Recent infective endocarditis research findings suggest dentists prescribe prophylactic antibiotics for patients having a bicuspid aortic valve or mitral valve prolapse.

BACKGROUND: The scientific validity of the European Society of Cardiology's (ESC) infective endocarditis (IE) guidelines limiting provision of prophylactic antibiotics (AP) only to patients having cardiac anomalies (e.g., prosthetic valves) believed to place them at "high risk" of adverse events when undergoing high risk dental procedures (HRDP) is unclear. MATERIAL AND METHODS: A systematic review of studies conducted between 2017 and 2022 and catalogued in the PubMed database was undertaken to ascertain if this edict was associated with changes in IE incidence, development of infection in unprotected cardiac anomalies, developing infection and resultant adverse clinical outcomes. RESULTS: Retrieved were 19 published manuscripts, however of these, 16 were excluded because they did not bare upon the issues of concern. Among the three studies eligible for review were those in the Netherlands, Spain, and England. The results of the Dutch study denoted a significant increase in the incidence of IE cases over the projected historical trend (rate ratio: 1327, 95% CI 1.205-1.462; p<0.001) after the introduction of the ESC guidelines. The findings from the Spanish study evidenced the uniquely high in-hospital IE associated fatality rates suffered by patients having bicuspid aortic valves (BAV); 5.6% or mitral valve prolapse (MVP); 10%. The British study provided evidence that the incidence of fatal IE infection was significantly greater among an "intermediate risk" cohort of patients, (a group likely including those with BAC and MVP for which the ESC guidelines don't recommend AP), than among "high risk" patients (P = 0.002). CONCLUSIONS: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the "high risk" category so that AP are recognized as being needed prior to provision of HRDP.

Detection of carotid artery calcification on the panoramic images of post-menopausal females is significantly associated with severe abdominal aortic calcification: a risk indicator of future adverse vascular events.

OBJECTIVES: Outcome studies among post-menopausal females with calcified carotid artery plaque (CCAP) on their panoramic images have not been previously undertaken. We sought to compare the extent of abdominal aortic calcification (AAC) on lateral lumbar spine radiographs (LLSRs), among groups of females with (CCAP+) and without (CCAP-) carotid lesions on their panoramic images. "Severe" levels of AAC have previously been validated as a risk indicator of future adverse cardiovascular events. METHODS: This cross-sectional case-control study included a "CCAP+ group" consisting of females more than 50 years of age having the carotid lesion diagnosed by their dentists and an atherogenic risk factor (age, body mass index, hypertension, diabetes and dyslipidaemia)-matched "CCAP- group". A physician radiologist, using the Framingham index, evaluated the LLSRs for the magnitude of AAC. Summary statistics for key variables were computed and conditional logistic regression techniques were considered. RESULTS: Members of the CCAP+ group were significantly (p=0.038) more likely to demonstrate "severe" levels of AAC on their LLSRs than members of the CCAP group. CONCLUSIONS: This is the first published study demonstrating that CCAP on panoramic images of post-menopausal females is significantly associated with "severe" levels of AACs on LLSRs independent of traditional risk factors. Given that these levels of AAC are a validated risk indicator of future myocardial infarction and stroke, dentists must evaluate the panoramic images of post-menopausal females for the presence of CCAP. Patients with carotid atheromas should be referred to their physicians for further evaluation given the systemic implications.

Mandible stabilization between ablative and reconstructive surgery.

The biphase external skeletal-fixation splint (Morris splint) for mandibular stabilization has been used in cases of ablative surgery. It is a practical approach to stabilization for patients whether or not they undergo reconstruction, either immediate or delayed. The Morris splint can be applied without increasing the time required for major resection. It can be left in place for prolonged periods, but it still allows easy surgical access and easy postoperative care and observation. While not a new tool, it has been little used by the head and neck cancer surgeon, probably because it has not been presented for this purpose but rather for treating fractures. A practical approach to the use of the Morris biphase splint is presented, as well as the indications for its use and some results of our experience with this tool.

Detection of radiation-induced cervical atheromas by panoramic radiography.

