U.K. hemophilia treaters' knowledge of risk assessment for prolonged bleeding associated with dental procedures.

INTRODUCTION: Optimal delivery of dental care for adults with congenital bleeding disorders (CBD) requires close collaboration between hemophilia treaters and dentists. AIM: To explore U.K. hemophilia treaters' knowledge of dental procedures and associated hemostatic management in adults with CBD. METHOD: Staff (N = 180) from N = 60 hemophilia facilities in the United Kingdom were invited to participate in a questionnaire-based study using a web-based tool. The questionnaire assessed participants' knowledge, adherence and appropriateness of application of U.K. guidance on hemostatic management of common dental procedures. RESULTS: The response rate was 23% of treaters (n = 41) from 62% (n = 32) hemophilia facilities. Individual participants (87%; n = 34) reported they adhered to guidelines, though knowledge of guidance was poor with only 36% (n = 15) applying guidance appropriately in 3 common dental scenarios. There was a tendency for participants to assign the use of systemic hemostatic measures independent of the agreed bleeding risk associated with the proposed dental procedure. CONCLUSION AND RECOMMENDATIONS: While hemophilia treaters were aware of current guidelines, their knowledge of the guidelines and ability to risk assess dental procedures was poor. There was a tendency to overprescribe systemic hemostatic measures for dental procedures. Education initiatives to aid decision making are needed.

Does Achievement of Hemostasis After Pulp Exposure Provide an Accurate Assessment of Pulp Inflammation?

PURPOSE: The purpose of this study was to determine in primary molars with carious exposures whether hemostasis at the exposure site and pulp orifice reflected inflammatory status of the pulp at the canal orifice based on cytokine levels. METHODS: Forty mandibular primary molars with deep caries were included in the study. Teeth were divided into two groups: group A had teeth where hemostasis at the exposure site was achieved within five minutes, and group B had teeth where hemostasis at the exposure site could not be achieved within five minutes. Blood samples were harvested from the exposure sites and canal orifices. Cytokine levels for IL-1ß, IL-2, IL-6, IL-8, IL-10, TNF-α, and PGE2 were measured using ELISA for all sample sites. RESULTS: The IL-6 levels at the exposure sites were found to be significantly higher in group A when compared to group B, but there was no statistically significant differences in any of the cytokine levels at the canal orifices between the two groups. CONCLUSIONS: Controlling bleeding at the exposure site or canal orifices does not provide accurate assessment of inflammation at the canal orifice and may be misleading for diagnosing vital pulp treatment in primary teeth with a carious pulp exposure.

The Occurrence Rate and Diameter of Arteries Traveling Near the Mandible and an Assessment of the Relative Hemorrhage Risk in Implant Surgery.

BACKGROUND: Bleeding in the floor of the mouth during implant surgery is attributed to arterial injuries in the sublingual space. PURPOSE: This study aimed to assess the relative hemorrhage risk during implant surgery. MATERIALS AND METHODS: We investigated the occurrence rate and diameter of submental and sublingual arteries with special reference to their relationship with the course patterns of these arteries using 26 human cadavers. RESULTS: Three types of arteries were distinguished: main duct (MD), mucoperiosteal branches (MB), and cortical branches (CB). The occurrence rate of MB and CB was significantly high at the central incisor region in the upper part of the mylohyoid muscle, whereas the diameter of the MB and CB was significantly smaller than the occurrence rate of MD at the incisor regions. The occurrence rate of MD in the submental artery was significantly higher at the lateral incisor, canine, and premolar regions in the lower parts, whereas the occurrence rate of MD was significantly lower at the second and third molars in the upper parts. CONCLUSION: The susceptibility of the submental artery to injury is suggested at the incisors, canine, premolars, and first molar regions during implant surgery.

