Screening testing in health care: Getting it right.

BACKGROUND: There is a movement to engage oral health care professionals in administering tests to identify people at risk of developing contagious diseases and other medical conditions. The purpose of this overview was to provide clinicians with fundamental concepts to understand how to evaluate a screening test's capability to give a correct result and its implications for practice (health outcomes). TYPES OF STUDIES REVIEWED: The authors reviewed epidemiologic and statistical articles addressing the purpose of performing screening tests for medical conditions with a special emphasis on understanding and interpreting test results on the basis of specific test characteristics. RESULTS: Tests with different sensitivities and specificities will provide different probabilities of correctly classifying people with or without a disease of interest. By understanding how to interpret tests results and how to communicate the consequences (that is, impact on health outcomes) of positive and negative test results, oral health care professionals will be able to generate appropriate medical referrals and determine the need for further testing, as well as provide a public service. CONCLUSIONS AND PRACTICAL IMPLICATIONS: An understanding by oral health care professionals of how to interpret screening test results will benefit their patients substantially and, in the case of contagious diseases, the public at large.

World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta-analysis.

OBJECTIVES: This systematic review aimed to evaluate the current literature regarding the importance of discontinuing or not discontinuing direct oral anticoagulants (DOACs) before invasive oral procedures, and to establish the frequency and type of postoperative bleeding events in patients. MATERIAL AND METHODS: We searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up until November 5, 2018. Selection of the studies, extraction of data, qualitative, and bias assessment was performed independently by two authors. RESULTS: Twenty-one studies were included. No randomized controlled studies were identified. Six studies reported a direct comparison between patients taking DOACs and those who discontinued DOACs. The meta-analysis of these studies resulted in an OR of 0.92 (95% CI = 0.37-2.27, I2  = 9%) for postoperative bleeding events for patients taking DOACs. We found that 59/497 (11.8%) postoperative bleeding events occurred in patients who continued DOACs, while 27/200 (13.5%) events were reported for patients who discontinued treatment. All postoperative bleeding events were controlled with local measures. CONCLUSION: Results from the included studies did not discern any important differences in postoperative bleeding events in patients who continued versus patients who discontinued DOACs. Furthermore, no thromboembolic events were recorded. However, the low quality of the studies must be considered.

World Workshop on Oral Medicine VII: Non-opioid pain management of head and neck chemo/radiation-induced mucositis: A systematic review.

OBJECTIVE: To evaluate the current evidence regarding the effectiveness of non-opioid interventions for the therapeutic management of pain in head and neck cancer patients with oral mucositis resulting from radiotherapy only or chemoradiotherapy. MATERIALS AND METHODS: A literature search was conducted which included randomised controlled trials that assessed patient-related outcome of pain in patients with oral mucositis associated with radiation therapy only or chemoradiotherapy. Literature searches were conducted in MEDLINE via Pubmed, Embase, Scopus and CINAHL. RESULTS: The electronic searches identified 846 articles. Screening revealed that six articles met all eligibility inclusion criteria. Interventions showing statistically significant benefits to reduce oral mucositis associated pain compared to placebo included doxepin (p < 0.001, 95% CI -6.7 to -2.1), amitriptyline (p = 0.04), diclofenac (p < 0.01) and benzydamine (p = 0.014). CONCLUSIONS: Non-opioid interventions, including topical doxepin, amitriptyline, diclofenac and benzydamine, were found to provide relief of pain due to mucositis, and when effective may allow for reduction in the use of opioids in pain management.

Providing Health Screenings in a Dental Setting to Enhance Overall Health Outcomes.

Data suggest that providers and patients have a favorable attitude toward chairside screening in the dental setting and are willing to participate in these activities. Likewise, efficacy studies indicate this strategy can effectively identify patients who are at increased risk of disease or have the presence of disease risk factors and could benefit from medical follow-up. Studies suggest it is feasible to conduct these screenings in the dental setting. Although the American Dental Association has established screening treatment codes, challenges to widespread implementation still exist, including developing a provider reimbursement strategy and the need for adequate provider training.

