Top studies of 2023 relevant to primary care: From the PEER team.

OBJECTIVE: To provide a summary of the noteworthy medical articles published in 2023 that are relevant to family physicians. SELECTING THE EVIDENCE: Articles were chosen and ranked by the PEER (Patients, Experience, Evidence, Research) team, a group of primary care health professionals focused on evidence-based medicine. The selection process involved routine surveillance of tables of contents in high-impact medical journals and continuous monitoring of EvidenceAlerts. Articles were prioritized based on their direct applicability to and potential to influence primary care practice. MAIN MESSAGE: Selected articles addressed various clinical areas of primary care. The topics included a comparison of a treat-to-target approach versus a high-intensity statins prescription for lipid management; semaglutide and its impact on cardiovascular outcomes; respiratory syncytial virus vaccine for older adults; chlorthalidone versus hydrochlorothiazide in preventing cardiovascular events; amitriptyline for irritable bowel syndrome; the role of opioids in acute back pain; safety of oral penicillin challenges in patients allergic to penicillin; spironolactone for facial acne; strategies to reverse frailty in older adults; and identifying the provider of chronic disease management. Two "up and coming" medications are also mentioned: retatrutide for weight loss and fezolinetant for vasomotor symptoms of menopause. CONCLUSION: Research published in 2023 yielded several high-quality articles with topics relevant to primary care, including cardiovascular care, irritable bowel syndrome, care of the elderly, and acne management.

Lipid-lowering therapies for cardiovascular disease prevention and management in primary care: PEER umbrella systematic review of systematic reviews.

OBJECTIVE: To assess the benefits and harms of lipid-lowering therapies used to prevent or manage cardiovascular disease including bile acid sequestrants (BAS), ezetimibe, fibrates, niacin, omega-3 supplements, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, and statins. DATA SOURCES: MEDLINE, the Cochrane Database of Systematic Reviews, and a grey literature search. STUDY SELECTION: Systematic reviews of randomized controlled trials published between January 2017 and March 2022 looking at statins, ezetimibe, PCSK9 inhibitors, fibrates, BAS, niacin, and omega-3 supplements for preventing cardiovascular outcomes were selected. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, and adverse events. SYNTHESIS: A total of 76 systematic reviews were included. Four randomized controlled trials were also included for BAS because no efficacy systematic review was identified. Statins significantly reduced MACE (6 systematic reviews; median risk ratio [RR]=0.74; interquartile range [IQR]=0.71 to 0.76), cardiovascular mortality (7 systematic reviews; median RR=0.85, IQR=0.83 to 0.86), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.88 to 0.92). Major adverse cardiovascular events were also significantly reduced by ezetimibe (3 systematic reviews; median RR=0.93, IQR=0.93 to 0.94), PCSK9 inhibitors (14 systematic reviews; median RR=0.84, IQR=0.83 to 0.87), and fibrates (2 systematic reviews; mean RR=0.86), but these interventions had no effect on cardiovascular or all-cause mortality. Fibrates had no effect on any cardiovascular outcomes when added to a statin. Omega-3 combination supplements had no effect on MACE or all-cause mortality but significantly reduced cardiovascular mortality (5 systematic reviews; median RR=0.93, IQR=0.93 to 0.94). Eicosapentaenoic acid ethyl ester alone significantly reduced MACE (1 systematic review, RR=0.78) and cardiovascular mortality (2 systematic reviews; RRs of 0.82 and 0.82). In primary cardiovascular prevention, only statins showed consistent benefits on MACE (6 systematic reviews; median RR=0.75, IQR=0.73 to 0.78), cardiovascularall-cause mortality (7 systematic reviews, median RR=0.83, IQR=0.81 to 0.90), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.87 to 0.91). CONCLUSION: Statins have the most consistent evidence for the prevention of cardiovascular complications with a relative risk reduction of about 25% for MACE and 10% to 15% for mortality. The addition of ezetimibe, a PCSK9 inhibitor, or eicosapentaenoic acid ethyl ester to a statin provides additional MACE risk reduction but has no effect on all-cause mortality.

PEER simplified lipid guideline 2023 update: Prevention and management of cardiovascular disease in primary care.