Valoración por tomografía computada de los canales vasculares linguales de la mandíbula / Evaluation by computed tomography of lingual vascular canals of the mandible

Propósito: determinar la frecuencia, localización y posición de los canales vasculares linguales de la mandíbula mediante Tomografía Computada (TC) dentral y clasificarlos en base a su ubicación. Material y Métodos: se estudiaron en forma retrospectiva las TC dentales de 100 pacientes consecutivos solicitadas como evaluación previa a la colocación de implantes dentales con el fin de detectar canales vasculares linguales. Se los clasificó relacionando su localización en la mandíbula con el número de pieza dentaria presente o ausente en esa área. Resultados: todos los pacientes presentaron al menos un canal vascular lingual en la mandibula; 36 pacientes tuvieron dos, ocho pacientes tres y un paciente cuatro. La localización más frecuente fue entre las piezas 31 y 41. Dieciséis pacientes mostraton dos canales (superior e inferior) en esa ubicación. La segunda localizción por frecuencia fue entre las piezas 32 y 33 (nueve pacientes). Conclusión: la TC dentral es un excelente método para la identificación de canales vasculares linguales por su capacidad multiplanar y apropiada resolución de imagen. La caracterización y clasificación de estos conductos, mediante un método de fácil lectura para radiólogos y dentistas, aseguran una correcta valoración prequirúrgica evitando hemorragias durante la perforación de la mandíbula en la colocación de implantes dentales.

Morbidity and economic complications following mucogingival surgery in a hemophiliac HIV-infected patient: a case report.

BACKGROUND: This report describes the surgical treatment of a gingival recession in a hemophiliac HIV-infected patient. To our knowledge, mucogingival surgery has not been described previously in these patients. METHODS: Under the supervision of the patient's hematologist, a subepithelial connective tissue graft procedure was carried out to treat the recession. The treatment was performed after substitution therapy with factor VIII concentrate, supported by local antifibrinolytic treatment with epsilonaminocaproic acid. RESULTS: One week after surgery, the grafted zone showed a normal healing, but an area of necrosis appeared at the donor palatal site with spontaneous bleeding. The administration of factor VIII concentrate had to be prolonged to arrest the hemorrhage. In total, 44,500 units of factor VIII concentrate were used, the cost of which reached around $20,000. After 1 month the donor site had re-epithelialized by secondary intention. The root coverage was around 85% successful. CONCLUSIONS: Because of the surgical risk and the high economic cost in the use of the factor VIII concentrate, we do not recommend performing mucogingival surgery in HIV-infected hemophiliacs unless it is absolutely necessary. Prevention and early treatment must be the goal in the management of these patients.

An epidemic of scurvy in Afghanistan: assessment and response.

In March 2002, there were reports of a hemorrhagic fever outbreak in western Afghanistan. It was later confirmed that the hemorrhagic symptoms and increased mortality were actually due to scurvy. Most aid workers did not include scurvy in the initial differential diagnosis because it is uncommon throughout the world and has mainly been reported in refugee populations in recent times. A rapid assessment confirmed the cases clinically, estimated a prevalence rate of 6.3% (a severe public health problem), and determined that the attack rates peaked each year in January and February (the end of the winter). Many Afghans have limited dietary diversity due to isolated locations, lengthy winters, the continuing drought of the last four years, asset depletion, and loss of livelihood. After numerous food and fortification options to prevent future outbreaks had been considered, vitamin C tablet supplementation was selected because of the relatively rapid response time as compared with other prevention methods. A three-month course of vitamin C tablets was distributed to 827 villages in at-risk areas. The tablets were acceptable and compliance was good. No cases of scurvy were reported for the winter of 2002-03. The case study from Afghanistan demonstrates that scurvy can occur in nonrefugee or nondisplaced populations; vitamin C supplementation can be an effective prevention strategy; there is an urgent need to develop field-friendly techniques to diagnose micronutrient-deficiency diseases; food-security tools should be used to assess and predict risks of nutritional deficiencies; and the humanitarian community should address prevention of scurvy in outbreak-prone areas.

Clinical assessment and surgical implications of anatomic challenges in the anterior mandible.