Subtypes of endothelial progenitor cells affect healing of segmental bone defects differently.

PURPOSE: Treating fracture nonunion with endothelial progenitor cells (EPCs) is a promising approach. Nevertheless, the effect of different EPC-related cell populations remains unclear. In this study, we compared the therapeutic potential of early (E-EPCs) and late EPCs (L-EPCs). METHODS: Male Fischer 344 rats were used for cell isolation and in vivo experiments. Bone marrow-derived E-EPCs and L-EPCs were kept in culture for seven to ten days and four weeks, respectively. For each treatment group, we seeded one million cells on a gelatin scaffold before implantation in a segmental defect created in a rat femur; control animals received a cell-free scaffold. Bone healing was monitored via radiographs for up to ten weeks after surgery. In vitro, secretion of vascular endothelial growth factor (VEGF) and bone morphogenetic protein (BMP)-2 was quantified by ELISA for both cell populations. Tube formation assays were also performed. RESULTS: Final radiographs showed complete (four out of five rats) or partial (one out of five rats) union with E-EPC treatment. In contrast, complete healing was achieved in only one of five animals after L-EPC implantation, while control treatment resulted in nonunion in all animals. In vitro, E-EPCs released more VEGF, but less BMP-2 than L-EPCs. In addition, L-EPCs formed longer and more mature tubules on basement membrane matrix than E-EPCs. However, co-culture with primary osteoblasts stimulated tubulogenesis of E-EPCs while inhibiting that of L-EPCs. CONCLUSIONS: We demonstrated that bone marrow-derived E-EPCs are a better alternative than L-EPCs for treatment of nonunion. We hypothesize that the expression profile of E-EPCs and their adaptation to the local environment contribute to superior bone healing.

Addressing obesity in the dental setting: What can be learned from oral health care professionals' efforts to screen for medical conditions.

PURPOSE: This scoping review focused on what can be learned from oral health professionals' (OHCPs) efforts to provide screenings for medical conditions in the dental setting that could guide strategies for addressing childhood obesity. METHODS: PubMed, Embase, Cochrane, Grey Literature, and CINAHL were searched (limitation English language). Search terms covered OHCPs and various oral systemic conditions of interest (details provided in the paper. Nineteen unduplicated, relevant articles were categorized based on relationship to question. RESULTS: Screening for diabetes and heart disease risk in the dental setting has been shown to be effective and patients and providers are willing to participate, although not yet routinely implemented. Screening/counseling for tobacco-cessation has been shown to be effective, but few (<10 percent) OHCPs provided this activity or received tobacco cessation training. For obesity screening/counseling, the majority of dentists (82 percent) reported they would be more willing to offer this service if obesity were directly related to oral disease. The one healthy weight intervention pilot study was well received by caregivers/patients and resulted in improved food choices. Successful implementation included a dedicated staff member, the dental hygienist. Lack of adequate training was a commonly reported barrier for all of these conditions; in addition, for obesity screening/counseling fear of appearing judgmental, and fear of patient rejection were also commonly reported. CONCLUSIONS: Systematic studies are needed building on existing literature and exploring best implementation practices. Enhanced training is needed on relationship of oral health and systemic health and OHCPs' role.

Pointing towards colonoscopy: sharp foreign body removal via colonoscopy.

Removal of sharp foreign bodies via upper endoscopy is common; however, management in the setting of distal migration is not well-documented. We report two cases of objects beyond the ligament of Treitz, including successful extraction of a 4.4 cm sewing pin from the cecum using hot biopsy forceps with a protector hood to shield colonic mucosa, and in a separate case, a 3.4 cm glass shard from the ascending colon using a Roth Net retriever. We demonstrate that monitoring with serial radiographs and examination may allow for supervised passage of sharp objects into the colon, where removal can be performed safely via colonoscopy.

Endothelin-1 in the tumor microenvironment correlates with melanoma invasion.

