Warfarin and Drug Interactions: Prescribing Vigilance.

A patient taking warfarin presented to the Oral Medicine Clinic at Liverpool University Dental Hospital, having been prescribed metronidazole and miconazole by his general dental practitioner (GDP) for his oral mucosal problem. He subsequently developed bruising on his torso following mild trauma. Having read the drug information leaflet provided with his metronidazole and miconazole, he noted the potential drug interactions between these and warfarin. He therefore stopped his warfarin. The details of this case are outlined, and the potential for significant drug interactions with warfarin are highlighted. The need for dental practitioners to be vigilant concerning drug interactions is emphasized, together with the importance of CPD in relation to drug prescribing. CPD/CLINICAL RELEVANCE: This case report, which is of relevance to all dental practitioners, highlights the importance of up-to-date medical and drug histories and the continuing awareness of potential drug interactions. In this case, patient intervention after checking drug information leaflets prevented serious consequences. The importance and potentially serious consequences of significant drug interactions needs to be understood.

Forty years of suffering chronic TMJ dysfunction: lessons learnt.

Temporomandibular joint dysfunction (TMD) is a common condition, with patients reporting symptoms to both dentists and doctors. The aetiology of TMD is likely to be multifactorial, with occlusal, parafunctional and psychological factors all potentially playing a part to varying degrees in different individuals. A personal account by a dentist, suffering from TMD for over 40 years, chronicles their experience of different treatments and concludes that supporting a patient to 'learn to live' with TMD is pivotal to management.

Ocular and oral grading of mucous membrane pemphigoid.

BACKGROUND: A variety of methods have been described for grading ocular mucous membrane pemphigoid (MMP), each with their own limitations. In contrast, there are no reported grading systems for involvement of the oral mucosa. We wished to evaluate two ocular (one established and one proposed) and an oral mucosal grading system for MMP. METHODS: Patients with MMP were assessed by three ophthalmologists and two oral medicine physicians. Ocular disease was graded using the system described by Rowsey and a proposed system based on measurement of vertical depth and horizontal width measured from the bulbar conjunctival aspect. Oral assessment used a 'mucosal disease severity score' originally described for lichen planus, in which 17 areas of the mouth are scored for involvement, together with a pain score. Levels of agreement were evaluated using Fleiss' Kappa Statistic (k). RESULTS: Forty-four patients with MMP encompassing mild to severe disease were included. Good levels of agreement were observed between observers for both vertical (k:0.86) (upper 95% CI: 1.03 mm) and horizontal (k:0.80) (upper 95% CI: 3.01 mm) involvement for the proposed ocular system and the Rowsey system (k: 0.83) (upper 95% confidence interval: 3.19 mm). There was a high coefficient of determination (R(2)) between the ocular grading systems (0.81, p < 0.01). Oral grading showed excellent levels of agreement (k: 0.71) between observers. There was no significant association between the severity of oral and ocular disease using described grading systems. CONCLUSIONS: The proposed grading systems for both oral and ocular involvement in MMP are easy to use, and show good agreement between observers. The proposed ocular system correlates well with a currently used system, and overcomes some of the difficulties encountered with existing systems. For the individual patient, changes greater than 1.5 mm (vertical) and 3 mm (horizontal) are significant. This may increase our ability to detect change or disease progression. Although the risk of ocular involvement in patients with only oral involvement has been demonstrated, the severity of oral and ocular disease are not well-correlated, due in part to an absence of an ocular disease activity score.

UK Dental Medicines Advisory Service: questions asked by dentists - part 2: drugs used for medical emergencies in dental practice.

The UK Dental Medicines Advisory Service (UKDMAS) provides advice to dentists and other dental healthcare professionals concerning the use of medicines and medical devices in dentistry. The commonly asked questions posed to the UKDMAS concerning the prescribing and administering of dental emergency drugs in dental practice are discussed, with answers supplemented by relevant information from clinicians. These include the drugs that need to be stocked in the emergency drugs kit in dental practice, their formats and storage, and the restrictions on which members of the dental team can administer the drugs.

UK Dental Medicines Advisory Service: questions asked by dentists - part 1: prescribing regulations and medicines use.

The UK Dental Medicines Advisory Service (UKDMAS) provides advice to dentists and other dental healthcare professionals concerning the use of medicines and medical devices in dentistry. The commonly asked questions posed to the UKDMAS concerning the prescribing, administering or dispensing of medicines in dental practice are discussed with answers supplemented by relevant information from clinicians. These include: different classes of medicines, unlicensed medicines, prescriptions, Patient Group Directions, Patient Specific Directions and dispensing of medicines - if appropriate.

UK Dental Medicines Advisory Service: questions asked by dentists - part 5: prescribing for oromucosal diseases and dry mouth.

The UK Dental Medicines Advisory Service (UKDMAS) provides advice to dentists and other dental healthcare professionals concerning the use of medicines and medical devices in dentistry. The commonly asked questions posed to the UKDMAS concerning medicines used for the management of oromucosal disease and dry mouth are discussed with answers supplemented by relevant information from clinicians. This article includes questions related to topical corticosteroids and analgesics used for oral ulceration, antifungal therapy and saliva replacement products.