OBJECTIVE: To update the 2015 clinical practice guideline and provide a simplified approach to lipid management in the prevention of cardiovascular disease (CVD) for primary care. METHODS: Following the Institute of Medicine's Clinical Practice Guidelines We Can Trust, a multidisciplinary, pan-Canadian guideline panel was formed. This panel was represented by primary care providers, free from conflicts of interest with industry, and included the patient perspective. A separate scientific evidence team performed evidence reviews on statins, ezetimibe, proprotein convertase subtilisin-kexin type 9 inhibitors, fibrates, bile acid sequestrants, niacin, and omega-3 supplements (docosahexaenoic acid with eicosapentaenoic acid [EPA] or EPA ethyl ester alone [icosapent]), as well as on 11 supplemental questions. Recommendations were finalized by the guideline panel through use of the Grading of Recommendations Assessment, Development and Evaluation methodology. RECOMMENDATIONS: All recommendations are presented in a patient-centred manner designed with the needs of family physicians and other primary care providers in mind. Many recommendations are similar to those published in 2015. Statins remain first-line therapy for both primary and secondary CVD prevention, and the Mediterranean diet and physical activity are recommended to reduce cardiovascular risk (primary and secondary prevention). The guideline panel recommended against using lipoprotein a, apolipoprotein B, or coronary artery calcium levels when assessing cardiovascular risk, and recommended against targeting specific lipid levels. The team also reviewed new evidence pertaining to omega-3 fatty acids (including EPA ethyl ester [icosapent]) and proprotein convertase subtilisin-kexin type 9 inhibitors, and outlined when to engage in informed shared decision making with patients on interventions to lower cardiovascular risk. CONCLUSION: These updated evidence-based guidelines provide a simplified approach to lipid management for the prevention and management of CVD. These guidelines were created by and for primary health care professionals and their patients.

Lignes directrices simplifiées de PEER sur les lipides : actualisation 2023: Prévention et prise en charge des maladies cardiovasculaires en soins primaires.

OBJECTIF: Actualiser le guide de pratique clinique de 2015 et présenter une approche simplifiée de la prise en charge des lipides dans la prévention des maladies cardiovasculaires (MCV) en première ligne. MÉTHODES: Conformément aux recommandations de l'Institute of Medicine dans Clinical Practice Guidelines We Can Trust, un panel pancanadien d'experts multidisciplinaires en lignes directrices a été formé. Ce panel était représentatif des cliniciens en soins primaires, libre de tout conflit d'intérêts avec l'industrie, et il tenait compte des points de vue des patients. Une équipe distincte, responsable des données probantes scientifiques, a passé en revue l'information sur les statines, l'ézétimibe, les inhibiteurs de la proprotéine convertase subtilisine-kexine de type 9, les fibrates, les chélateurs des acides biliaires, la niacine et les suppléments d'omega-3 (acide docosahexaénoïque avec acide eicosapentaénoïque [EPA] ou ester éthylique de l'EPA seul [icosapent]), ainsi que sur la réponse à 11 questions supplémentaires. Le panel des lignes directrices a finalisé les recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). RECOMMANDATIONS: Toutes les recommandations sont présentées de manière à être centrées sur le patient et conçues en ayant à l'esprit les besoins des médecins de famille et des autres cliniciens des soins primaires. De nombreuses recommandations sont semblables à celles publiées en 2015. Les statines demeurent le traitement de première intention pour la prévention tant primaire que secondaire des MCV, et le régime méditerranéen et l'activité physique sont recommandés pour réduire le risque cardiovasculaire (en prévention primaire et secondaire). Le panel des lignes directrices a recommandé de ne pas utiliser le dosage des lipoprotéines a, des apolipoprotéines B ou le score calcique coronarien (SCC) dans l'évaluation du risque cardiovasculaire, et de ne pas cibler de seuils précis de taux lipidiques. L'équipe a aussi passé en revue de nouvelles données concernant les acides gras omega-3 (y compris l'ester éthylique d'EAP [icosapent]) et les inhibiteurs de la proprotéine convertase subtilisine-kexine de type 9, et a précisé les moments où il convient de procéder à une prise de décision partagée avec les patients sur les interventions pour diminuer le risque cardiovasculaire. CONCLUSION: Ces lignes directrices actualisées et fondées sur des données probantes présentent une approche simplifiée de la prise en charge des lipides pour la prévention et le traitement des MCV. Ce guide de pratique clinique a été conçu par et pour des professionnels de la santé en soins primaires et leurs patients.