Endothelin-1 (ET-1) is a vasoactive peptide that also plays a role in the tanning response of the skin. Animal and cell culture studies have also implicated ET-1 in melanoma progression, but no association studies have been performed to link ET-1 expression and melanoma in humans. Here, we present the first in-vivo study of ET-1 expression in pigmented lesions in humans: an ET-1 immunohistochemical screen of melanocytic nevi, melanoma in situ lesions, invasive melanomas, metastatic melanomas, and blue nevi was performed. Twenty-six percent of melanocytic nevi and 44% of melanoma in situ lesions demonstrate ET-1 expression in the perilesional microenvironment, whereas expression in nevus or melanoma cells was rare to absent. In striking contrast, 100% of moderately to highly pigmented invasive melanomas contained numerous ET-1-positive cells in the tumor microenvironment, with 79% containing ET-1-positive melanoma cells, confirmed by co-staining with melanoma tumor marker HMB45. Hypopigmented invasive melanomas had reduced ET-1 expression, suggesting a correlation between ET-1 expression and pigmented melanomas. ET-1-positive perilesional cells were CD68-positive, indicating macrophage origin. Sixty-two percent of highly pigmented metastatic melanomas demonstrated ET-1 expression in melanoma cells, in contrast to 28.2% of hypopigmented specimens. Eighty-nine percent of benign nevi, known as blue nevi, which have a dermal localization, were associated with numerous ET-1-positive macrophages in the perilesional microenvironment, but no ET-1 expression was detected in the melanocytes. We conclude that ET-1 expression in the microenvironment increases with advancing stages of melanocyte transformation, implicating a critical role for ET-1 in melanoma progression, and the importance of the tumor microenvironment in the melanoma phenotype.

Association between immunologic parameters, glycemic control, and postextraction complications in patients with type 2 diabetes.

BACKGROUND: The purpose of this study was to assess the association between metabolic control and immune dysfunction, and postoperative complications and wound healing after dental extractions in people with type 2 diabetes and control participants. METHODS: The authors performed a prospective, case-control study enrolling 53 participants with type 2 diabetes and 29 participants who did not have type 2 diabetes. Exclusion criteria included being a smoker and having teeth with periodontal pockets deeper than 4 millimeters, among others. All participants underwent an extraction of 1 erupted tooth. The investigators assessed patients' signs and symptoms at 3, 7, 21, and 60 days after surgery. The investigators measured glycemic control and immunologic profile at the time of the extraction. They compared the pattern of healing and the incidence of postextraction complications between the 2 groups. RESULTS: Even in the presence of impaired neutrophil function and poor glycemic control, we found no increase in the number of postoperative complications. There was no association between delayed wound epithelialization on postoperative day 21 and level of glycemic control, and reduced neutrophil function. On postoperative day 60, all alveolar sockets were epithelialized completely and showed no signs of infection. CONCLUSIONS: The study results suggest that type 2 diabetes per se or glycemic control is not a risk factor for experiencing postoperative complications in people undergoing dental extractions. Although people with type 2 diabetes may have impaired neutrophil function, the study results revealed that having this condition was not associated with an increased risk of experiencing postoperative complications. Additional research studies with larger sample sizes of patients who have diabetes are needed to confirm this study's findings. PRACTICAL IMPLICATIONS: The results allow clinicians to infer that people with type 2 diabetes undergoing dental extractions of erupted teeth that do not have an acute odontogenic infection should not receive antibiotic prophylaxis simply because of their diabetic status or level of glycemic control.

Indian patients' attitudes towards chairside screening in a dental setting for medical conditions.

