Postoperative hypersensitivity in class I resin-based composite restorations in general practice: interim results.

Posterior permanent teeth with carious lesions radiographically extending no further than halfway into dentin (N = 565) were restored by 38 dentists in a practice-based research network, using a resin-based composite. Preoperative and 1-, 4-, and 13-week posttreatment hypersensitivity was recorded with an 11-point visual analog scale that was completed anonymously by participants. The analyses determined whether any correlation or association existed among several variables, including degree of carious activity; cavity extent; application of antimicrobial or desensitizing agents; application of liner, dentin-bonding agent and resin-based composite employed; and composite placement method. Three results were fairly unexpected: Only 36% of lesions were ranked as caries-active, 31% of teeth had appreciable preoperative hypersensitivity, and 16% of teeth with no preoperative hypersensitivity had appreciable hypersensitivity at 1 week posttreatment. Preoperative hypersensitivity was correlated with lesion visibility on radiographs but not with dentin caries activity (ranked on opening enamel), preparation depth, or preparation volume. Accrual to the study continues, and conclusions regarding other relationships await 13-week results.

Dose-effect relationships for the submandibular salivary glands and implications for their sparing by intensity modulated radiotherapy.

PURPOSE: Submandibular salivary glands (SMGs) dysfunction contributes to xerostomia after radiotherapy (RT) of head-and-neck (HN) cancer. We assessed SMG dose-response relationships and their implications for sparing these glands by intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: A total of 148 HN cancer patients underwent unstimulated and stimulated SMG salivary flow rate measurements selectively from Wharton's duct orifices, before RT and periodically through 24 months after RT. Correlations of flow rates and mean SMG doses were modeled throughout all time points. IMRT replanning in 8 patients whose contralateral level I was not a target incorporated the results in a new cost function aiming to spare contralateral SMGs. RESULTS: Stimulated SMG flow rates decreased exponentially by (1.2%)(Gy) as mean doses increased up to 39 Gy threshold, and then plateaued near zero. At mean doses < or =39 Gy, but not higher, flow rates recovered over time at 2.2%/month. Similarly, the unstimulated salivary flow rates decreased exponentially by (3%)(Gy) as mean dose increased and recovered over time if mean dose was <39 Gy. IMRT replanning reduced mean contralateral SMG dose by average 12 Gy, achieving < or =39 Gy in 5 of 8 patients, without target underdosing, increasing the mean doses to the parotid glands and swallowing structures by average 2-3 Gy. CONCLUSIONS: SMG salivary flow rates depended on mean dose with recovery over time up to a threshold of 39 Gy. Substantial SMG dose reduction to below this threshold and without target underdosing is feasible in some patients, at the expense of modestly higher doses to some other organs.

Hyposalivation, xerostomia and the complete denture: a systematic review.

BACKGROUND: To determine the treatment effects of hyposalivation on denture retention, the authors conducted a systematic review of the literature. TYPES OF STUDIES REVIEWED: The authors reviewed clinical investigations that assessed the treatment effects of hyposalivation on denture retention. They searched six electronic databases for works from 1950 to the second week of September 2007 by using the key words "denture," "hyposalivation," "xerostomia," "dry mouth," "elderly" and "aged." They limited the citation search to articles written in English and describing studies that involved human subjects. RESULTS: The authors identified 11 articles in the search; none was a report of a randomized controlled clinical trial. CLINICAL IMPLICATIONS: The few clinical research studies published on the topic of hyposalivation and denture retention represent a low level of evidence for establishing clinical practice guidelines. The authors found that they could make no conclusions regarding the treatment effects of hyposalivation on denture retention. The article provides a literature review regarding the etiologies and clinical presentation of salivary disorders and xerostomia in elderly people, the role of saliva in denture retention, the effect of dry mouth on denture use and the treatment of dry mouth problems in denture wearers. Prospective clinical trials are needed to establish a framework for evidence-based treatment of denture-wearing patients experiencing dry mouth.

Treatment of deep carious lesions by complete excavation or partial removal: a critical review.

