 of these 26, cultures remained negative after 2 weeks; most of them had CD4 lymphocyte count > 400/ml. In the other 16 patients (53%), cultures showed a microbiologic relapse 2 weeks after treatment. In spite of clinical improvement, treatment failure was observed in four patients, all of them with CD4 lymphocyte count < 50 ml.

Frequency of oropharyngeal candidiasis in HIV-infected patients on protease inhibitor therapy.

OBJECTIVE: The purpose of this study was to investigate the effect of HIV-1 protease inhibitors on the frequency of oropharyngeal candidiasis in HIV-infected patients. STUDY DESIGN: A clinical and analytic follow-up was carried out to determine the number of episodes of oropharyngeal candidiasis during HIV-1 protease inhibitor therapy and the relation of this incidence to the CD4 lymphocyte count and circulating neutrophils level. Seventy-five HIV-positive patients were selected, and HIV-1 protease inhibitor therapy was administered to each patient over a minimum of 6 months. These patients did not receive long-term preventive antifungal therapy for oral candidiasis, even as secondary prophylaxis against cryptococcosis. Results were compared with those obtained during the previous 6 months, during which patients had been treated only with reverse transcriptase inhibitors. RESULTS: At least one episode of oropharyngeal candidiasis was seen in 56% (42/75) of patients during reverse transcriptase inhibitor therapy and in only 9.3% (7/75) of patients after the initiation of protease inhibitor therapy. The number of relapses decreased significantly when the 2 follow-up periods were compared (P<.0001). The CD4 and CD8 lymphocyte counts increased significantly with protease inhibitor therapy (P<.001 and P<.05, respectively). During reverse transcriptase inhibitor treatment, the probability of the presentation of oropharyngeal candidiasis correlated with falling CD4 counts (P<.0001). The HIV-1 protease inhibitor therapy was associated with a significant increase in the neutrophil count (P<.01). The probability of the occurrence of some episode of candidiasis correlated inversely with the circulating neutrophil level (P<.05). CONCLUSIONS: Protease inhibitor therapy decreases the frequency of HIV-related oropharyngeal candidiasis. The mechanism involved is unknown, but it can be speculated that a reduction of the viral load increases the number of intact T helper cells, which in turn enhances the number of circulating polymorphonuclear neutrophils and regulates their function by means of colony-stimulating factors.