BACKGROUND: India has a high prevalence of cardiovascular disease (CVD), diabetes mellitus (DM), tuberculosis (TB), human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) and hepatitis B. United States-based studies indicate provider and patient support for medical screening in the dental setting. We assessed patient attitudes towards, and willingness to participate in, medical screening in the dental setting in India. METHOD: A 5-point Likert scale survey (with scores ranging from 1=very important/willing to 5=very unimportant/unwilling) was given to a convenience sample of adult patients visiting five university-based dental clinics (clinic group) and one private-practice setting (private group). The Mann-Whitney U-test was used to compare mean response scores between patient groups. Logistic regression was used to assess factors associated with a favourable outcome. RESULTS: Both patient groups felt it important for dentists to identify increased risk for medical conditions (89.3% vs. 94.9%, respectively; P=0.02). The majority of patients were willing to have a dentist screen for the specified conditions: CVD (80.6% clinic and 84.5% private); DM (84.5% clinic and 77.5% private); TB (76.7% clinic and 73.2% private); hepatitis (73.3% clinic and 67.5% private); and HIV/AIDS (71.0% clinic and 70.5% private). The majority of patients were willing to participate in chairside screening that yielded immediate results (84.6% clinic and 86.1% private), discuss results immediately (85.8% clinic and 87.2% private) and pay 150 Indian rupees (55.9% clinic and 91.7% private). Younger patients (<40 years of age) were significantly less likely to respond favourably to: importance of medical screening in dental settings [adjusted odds ratio (OR)=0.63; 95% confidence interval (95% CI): 0.26-0.84] and be available for screening that yielded immediate results (adjusted OR=0.63; 95% CI: 0.40-0.99). CONCLUSIONS: Indian dental patients were in favour of chairside medical screening.

Dentists' willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey.

OBJECTIVES: Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting. METHODS: From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role. RESULTS: Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness. CONCLUSIONS: Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.

The effect of chairside chronic disease screenings by oral health professionals on health care costs.

OBJECTIVES: We estimated short-term health care cost savings that would result from oral health professionals performing chronic disease screenings. METHODS: We used population data, estimates of chronic disease prevalence, and rates of medication adherence from the literature to estimate cost savings that would result from screening individuals aged 40 years and older who have seen a dentist but not a physician in the last 12 months. We estimated 1-year savings if patients identified during screening in a dental setting were referred to a physician, completed their referral, and started pharmacological treatment. RESULTS: We estimated that medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the health care system from $42.4 million ($13.51 per person screened) to $102.6 million ($32.72 per person screened) over 1 year, dependent on the rate of referral completion from the dental clinic to the physician's office. CONCLUSIONS: Oral health professionals can potentially play a bigger role in detecting chronic disease in the US population. Additional prevention and monitoring activities over the long term could achieve even greater savings and health benefits.

Screening for coronary heart disease and diabetes risk in a dental setting.

OBJECTIVES: Diabetes mellitus (DM) and heart disease, among the most prevalent chronic conditions worldwide, are increasing among younger adults who are unaware of their risk status. Previous studies in the United States have shown the efficacy of screening for risk of heart disease and diabetes in a dental setting. A screening strategy was applied to facilitate early identification of individuals at increased disease risk in a single Indian dental institute. METHODS: 158 patients >30 years old, with no reported heart disease or diabetes, and unaware of any increased disease risk were enrolled. Blood pressure, total cholesterol, high-density lipoprotein levels and body mass index were collected. The Framingham Risk Score (FRS) was calculated as an indication of global risk of developing a coronary heart disease (CHD) event within 10 years; hemoglobin A1c level was used to determine DM risk. RESULTS: Eleven percent had increased risk of heart disease (FRS >10%) and 32% had abnormal A1c levels (>5.7%). At least one risk factor was present in 61 and 39% presented with two or more risk factors. Hypertension and obesity were the most common risk factors. CONCLUSIONS: The use of a dental setting in a developing country could serve as a resource for early identification of patients at increased risk of developing CHD and DM, yet unaware of their increased risk. The dental setting can also serve as an entry point into the medical care system by identifying asymptomatic patients at increased risk of disease and referring these individuals to a primary care provider.

Assessing systemic disease risk in a dental setting: a public health perspective.