UK Dental Medicines Advisory Service - questions asked by dentists: part 3 - prescribing of anxiolytic medications in dental practice.

The UK Dental Medicines Advisory Service (UKDMAS) provides advice to dentists and other dental healthcare professionals concerning the use of medicines and medical devices in dentistry. The commonly asked questions posed to the UKDMAS concerning the prescribing, administering or dispensing of oral anxiolytic medicines in dental practice are discussed with answers supplemented by relevant information from clinicians. These include: types of oral anxiolytics available, prescribing guidelines, appropriate dosing regimens, indications and contraindications to prescribing and drug interactions.

UK Dental Medicines Advisory Service: questions asked by dentists - part 4: prescribing of high-strength fluoride toothpastes and use of fluoride varnishes in dental practice.

The UK Dental Medicines Advisory Service (UKDMAS) provides advice to dentists and other dental healthcare professionals concerning the use of medicines and medical devices in dental prescribing, administering, or dispensing. The commonly asked questions posed to the UKDMAS concerning the prescribing of high-strength fluoride toothpastes and use of fluoride varnishes in dental practice are discussed with answers, supplemented by relevant information from clinicians. These include: the prescribing of high-strength fluoride toothpastes and application of fluoride varnish in particular patient groups; issues concerning the amounts of fluoride toothpaste that can be prescribed; regulations related to the supply of fluoride toothpastes by dental hygienists and therapists; and the constituents and selection of fluoride varnishes.

Lung cancer: a potential role for dentists.

Lung cancer is the leading cause of death from cancer worldwide and causes more deaths than breast, colorectal and cervical cancers combined. The five-year survival rate for lung cancer in the UK is approximately 15%. Over many years, lung cancer has failed to attract the attention and resources given to other cancers; it has also been stigmatised by a culture of blame, attributable to the sufferer because of smoking. Anyone can develop lung cancer, and between 15% and 20% of people with this diagnosis have never smoked. Many patients with lung cancer are diagnosed at late stages; therefore, early detection is pivotal to improving their survival. Dentists and their teams could potentially play a role in the public perception, prevention and detection of lung cancer.

Two case reports of orofacial paraesthesia demonstrating the role of the general dental practitioner in identifying patients with intracranial tumours.

The following case reports describe the clinical features, diagnosis and management of two patients who presented to their general dental practitioner with a complaint of orofacial paraesthesia. After appropriate investigations, both patients were diagnosed as having benign intracranial tumours and were managed by a neurosurgeon. These cases illustrate the important role the general dental practitioner has in the early recognition of potentially life-threatening conditions.

p16 Promoter methylation is a potential predictor of malignant transformation in oral epithelial dysplasia.

Management of the patient with oral epithelial dysplasia depends on the ability to predict malignant transformation. Histologic grading of this condition fails in this regard and is also subject to interpathologist and intrapathologist variability. This study uses longitudinal clinical samples to explore the prognostic value of a previously validated panel of methylation biomarkers in a cohort of patients with histologically proven oral dysplasia. Methylation enrichment pyrosequencing assays were used to provide the sensitivity of traditional methylation-specific PCR with the additional specificity advantages of a subsequent confirmatory sequencing reaction. In 57% (8 of 14) patients with a lesion that transformed to oral squamous cell carcinoma, 26% (26 of 100) of longitudinal samples collected over > or =3 years showed p16 methylation. Only 1% (2 of 184) of samples from 8% of patients (2 of 24) not undergoing malignant transformation within 3 years had p16 methylation. Both of these samples with p16 promoter methylation were the most recently collected and the patients remain under continuing clinical review. Promoter methylation of MGMT, CYGB, and CCNA1 did not correlate with malignant progression. We thus conclude that methylation of the p16 gene promoter shows promise as a predictor for malignant transformation (Fisher's exact, P = 0.002) in a subset of patients.

Management of proliferative verrucous leukoplakia: Justification for a conservative approach.

BACKGROUND: Proliferative verrucous leukoplakia (PVL) is a progressive, multifocal, exophytic form of leukoplakia with high rates of malignant transformation. The purpose of this study was to evaluate a cohort of patients with PVL in a single tertiary referral clinic. METHOD: Cases meeting accepted diagnostic criteria were reviewed with regard to their pathology, demographic characteristics, management, and outcomes. Human papillomavirus (HPV) testing was undertaken on a subset. RESULTS: Almost half of the 48 patients with PVL (48%; n = 23) underwent malignant transformation after a median 23.4 months. The characteristics of this cohort were similar to those previously described, but management was notably more conservative. Conservative management of PVL was used in 92% of our patients, but the clinical outcomes seem comparable with previously described cohorts in which PVL was predominantly treated by surgical excision. All HPV testing was negative. CONCLUSION: Aggressive surgical intervention in the premalignant phase of PVL may not influence the rate of malignant transformation.