BACKGROUND: The classical approach to treatment of deep carious lesions approaching the pulp mandates removing all infected and affected dentin. Several studies call this approach into question. TYPES OF STUDIES REVIEWED: A search of five electronic databases using selected key words to identify studies relating to partial versus complete removal of carious lesions yielded 1,059 reports, of which the authors judged 23 to be relevant. Three articles reported the results of randomized controlled trials. RESULTS: The results of three randomized controlled trials, one of which followed up patients for 10 years, provide strong evidence for the advisability of leaving behind infected dentin, the removal of which would put the pulp at risk of exposure. Several additional studies have demonstrated that cariogenic bacteria, once isolated from their source of nutrition by a restoration of sufficient integrity, either die or remain dormant and thus pose no risk to the health of the dentition. CLINICAL IMPLICATIONS: There is substantial evidence that removing all vestiges of infected dentin from lesions approaching the pulp is not required for caries management.

Reduction in bacterial contamination of toothbrushes using the Violight ultraviolet light activated toothbrush sanitizer.

PURPOSE: This two armed, self-controlled, investigator blinded, clinical study tested the efficacy of an ultraviolet (UV) light toothbrush holder (Violight) to decrease toothbrush bacterial contamination. METHODS: 25 subjects were randomly assigned to control or experimental groups and received two toothbrushes for home use on either even or odd days. The control group rinsed both toothbrushes after use in cold tap water with no mechanical manipulation. The experimental group rinsed one toothbrush in cold running water while storing the other toothbrush in the Violight toothbrush holder after use. The toothbrushes were returned after 2 weeks use in sealed plastic bags and were analyzed for the number of colony forming units (CFU) of S. mutans, S. salivarius, lactobacilli, E. coli, and other coliforms, and total bacterial counts by culture. An additional analysis of the total bacterial profile was performed using denaturing gradient gel electrophoresis (DGGE). RESULTS: The Violight toothbrush holder reduced total CFU by an average of 86% (ANCOVA, P = 0.037). In addition, a tendency was noted for a reduction in total bacterial population as detected by DGGE.

Open-label, long-term safety study of cevimeline in the treatment of postirradiation xerostomia.

PURPOSE: To assess the safety of long-term cevimeline treatment of radiation-induced xerostomia in patients with head-and-neck cancer; and to assess the efficacy of cevimeline in these patients. METHODS AND MATERIALS: A total of 255 adults with head-and-neck cancer who had received more than 40 Gy of radiation 4 months or more before entry and had clinically significant salivary gland dysfunction received cevimeline hydrochloride 45 mg t.i.d. orally for 52 weeks. Adverse events (AEs), their severity, and their relationship to the study medication were assessed by each investigator. The efficacy assessment was based on subjects' global evaluation of oral dryness on a scale of 0 (none) to 3 (severe). RESULTS: Overall, 175 subjects (68.6%) experienced expected treatment-related AEs, most mild to moderate. The most frequent was increased sweating (47.5%), followed by dyspepsia (9.4%), nausea (8.2%), and diarrhea (6.3%). Fifteen subjects (5.9%) experienced Grade 3 treatment-related AEs, of which the most frequent was increased sweating. Eighteen subjects (7.1%) reported at least one serious AE, and 45 subjects (17.6%) discontinued study medication because of an AE. The global efficacy evaluation at the last study visit showed that cevimeline improved dry mouth in most subjects (59.2%). Significant improvement was seen at each study visit in the mean change from baseline of the numeric global evaluation score (p < 0.0001). CONCLUSIONS: Cevimeline 45 mg t.i.d. was generally well tolerated over a period of 52 weeks in subjects with xerostomia secondary to radiotherapy for cancer in the head-and-neck region.

Dry mouth and its effects on the oral health of elderly people.

BACKGROUND: The objective of this literature review is to summarize information about the etiology, diagnosis, oral sequelae and treatment of dry mouth in elderly patients. TYPES OF STUDIES REVIEWED: The authors conducted a comprehensive review of the English-based scientific literature from the past 10 years. They selected the studies on the basis of clinical investigations to provide an objective assessment of dry mouth problems among older people. RESULTS: Dry mouth (salivary hypofunction, xerostomia) is a common problem among older people. It causes significant oropharyngeal disorders, pain and an impaired quality of life. Dry mouth has many causes, from local salivary disorders to a plethora of medications and medical conditions. Treatments are designed to correct the underlying cause and/or to enhance salivation with topical and systemic stimulants. Early intervention for dry mouth problems helps prevent the deleterious consequences of this disorder in elderly people. CLINICAL IMPLICATIONS: Clinicians must be aware of dry mouth problems in older patients, and they should be prepared to provide a diagnosis and administer treatment to protect a patient's oropharyngeal health and quality of life.