Screening and monitoring for systemic disease risk in a dental setting are valuable components for more effective disease prevention and control and health care delivery. This strategy can identify patients at increased risk of disease yet unaware of their increased risk and who may benefit from proven prevention/intervention strategies. The involvement of oral health care professionals in strategies to identify individuals at risk for coronary heart disease and diabetes will extend preventive and screening efforts necessary to slow the development of these diseases, and provide a portal for individuals who do not see a physician on a regular basis to enter into the general health care system.

Patients' attitudes toward screening for medical conditions in a dental setting.

OBJECTIVES: Previous studies demonstrated the efficacy of chairside medical screening by dentists to identify patients who are at increased risk for developing cardiovascular-associated events and the favorable attitude of dentists toward chairside medical screening. This study assessed patient attitudes toward chairside medical screening in a dental setting. METHODS: A self-administered questionnaire of eight five-point response scale questions was given to a convenience sample of adult patients attending an inner-city dental school clinic and two private practice settings. Wilcoxon-Mann-Whitney tests and t-tests were used to compare responses between study groups. Friedman nonparametric analysis of variance was used to compare response items within each question. RESULTS: Regardless of setting, the majority of respondents was willing to have a dentist conduct screening for heart disease, high blood pressure, diabetes, human immunodeficiency virus infection, and hepatitis infection (55-90 percent); discuss results immediately (79 percent and 89 percent); provide oral fluids, finger-stick blood, blood pressure measurements, and height and weight (60-94 percent); and pay up to $20 (50-67 percent). Respondents reported that their opinion of the dentist would improve regarding the dentist's professionalism, knowledge, competence, and compassion (48-77 percent). The fact that the test was not done by a physician was ranked as the least important potential barrier. While all respondents expressed a favorable attitude toward chairside screening, the mean score was significantly lower among clinic patients across most questions/items. The priority rankings within an item were similar for both groups. CONCLUSIONS: Acceptance by patients of chairside medical screening in a dental setting is a critical element for successful implementation of this strategy.

Polysomy and p16 deletion by fluorescence in situ hybridization in the diagnosis of indeterminate biliary strictures.

BACKGROUND: The diagnosis of indeterminate biliary strictures is limited because of the low sensitivity of cytology. However, an accurate diagnosis of malignancy is critical in the management of patients with suspected biliary malignancy. Testing for chromosomal aneuploidy by fluorescence in situ hybridization (FISH) may increase the yield. OBJECTIVE: To evaluate the diagnostic accuracy of FISH in indeterminate biliary strictures and the additional value of including deletion of 9p21 (p16) in the diagnostic criteria of malignant biliary strictures. DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: This study involved 76 consecutive patients who were seen for the evaluation of indeterminate strictures at our institution. These patients were screened, and 50 patients with either a final pathologic diagnosis or ≥ 12 months' conclusive follow-up were included in the analysis. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, and area under the curve (AUC) analysis of cytology alone compared with the presence of FISH polysomy versus FISH polysomy and 9p21 deletion. RESULTS: The presence of increased copy numbers (polysomy) of chromosome 3, 7, or 17 by FISH increased the sensitivity of brush cytology from 21% to 58%, and when the presence of 9p21 deletion was included, the sensitivity increased to 89%. The specificity of FISH was 97% (vs 100% for cytology). The accuracy of cytology combined with FISH polysomy (AUC = 0.93) or p16 deletion was significantly greater than the accuracy of cytology alone (AUC 0.6; P < .001) or even cytology combined with FISH polysomy (AUC = 0.77; P ≤ .05). LIMITATIONS: Sample size. There is a relatively high incidence of malignant biliary strictures in the entire cohort but low incidence among primary sclerosing cholangitis patients, and the majority of cancers are cholangiocarcinomas (as opposed to pancreatic). CONCLUSION: FISH significantly improves the diagnostic accuracy of brush cytology in indeterminate biliary strictures. In our series, the addition of 9p21 deletion to FISH polysomy and cytology further improved sensitivity. This suggests that 9p21 deletion may be added to the diagnostic criteria in indeterminate strictures.