Herpes zoster of gingiva in an older woman: a rare case report.

OBJECTIVE: The aim of the article is to highlight the distinguishing features of secondary varicella gingival infection in an older women. BACKGROUND: Herpes zoster is an acute sporadic, painful viral infection in older people caused by the reactivation of the latent varicella zoster virus. Herpes zoster affecting the gingiva without any dermal lesions is a rare pathological condition that mimics many intraoral vesiculobullous lesions. The ambiguous nature of this condition creates a diagnostic dilemma. MATERIALS AND METHODS: A 58-year-old woman presented with an acute, unilateral and persistent burning sensation and pain in the gingiva with desqaumating vesicullobulous lesion. RESULTS: The women was diagnosed with secondary varicella zoster infection. CONCLUSION: Herpes zoster of the gingiva could manifest as painful desquamative vesicular lesions, pulpal or other painful neuralgic condition in older individuals which need careful diagnosis before formulating appropiate treatment plan.

Auditory and Nonauditory Effects of Ultrasonic Scaler Use and Its Role in the Development of Permanent Hearing Loss.

PURPOSE: To evaluate the negative auditory and non-auditory effects developed immediately after using ultrasonic scalers and their potential role in the development of permanent hearing loss. MATERIALS AND METHODS: The auditory functions of 60 dental clinicians were evaluated with the pure tone audiometry test (PTA), tympanogram and the otoacoustic emission test (OAE) before and immediately after using ultrasonic scalers. The paired t-test was used to evaluate the difference in the pre- and post-exposure recordings for all three tests. RESULTS: There was a significant increase in the PTA and tympanogram test results, along with reduced OAE values immediately after using ultrasonic scalers. Hearing ability dropped by 63% to 66% immediately after using ultrasonic scalers. The maximum hearing disability was noted for low-frequency thresholds. The reduction was greater in the left than in the right ear. CONCLUSIONS: Noise-emitting devices such as ultrasonic scalers produce significant immediate auditory and non-auditory changes. It is important that dentists recognise the initial signs of hearing damage and adopt appropriate measures while working to prevent the development of permanent hearing impairment in future.

Green Tea Intake as an Adjunct to Mechanical Periodontal Therapy for the Management of Mild to Moderate Chronic Periodontitis: A Randomized Controlled Clinical Trial.

PURPOSE: To evaluate and compare the beneficial effects of green tea intake on the total antioxidant capacity of gingival crevicular fluid (GCF) and plasma, and to examine its role as an adjunct to nonsurgical periodontal therapy for the management of chronic periodontitis. MATERIALS AND METHODS: 120 subjects with mild to moderate chronic periodontitis were divided equally into two groups. After scaling and root planing in all subjects, green tea supplements were given to the case group and a placebo to the control group. The clinical parameters gingival index, plaque index, clinical probing depth, clinical attachment loss, percentage of sites with bleeding on probing, along with total antioxidant capacity of GCF and plasma were recorded at baseline, one and three months. RESULTS: There was a significant improvement in all clinical parameters along with an 8-fold greater antioxidant capacity in GCF in the case group than in the control group. CONCLUSION: Green tea intake as a component of nonsurgical periodontal therapy is promising for superior and rapid resolution of the disease process. Green tea increases the total antioxidant capacity of GCF and plasma along with potent anti-inflammatory, astringent and anti-plaque effects.

Manual toothbrushing reinforced with audiovisual instruction versus powered toothbrushing among institutionalized mentally challenged subjects--a randomized cross-over clinical trial.