Attitudes and expectations of treating deep caries: a PEARL Network survey.

A survey was conducted within a practice-based dental research network to determine dentists' treatment methods for deep caries lesions and whether the dentists' intended treatment approaches were influenced by their expectations for pulpal exposure. The survey further examined how general dentistry practices have adopted scientific evidence of caries classification, excavation, and capping techniques. Dentists were queried regarding liner use, hypersensitivity considerations, point of endodontic therapy, and anticipated vitality outcomes from Class I resin-based composite restorations over three to five years. Of the 93 practitioner-investigators who were in the network at the time of the survey, 85 (92%) completed it. Of those who responded, 62% said that they would remove all caries when presented with a case in which one would expect pulpal exposure, while 18% would partially remove caries and 21% would initiate endodontic treatment; 17% reported that they would utilize an antimicrobial agent before a liner or bonding agent during restoration. The outcomes projected for tooth vitality over the next three to five years were equivalent regardless of the caries removal approach or the use of a liner/bonding agent. When beginning the preparation, the method of treatment did not change if a pulpal exposure was anticipated, other than a threefold increase in immediate endodontic treatment. When dentists were given a direct pulp cap scenario, the projected use of a liner/bonding agent changed little while the vitality projections decreased. Overall survey findings indicate that approximately 20% of network dentists favor partial caries removal techniques and that deep caries treatment outcome studies are warranted, given the various treatments employed.

Mechanisms associated with unusual orofacial pain.

This article presents an overview of possible mechanisms associated with pain perception, with a specific focus on understanding unusual manifestations of orofacial pain associated with nerve insult. It includes recent evidence concerning neurobiological changes that occur in the periphery at tissue and nerve sites, or within the central nervous system, and that may involve chemical and inflammatory responses, sensitization, or alterations of cellular function. Moreover, the contribution of the autonomic nervous system, changes in emotional reactivity and vigilance, the roles of high brain centers such as the basal ganglia (nigro-striatal) system, and the influence of aging and gender, are briefly described.

Radiotherapy-induced salivary dysfunction.

Dry mouth (xerostomia) is one of the most common complaints following radiation therapy (RT) for head and neck cancers. Notably, RT causes irreparable damage to salivary glands that increases the risk for severe and long-term oral and pharyngeal disorders. Several strategies in the treatment of head and neck cancers have been developed to prevent RT-induced salivary dysfunction while providing definitive oncologic therapy. These include salivary-sparing RT; cytoprotectants (such as amifostine); combination therapy of high-dose-rate intraoperative RT, external beam RT, plus a cytoprotectant; salivary gland surgical transfer; and gene therapy. Future research that incorporates biologic, pharmacologic, and technologic advancements that optimize therapeutic ratios and minimizes adverse oral sequelae is warranted.

Rationale for integrating high-dose rate intraoperative radiation (HDR-IORT) and postoperative external beam radiation with subcutaneous amifostine for the management of stage III/IV head and neck cancer.

Locoregional recurrence remains a major obstacle to achieving cure of locally advanced head and neck cancers despite maximal resection and postoperative external beam radiation therapy (EBRT). Locoregional failure occurs in 30% to 40% of high-risk resected head and neck cancer patients after standard postoperative EBRT. In an effort to overcome this problem, a number of strategies have been designed to enhance the effectiveness of radiation including concurrent postoperative chemoradiation, accelerated radiation schedules, incorporation of targeted biologic therapies, and improved radiation delivery techniques such as intensity modulated radiation and high-dose rate (HDR) intraoperative radiation therapy. Intraoperative radiation therapy (IORT) represents an important approach to improve outcome in head and neck cancer patients treated with definitive surgery. High-dose rate IORT is defined as the delivery of a single, large dose of radiation at the time of surgery when the tumor bed is exposed. In conjunction with EBRT, HDR-IORT offers several advantages including: (1) conformal delivery of a large dose of radiation while the tumor bed is precisely defined, minimizing the risk of a geographic miss; (2) potential for subsequent dose reduction of EBRT; (3) shortening overall treatment time; and (4) dose-escalation. Because mucositis represents the dose-limiting acute toxicity and xerostomia ranks as the most common long-term quality-of-life complaint, a reduction of the EBRT dose may provide an important benefit in reducing toxicity, especially when combined with the radioprotectant amifostine (Ethyol, WR-2721; MedImmune, Inc, Gaithersburg, MD). The purpose of this article is to review the rationale for integrating HDR-IORT with a reduced dose of postoperative EBRT combined with amifostine to improve locoregional control and quality of life outcomes in advanced-stage resected head and neck cancer patients.