The statins: drug interactions of significance to the dental practitioner.

UNLABELLED: This report outlines the potential for concomitant use of dentally prescribed medication to increase the risk of statin-induced myopathy. The associated signs and symptoms of statin-induced myopathy are also highlighted, as well as the need for an accurate and updated drug history for all dental patients. CLINICAL RELEVANCE: This article describes the recognized adverse interactions associated with concomitant drug therapy for patients on statins.

Drug profile of adult patients attending five general dental practices in Merseyside: oral side-effects and potential interactions with dentally prescribed medication.

OBJECTIVE: To evaluate the drug profile of patients attending general dental practice and to assess the significance of this for the provision of dental care. DESIGN AND SETTING: Prospective study of adult patients attending five general dental practices in Merseyside. MATERIALS AND METHODS: Patients were questioned about prescribed medication. The data were analysed to assess any potential oral side-effects, pertinent drug interactions, or potential complications of dental treatment. RESULTS: A total of 1103 patients were recruited; of these, 287 (26%) were taking systemic medication. CONCLUSION: Approximately a quarter of dental patients attending for routine dental care were taking prescribed medication. The majority of these drugs have significant implications for the general dental practitioner.

Angioedema of the lips and tongue induced by angiotensin-converting enzyme inhibitor. A report of two cases.

The following case reports describe the clinical presentation, diagnosis and management of two patients who attended Liverpool University Dental Hospital with rapidly increasing swelling of the lips and tongue. Both patients were suffering from angioedema and were taking an angiotension-converting enzyme (ACE) inhibitor (ACEI). A provisional diagnosis of ACEI-induced angioedema was made. An intramuscular injection of chlorpheniramine maleate was given to both patients and they were immediately transferred to the local accident and emergency department. These cases illustrate the potential role of the general dental practitioner in the early recognition and management of this potentially life-threatening condition.

Case report: exfoliative cheilitis managed with antidepressant medication.

Exfoliative cheilitis is an unsightly and uncommon, chronic superficial inflammatory disorder that affects the vermilion zone of the lips. This case report describes the presentation of exfoliative cheilitis in a young man, and his subsequent management with antidepressant medication. The differential diagnosis of chronic exfoliative cheilitis is outlined.

Orofacial paraesthesia: an unusual presentation of acoustic neuroma.

Patients with acoustic neuromas commonly present with unilateral hearing loss, tinnitus and unsteadiness. An uncommon initial feature is involvement of the trigeminal nerve. The unusual feature in the case reported here was orofacial paraesthesia, which preceded hearing loss by 3-4 years. Diagnosis was made following a referral by the patient's dentist.

Health-related quality of life in patients with primary Sjögren's syndrome and xerostomia: a comparative study.

OBJECTIVE: To compare the health status of groups of Primary Sjögren's and Xerostomia patients, using the Medical Outcomes Short Form 36 (SF-36). The SF-36 is a generic measure, divided into eight domains, used in the assessment of health-related quality of life. PATIENTS AND METHODS: The SF-36 was given to 2 groups: Group 1 comprised 43 patients diagnosed with Primary Sjögren's Syndrome (1 degrees SS) and an unstimulated whole salivary flow rate (UFR) of <0.1 ml/min). Group 2 (n = 40) reported Xerostomia but had an UFR >0.2 ml/min. Sub groups of patients in Groups 1 and 2 were compared with community normative data, for the SF-36. RESULTS: There were trends to suggest lower SF36 scores for 1 degrees SS patients but there were no significant differences between the mean domain scores of Groups 1 and 2. 1 degrees SS and Xerostomia patients registered lower mean scores across all 8 domains, compared with normative community data. CONCLUSION: The SF-36 was unable to detect significant differences between subjects with 1 degrees SS and Xerostomia but a larger sample size is required to confirm these findings. The results of this limited study suggest that a disease-specific measure is required to assess the impact 1 degrees SS on health-related Quality of life (QOL).

The development and initial validation of the Liverpool sicca index to assess symptoms and dysfunction in patients with primary Sjögren's syndrome.

BACKGROUND: A validated measure to assess sicca-related symptoms in patients with primary Sjögren's syndrome (1 degrees SS) is required for clinical studies. METHODS: A self-administered questionnaire was developed to assess sicca-related symptoms and dysfunction in 1 degrees SS. This was administered to three groups of 40 respondents to measure construct validity: 1 degrees SS patients, non-SS patients reporting xerostomia and a non-patient group. The frequency of scores and the mean score for each question were calculated for each group. Reliability was assessed by test/retest. RESULTS: The measure consisted of 28 items divided into five domains. Scores for questions in domains were generally worse (higher) for 1 degrees SS patients than for patients with xerostomia. The non-patient group reported the best (lowest) scores for all questions. The Kappa statistic for all but four questions was greater than 0.6, suggesting good reliability. CONCLUSION: Questionnaire showed good construct validity and reliability. The Liverpool sicca index needs to be further validated in larger, multicentre studies.