Therapeutic irradiation of the neck is frequently used to treat patients with head and neck carcinoma. The irradiation, however, has been implicated as the cause of cervical carotid artery atherosclerotic lesions and subsequent stroke. Panoramic radiography previously shown capable of demonstrating isolated lesions was used to assess their development over time. Individuals with a pre-irradiation radiograph free of atheromas were enrolled for study. The prevalence rate of atheroma formation on post-irradiation (bilateral portals at >/=45 Gy) radiographs obtained at an interval of >/=36 months was determined. A control group of non-irradiated patients having similar risk factors for head and neck carcinoma and atherosclerosis and having an initial radiograph free of atheroma formation were likewise enrolled for study. The prevalence rate of atheroma formation on a second radiograph obtained from these individuals at an interval of >/=36 months was determined. The study population consisted of 17 patients, with a mean age of 56.5 (range 21.5-77.8) years who received a mean therapeutic irradiation dose of 53.2 Gy (range 45-71) to each side of their neck. The prevalence rate of atheromas manifested on the post-irradiation radiographs was 53%. These radiographs were obtained, on average, 69.7 (range 37-133) months after completion of radiation therapy. The prevalence rate of atheromas manifested on the second radiograph of patients in the control group was 5.9%. These radiographs were obtained, on average, 53.5 (range 52-55) months after the first. The difference in prevalence rates was statistically significant (p=0.0003). Individuals who have received therapeutic irradiation to the neck are more likely to develop carotid artery atheromas after treatment than are risk-matched control patients who have not been irradiated. These lesions can be detected by panoramic radiography.

Pathogenesis and prevention of native valve infective endocarditis in elderly dental patients.

Elderly dental patients are at risk of developing infective endocarditis. Increased longevity is associated with an increased prevalence of cardiac valvular disease and impairment of the immune system. Aortic stenosis commonly occurs in persons between 60 and 75 years of age. Degenerative calcification of the mitral valve ring leading to valve incompetency often develops in those over age 70 years. Men over the age of 60 years with mitral valve prolapse and systolic hypertension are at risk of infective endocarditis because the excessive haemodynamic load placed upon the abnormal valve causes extensive stretching of cusps and loss of valve surface endothelium. Dental procedures, that result in mucosal or gingival bleeding (most notably dental extractions, periodontal probing, scaling and surgery, endodontics and restorative procedures which extend below the gingival line), frequently produce a bacteraemia. Anaerobic strains of bacteria are isolated twice as frequently as aerobic strains. Antibiotic prophylaxis decreases the level of bacteraemia, prevents adherence of bacteria to the damaged valvular epithelium and suppresses the growth of those microbes that manage to adhere to the valve. The standard prophylactic regimen consists of amoxicillin 3g 1 hour before the dental procedure, then 1.5g 6 hours after the initial dose. Erythromycin is a good alternative for penicillin-allergic patients. Topical chlorhexidine 5 minutes before initiating dental therapy reduces the bacterial inoculum and the likelihood of endocarditis.

The role of panoramic radiography in determining an increased risk of cervical atheromas in patients treated with therapeutic irradiation.

PURPOSE: Therapeutic irradiation of the neck is a common component of treatment for those with carcinoma of the oral cavity, pharynx, and larynx. Such irradiation, however, has been implicated as the cause of accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in non-irradiated individuals, was used to assess the carotid vasculature of patients who had been treated for cancer with therapeutic irradiation. METHODS: The panoramic radiographs of 33 male subjects who had received therapeutic irradiation (> or = 50 Gy) to the neck 30 or more months previously were assessed for the presence of calcified carotid artery atherosclerotic lesions. Age-matched controls, similarly liable for oropharyngeal malignancy and atherosclerosis by virtue of their medical and habitual risk factors (hypertension, smoking, obesity) were assessed in a like manner. RESULTS: The panoramic radiographs of the irradiation-treated subjects (age range, 32 to 84 years; mean age, 66.1 years) showed that 21% (7 of 33 subjects) had calcified atherosclerotic lesions. The mean age of these seven subjects was 64.6 years; four had unilateral lesions and three had bilateral lesions. The radiographs of the control subjects showed that 4.7% (5 of 107 subjects) had calcified atherosclerotic lesions. The mean age of these five subjects was 67; three had unilateral lesions and two had bilateral lesions. The lesions seen in the two populations had similar morphologic appearances. The discrete radiopaque calcifications were located within the soft tissues of the neck, approximately 2.5 cm inferior-posterior to the angle of the mandible. CONCLUSIONS: Subjects who had received therapeutic irradiation of the neck had a statistically higher risk (p = 0.007, according to Fisher's Exact Test) of the development of calcified carotid artery atherosclerotic lesions than age-matched, risk-matched, non-irradiated control subjects. These lesions can be detected on routine panoramic radiographs.

The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus.