Quality of life after parotid-sparing IMRT for head-and-neck cancer: a prospective longitudinal study.

PURPOSE: Parotid-sparing intensity-modulated radiotherapy (IMRT) for head-and-neck cancer reduces xerostomia compared with standard RT. To assess potential improvements in broader aspects of quality of life (QOL), we initiated a study of patient-reported QOL and its predictors after IMRT. MATERIALS AND METHODS: This was a prospective longitudinal study of head-and-neck cancer patients receiving multisegmental static IMRT. Patients were given a validated xerostomia questionnaire (XQ), and a validated head-and-neck cancer-related QOL questionnaire consisting of four multi-item domains: Eating, Communication, Pain, and Emotion. The Eating domain contains one question (total of six) asking directly about xerostomia. In both questionnaires, higher scores denote worse symptoms or QOL. The questionnaires and measurements of salivary output from the major glands were completed before RT started (pre-RT) and at 3, 6, and 12 months after RT. The association between the QOL scores and patient-, tumor-, and therapy-related factors was assessed using the random effects model. RESULTS: Thirty-six patients participating in the study completed the questionnaires through 12 months. The XQ scores worsened significantly at 3 months compared with the pre-RT scores, but later they improved gradually through 12 months (p = 0.003), in parallel with an increase in the salivary output from the spared salivary glands. The QOL summary scores were stable between the baseline (pre-RT) and 3 months after RT scores. Patients receiving postoperative RT (whose pre-RT questionnaires were taken a few weeks after surgery) tended to have improved scores after RT, reflecting the subsidence of acute postoperative sequelae, compared with a tendency toward worsened scores in patients receiving definitive RT. After 3 months, statistically significant improvement was noted in the summary QOL scores for all patients, through 12 months after RT (p = 0.01). The salivary flow rates, tumor doses, mean oral cavity dose, age, gender, sites or stages of tumor, surgery, and use of chemotherapy were not associated with the QOL scores at any point. The mean dose to the parotid glands correlated with the QOL scores at 3 months (p = 0.05) but not at other post-RT periods. The XQ and QOL summary scores did not correlate before RT but were significantly correlated at each post-RT point (p < 0.01), with a linear correlation coefficient (r) of 0.59, 0.72, and 0.67 at 3, 6, and 12 months, respectively. At these points, the XQ scores also correlated significantly with the scores of each of the individual QOL domains (p < or = 0.01), including the domains Pain and Emotion, which did not contain any xerostomia-related question. CONCLUSION: After parotid-sparing IMRT, a statistically significant correlation was noted between patient-reported xerostomia and each of the domains of QOL: Eating, Communication, Pain, and Emotion. Both xerostomia and QOL scores improved significantly over time during the first year after therapy. These results suggest that the efforts to improve xerostomia using IMRT may yield improvements in broad aspects of QOL.

Xerostomia and the geriatric patient.

Saliva is essential for the preservation of oral-pharyngeal health, and disorders of salivary physiology are associated with numerous oral and pharyngeal problems, particularly in older people. Although salivary function is remarkably intact in healthy aging, medical problems, medications, and head and neck radiotherapy can cause salivary dysfunction and complaints of xerostomia among older people. Sjögren's syndrome, an autoimmune exocrinopathy, is the most common medical disease associated with salivary dysfunction. Medications with anticholinergic side effects will impair salivary output, and head and neck radiotherapy for cancer will cause permanent destruction of salivary glands. Treatments for salivary problems are based upon establishing a diagnosis, protecting oral and pharyngeal health, stimulating remaining glands, and replacing lost salivary fluids.

Management strategies for HIV-associated aphthous stomatitis.