AIM: To assess and compare the effectiveness of Manual toothbrushing reinforced with audiovisual instructions with powered toothbrushing, among the institutionalized mentally challenged individuals under supervision of trained caretakers. MATERIALS AND METHODS: A randomized cross over clinical trial of 6 months duration which included 16 subjects consisting of two phases of three months, for each of the 2 groups. In group A subjects were given manual toothbrushes with audio-visual aid followed by the powered toothbrushes & vice versa for group B. All subjects were instructed by trained care takers. An evaluation of the plaque & gingival scores was done at the end of 1, 2 & 3 months for both the groups. RESULTS: Phase I showed statistically significant decrease in mean plaque scores (p=0.037) but insignificant mean gingival scores (p=0.189) in group A at end of 3 months. In phase II, statistically insignificant decrease in mean plaque & gingival scores were recorded at end of 3 months. In group B a statistically significant decrease in both plaque (p=0.002) & gingival (p=0.001) was found at end in both phases. Comparison of mean plaque & gingival scores of manual & powered toothbrushes at different intervals in both groups were statistically insignificant. CONCLUSION: For mentally challenged individuals, manual toothbrushes reinforced with audio-visual instructions for brushing may be comparable to the use of powered toothbrushes.

Esthetic management of the upper labial frenum: a novel frenectomy technique.

An abnormal upper labial frenum is capable of retracting the gingival margin, creating a diastema, limiting lip movement, and in cases of a high smile line, affecting esthetics also. When an abnormal frenum is present, frenectomy is advised. This technique has been modified in many ways. But in most of the techniques the zone of attached gingiva and esthetics are not considered. This case report highlights a new technique of frenectomy that results in good esthetics, excellent color match, gain in attached gingiva, and healing by primary intention at the site of the thick, extensive abnormal frenum.

Periodontal diseases and awareness among patients.

Awareness of periodontal problems and how they interpret this and their timely intervention affects periodontal health. Many people neither recognize the symptoms of periodontal disease nor do they associate existing symptoms with the disease. Hence one should ensure that the routes of science transfer are open so that the appropriate knowledge regarding the prevention and control of periodontal diseases are available to the public.

Garlic burn as self-inflicted mucosal injury--a case report and review of the literature.

Garlic is considered a valuable herbal medicine and has been used for centuries for treatment of various ailments. Along with its benefits comes some adverse effects. The present case describes chemical burn of oral mucosa caused by crushed garlic. To relieve toothache, the patient placed crushed garlic cloves in the buccal vestibule overnight and developed garlic burn injury manifesting as slough and ulceration in that region. Diagnosis was made on the basis of definitive history elicited from the patient. Topical anesthetic and antibacterial agents were advised for local application, and systemic analgesic was prescribed. The patient was referred to the Department of Endodontics for further treatment of the toothache. Garlic burn should be considered in the differential diagnosis for chemical burn if the burn is not found to be associated with other common factors, and history taking should include questions regarding use of herbal products, home remedies, and alternative medicine. Possible adverse effects of these methods should be considered.

Manual toothbrushing reinforced with audiovisual instruction versuspowered toothbrushing among institutionalized mentally challengedsubjects-A randomized cross-over clinical trial

Aim: To assess and compare the effectiveness of Manual toothbrushing reinforced with audiovisual instructionswith powered toothbrushing, among the institutionalized mentally challenged individuals under supervision oftrained caretakers.Materials and Methods: A randomized cross over clinical trial of 6 months duration which included 16 subjectsconsisting of two phases of three months, for each of the 2 groups. In group A subjects were given manual toothbrusheswith audio-visual aid followed by the powered toothbrushes & vice versa for group B. All subjects wereinstructed by trained care takers. An evaluation of the plaque & gingival scores was done at the end of 1, 2 & 3months for both the groups.Results: Phase I showed statistically significant decrease in mean plaque scores (p=0.037) but insignificant meangingival scores (p=0.189) in group A at end of 3 months. In phase II, statistically insignificant decrease in meanplaque & gingival scores were recorded at end of 3 months. In group B a statistically significant decrease in bothplaque (p=0.002) & gingival (p=0.001) was found at end in both phases. Comparison of mean plaque & gingivalscores of manual & powered toothbrushes at different intervals in both groups were statistically insignificantConclusion: For mentally challenged individuals, manual toothbrushes reinforced with audio-visual instructionsfor brushing may be comparable to the use of powered toothbrushes (AU)

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