OBJECTIVE: Type 2 diabetes mellitus, which afflicts 15 million Americans, is associated with accelerated cervical carotid artery atherosclerosis and a heightened risk of stroke. This study attempted to determine the prevalence of calcified atherosclerotic lesions in a group of patients with type 2 diabetes mellitus. STUDY DESIGN: The panoramic radiographs of 49 men (age range, 55 to 81; mean age, 66.2 years) receiving routine dental treatment and insulin for diabetes at a Department of Affairs Veterans clinic were evaluated for calcified atheromas. Age-match controls, free of diabetes, were assessed in a like manner. Statistical comparison of the atheroma prevalence rates was by means of the Fisher exact test, and statistical comparison of atherogenic risk factors was by means of t test with Bonferroni adjustment and, where necessary, the Mann-Whitney U test. RESULTS: The radiographs of the diabetics (mean age, 66.9 years) revealed that 20.4% had atheromas whereas those of the controls (mean age, 68.1 years) demonstrated that 4% had atheromas (a statistically significant difference; P =.0275). Also statistically significant was the prevalence of atherogenic risk factors (plasma glucose, low-density lipoproteins, and serum triglycerides) identified in the diabetic group. The radiographic appearance of the atheromas manifested by both groups of individuals, however, was similar, with the lesions located 1.5-2.5 cm inferior-posterior to angle of the mandible. CONCLUSIONS: People with type 2 diabetes have a greater prevalence of calcified atheromas on their panoramic radiographs than do nondiabetics.

Panoramic radiography: an aid in detecting patients at risk of cerebrovascular accident.

Some individuals at risk for a cerebrovascular accident can be identified in the dental office by appropriate review of their panoramic radiographs. Radiographs were evaluated for 304 outpatients, 55 years or older, to check the presence of calcifications associated with artery disease. Three percent of the sample had such opacities.

Painless swelling of the lower lip.

A characteristic example of a mucocele has been presented. Clinicians should be aware that even though these lesions have a distinctive clinical appearance and react biologically in a fairly characteristic manner, they must be differentiated from benign and malignant neoplasms that appear and react clinically similar to mucous retention phenomenons. Microscopic examination of tissue from the lesion is the only definitive method to make this differentiation.

Major depressive disorder. Psychopathology, medical management and dental implications.

BACKGROUND: Major depressive disorder, or MDD, is a psychiatric illness in which mood, thoughts and behavioral patterns are impaired for long periods. The illness distresses the person and impairs his or her social functioning and quality of life. MDD is characterized by marked sadness or a loss of interest or pleasure in daily activities, and is accompanied by weight change, sleep disturbance, fatigue, difficulty concentrating, physical impairment and a high suicide rate. In 2000, the World Health Organization, or WHO, identified MDD as the fourth ranked cause of disability and premature death in the world. WHO projected that by 2020, MDD would rise in disease burden to be second only to ischemic heart disease. The disorder is common in the United States, with a lifetime prevalence rate of 17 percent and a recurrence rate of more than 50 percent. CONCLUSIONS: MDD may be associated with extensive dental disease, and people may seek dental treatment before becoming aware of their psychiatric illness. MDD frequently is associated with a disinterest in performing appropriate oral hygiene techniques, a cariogenic diet, diminished salivary flow, rampant dental caries, advanced periodontal disease and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management requires a vigorous dental education program, the use of saliva substitutes and anticaries agents containing fluoride, and special precautions when prescribing or administering analgesics and local anesthetics. CLINICAL IMPLICATIONS: Dentists cognizant of these signs and symptoms have an opportunity to recognize patients with occult MDD. After confirmation of the diagnosis and institution of treatment by a mental health practitioner, dentists usually can provide a full range of services that may enhance patients' self-esteem and contribute to the psychotherapeutic aspect of management.

Carotid artery atheromas in postmenopausal women. Their prevalence on panoramic radiographs and their relationship to atherogenic risk factors.

BACKGROUND: More than 60 percent of the deaths in the United States attributed to stroke occur in postmenopausal women. As estrogen levels decline, atherosclerotic lesions (that is, atheromas) develop in the region of the carotid bifurcation and have been implicated as the precipitating cause in the majority of these strokes. Atheromas often are calcified and have been detected on the panoramic radiographs of neurologically asymptomatic male veterans; however, similar studies have not been conducted among female veterans. METHODS: The authors assessed panoramic radiographs and medical records of 52 neurologically asymptomatic female veterans (mean age, 70.4 years), with a history of amenorrhea of more than 12 months' duration, for atheromas and risk factors associated with atherosclerosis. RESULTS: The radiographs of 16 subjects (31 percent) exhibited atheromas located in the neck about 2.0 centimeters inferior and posterior to the angle of the mandible. These findings were confirmed in all instances by the presence of atheromas on anteroposterior cervical spine radiographs. The medical histories of these subjects were heavily laden with atherogenic risk factors (hypertension, 94 percent; body mass index of 27 to 29.9 [characterized as overweight], 25 percent; body mass index of 30 or higher [characterized as obese], 25 percent; smoking more than 15 pack-years, 38 percent; hyperlipidemia, 69 percent; type 2 diabetes mellitus, 21 percent). Hypertension was significantly associated with the presence of atheromas. CONCLUSIONS: Some neurologically asymptomatic women at high risk of developing stroke can be identified in the dental office via panoramic radiography. Women whose X-rays show calcified carotid artery atheromas are almost always hypertensive and have medical histories heavily laden with other atherogenic risk factors. CLINICAL IMPLICATIONS: Dentists should refer patients with such calcifications to an appropriate physician for further evaluation and treatment.