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disorder found in men and women of all ages, races, and geographic regions. There are three forms of the lesions (minor, major, and herpetiform), with major aphthous ulcers causing significant pain and potential for scarring. In HIV-infected individuals, these ulcers occur more frequently, last longer, and produce more painful symptoms than in immunocompetent persons. In addition, they may be associated with similar ulcerations involving the esophagus, rectum, anus, and genitals. The diagnosis of HIV-induced RAS requires a careful history of the condition, and a thorough extra- and intra-oral examination. Oral mucosal biopsies are required for non-healing ulcers in order to exclude the possibility of deep fungal infections, viral infections, and neoplasms. The cause of the ulcers in HIV-positive persons has not been elucidated--local diseases, genetic, immunologic, and infectious factors all probably play a role. The goals of current treatments are to promote ulcer healing, to reduce ulcer duration and pain while maintaining nutritional intake, and to prevent or diminish the frequency of recurrence. Initial therapy for infrequent RAS recurrences includes over-the-counter topical protective and analgesic products. Initial therapy for frequent RAS outbreaks requires topical anesthetics, binding agents, and corticosteroids. Major RAS and non-healing minor or herpetiform RAS may require intralesional corticosteroids and systemic prednisone. Second-line immunomodulators for frequent and non-healing ulcers includes thalidomide and other immunomodulators.

The role of salivary function in modulating chemotherapy-induced oropharyngeal mucositis: a review of the literature.

Oropharyngeal mucositis is a common and significant complication of cancer chemotherapy and limits the delivery of chemotherapy, affects the quality of life, and increases the cost of care. Oral mucositis caused by cancer chemotherapy is associated with specific agents, but the origin of oral mucositis is poorly understood. These drugs may have direct toxic effects on the rapidly dividing cells of the oral mucosa and on cellular elements of the connective tissue. Microbial flora may play a role in the development of ulcerative mucositis. Chemotherapy may be directly toxic and affect the mucosa by systemic circulation and may be related to secretion of some chemotherapeutic drugs in the saliva, resulting in topical exposure to the oral environment. Other potential mechanisms include reduced saliva volume and change in saliva constituents that may affect epithelial maintenance and repair, the physiology of the oral microflora, and the interaction between the oral flora and the epithelium. Improved understanding of the mechanisms whereby specific chemotherapeutic agents cause mucositis may lead to management approaches that will reduce the incidence and severity of mucositis, improving quality of life and ensuring delivery of the necessary chemotherapy to improve cancer cure rates.

Diabetes and oral health: an overview.

BACKGROUND: Diabetes is a common disease with concomitant oral manifestations that impact dental care. The purpose of this review is to summarize the prevalence, signs, symptoms, diagnosis and treatment of diabetes, as well as dental treatment considerations for the patient with diabetes. CONCLUSIONS: Safely managing the patient with diabetes requires effective communication among multiple health care providers. Dentists must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patients with diabetes. PRACTICE IMPLICATIONS: Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment.

Refractory major aphthous stomatitis managed with systemic immunosuppressants: a case report.

This article presents an unusual case of major recurrent aphthous stomatitis that was refractory to multiple topical and systemic immunosuppressive therapies. Ultimately, thalidomide was selected despite its well-recognized adverse potential, and was successful in producing remission of ulcers. Strict clinical protocols were followed for this therapy in collaboration with numerous medical providers. This case illustrates the ability of multiple oral health and medical providers to collaborate in the diagnosis, management, and follow-up of a patient with an oral vesiculoerosive disease.

Diagnosis and treatment of salivary gland disorders.

The keystone of the architecture of the oral cavity is saliva; however, it is rarely acknowledged as a vital physiologic secretion. Saliva plays three major roles in oral and systemic health. It provides host protection, assists in the initiation of food and fluid intake, and enables communication through speech. Without adequate salivary output augmented by a rich assortment of salivary proteins and electrolytes, oral and pharyngeal health declines as well as a person's quality of life. This article will provide a brief summary of the function of saliva, oral and systemic etiologies of salivary dysfunction, and methods to treat and prevent salivary disorders. Oral health care professionals can play a vital role in identifying patients at risk for developing salivary dysfunction and should provide appropriate preventive and interventive techniques that will help preserve oral health and function.