Renal adenocarcinoma of the kidney with metastasis to the tongue.

A rare metastatic cancer in the soft tissues of the oral cavity has been discussed. The importance of a good clinical examination and the interrelationship between medicine and dentistry have been emphasized.

Systemic lupus erythematosus.

A case of osteomyelitis of the mandible in a patient with systemic lupus erythematosus is described. Both the disease process and the treatment modalities must be understood for correct management.

Lateral cephalometric radiographs: an aid in detecting patients at risk of stroke.

Stroke is often caused by atherosclerotic lesions in the bifurcation of the common carotid artery. The authors evaluated conventional lateral cephalometric radiographs of 1,063 healthy men aged 25 to 85 years for the presence of such lesions. Approximately 2 percent of these people had lesions, which were at the level fo the third and fourth cervical vertebrae and were superimposed over these structures, the pre-vertebral fascia and the pharyngeal air space. People with atherosclerotic lesions should be referred to their physicians because timely medical, surgical and lifestyle interventions can prevent strokes.

Ocular hypertelorism, facial basal cell carcinomas, and multiple odontogenic keratocysts of the jaws.

Dentists should be aware of the multiple jaw cysts of NBCS that may develop in patients as young as 7 to 8 years. As the jaw cysts frequently are the initial symptom, dentists have the opportunity to detect the syndrome early, before the patients seek medical treatment. Any young patient with multiple odontogenic keratocysts in the jaws can develop other conditions characteristic of the disease. A careful family history should be taken, and the patient should be monitored closely for subsequent clinical manifestations of the disease.

Asymptomatic red lesion in anterior floor of mouth: diagnosis and management.

We have presented a case illustrating that an asymptomatic, red lesion in the oral mucosa should be considered a malignant neoplasm, until proved otherwise. A biopsy and microscopic examination of such lesions are necessary to establish a definitive diagnosis. An appropriate method of obtaining a tissue specimen from the floor of the mouth has been described, and the importance of taking a comprehensive clinical history has been reviewed. The value of transmitting this information to the pathologist, who examines the removed tissue, has been stressed. Small, asymptomatic erythroplastic lesions of the oral mucosa that have not resolved or responded to treatment with two weeks should have a biopsy examination.

Diagnosing and comanaging patients with obstructive sleep apnea syndrome.

BACKGROUND: Obstructive sleep apnea syndrome, or OSAS, is a common, but underdiagnosed, disorder that potentially is fatal. It is characterized by repetitive episodes of complete or partial upper airway obstruction leading to absent or diminished airflow into the lungs. These episodes usually last 10 to 30 seconds and result in loud snoring, a decrease in oxygen saturation, and chronic daytime sleepiness and fatigue. The obstruction is caused by the soft palate, base of the tongue or both collapsing against the pharyngeal walls because of decreased muscle tone during sleep. Potentially fatal systemic illnesses frequently associated with this disorder include hypertension, pulmonary hypertension, heart failure, nocturnal cardiac dysrhythmias, myocardial infarction and ischemic stroke. CLINICAL IMPLICATIONS: The classic signs and symptoms of OSAS may be recognizable by dental practitioners. Common findings in the medical history include daytime sleepiness, snoring, hypertension and type 2 diabetes mellitus. Common clinical findings include obesity; a thick neck; excessive fat deposition in the palate, tongue (enlarged) and pharynx; a long soft palate; a retrognathic mandible; and calcified carotid artery atheromas on panoramic and lateral cephalometric radiographs. CONCLUSIONS: Dentists cognizant of these signs and symptoms have an opportunity to diagnose patients with occult OSAS. After confirmation of the diagnosis by a physician, dentists can participate in management of the disorder by fabricating mandibular advancement appliances and performing surgical procedures that prevent recurrent airway obstruction.

Panoramic dental radiography: an aid in detecting individuals prone to stroke.

Stroke (cerebrovascular accident, CVA) is the third leading cause of death and an important cause of hospital admission and long-term disability in England and Wales. Atherosclerotic lesions at the bifurcation of the common carotid artery are the most common cause of stroke. On occasion, these lesions are partially calcified and visible on a conventional panoramic dental radiograph. The atheroma may appear either as a nodular radiopaque mass or as two radiopaque vertical lines within the soft tissues of the neck at the level of the lower margin of the third cervical vertebra (C3). These opacities are separate and distinct from the hyoid bone and variably appear above or below it. Dentists should scrupulously review the panoramic radiographs of all individuals over the age 55 with medical histories (hypertension, diabetes mellitus, hypercholesterolaemia, coronary artery disease) and behaviours (smoking, alcohol abuse, dietary indiscretion, overweight, sedentary life-style) known to be associated with atherosclerosis and stroke.