BACKGROUND: The anterior mandible is generally considered a rather safe surgical area, involving few risks of damage to vital anatomic structures. Nevertheless, both neurosensory disturbances and hemorrhages have been reported after implant surgery in that particular area. PURPOSE: With the increasing demand for oral implant placement, the anatomy of the anterior mandible should receive more attention. This review will focus on the anatomic peculiarities of the anterior mandible and the related clinical implications. METHODS: The scientific evidence on the anatomic, histologic, physiologic, and clinical aspects of the neurovascularization of the anterior mandible will be reviewed. RESULTS: Surgical complications may be attributed to the existence of a mandibular incisive canal with a true neurovascular supply. Potential risks may also be related to the presence of the lingual foramen and anatomic variations, such as an anterior looping of the mental nerve. CONCLUSIONS: Preoperative radiographic planning for oral implant placement in the anterior mandible should therefore not only consider all esthetic and functional demands but should also pay particular attention to the anatomic peculiarities of this region to avoid any neurovascular complications.

Risk management aspects of implant dentistry.

PURPOSE: To categorize and review complications related to implant dentistry that have resulted in legal actions. MATERIALS AND METHODS: The records of 61 patients (39 women and 22 men) were retrospectively evaluated according to a structured form. Ages ranged from 28 years to 78 years (mean 49 +/- 12 years). The time lag in months between actual damage and legal action ranged from 0 months to 60 months (mean 12.7 months). RESULTS: Implant type, length, width, and locations varied widely and had no impact on the liability report. Half of the lawsuits were filed as a result of actual body damage (loss of sensation, oroantral fistula, life-threatening bleeding); 35% of the lawsuits were filed because of late complications; and 15% were related to immediate complications not leading to actual body damage. The dental consultants acknowledged liability in 41 of 61 cases. The clinician's errors that led to the reported complication were classified as preoperative in 39 of 41 cases. The doctor's attitude was considered positive in 40 cases and negative in 17 cases. DISCUSSION AND CONCLUSIONS: Clinicians should report as soon as possible to their insurance companies to get professional help. The main causes for lawsuits are actual body injury and major disappointment. Practitioners should dedicate a significant part of the entire treatment time to preoperative diagnosis and planning.

Dentists are innocent! "Everyday" bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children.

The literature related to three aspects of dental bacteremia has been reviewed in regard to postprocedure bleeding and bacteremia, intensity of bacteremia, and cumulative exposure to bacteremia from "everyday" events. The data on postprocedure bleeding and bacteremia show that there is no relationship between bleeding and bacteremia. Significant bacteremia can occur in the absence of clinically discernible bleeding. The intensity of bacteremia in humans is significantly less than that used in experimental endocarditis models. It is unlikely that the intensity of bacteremia following dental procedures in children could readily lead to endocarditis. The cumulative exposure to bacteremia is significantly greater from everyday procedures when compared to dental operative procedures. It is far more likely that such everyday procedures are the cause of bacterial endocarditis because the cumulative exposure is often hundreds, thousands, or even millions of times greater than that occurring following surgical procedures such as extraction of teeth. The value of antibiotic prophylaxis prior to dental treatment is questioned.

Pediatric bone marrow transplantation: oral complications and recommendations for care.

Bone marrow transplantation (BMT) has become an increasingly common treatment option for those patients who have a disease that affects the bone marrow (BM) directly or indirectly. Because of the level of immunosuppression achieved in BMT, any problems the pediatric patient presents in the oral cavity can become life-threatening and increase the length of hospital stay, the patient's discomfort, and the treatment costs. The oral cavity is a reservoir for microorganisms thus by reducing their number through optimal care, immunosuppressed patients may decrease their chance of a life-threatening systemic infection from an oral source. Many BMT teams believe that toothbrushing increases the risk of bacteremia and bleeding; however, problems are more likely to arise when patients are not compliant with good oral hygiene habits. It is vital to educate the caretaker and the child about the importance of oral care in order to minimize discomfort and maximize the chances for a successful transplant. This paper discusses the important and unique role that pediatric dentistry has in the multiprofessional BMT team to help bring about a successful outcome through the prevention and treatment of the acute oral complications often seen in these patients.

Taking dental self-care to the extreme: 24-month incidence of dental self-extractions in the Florida Dental Care Study.

OBJECTIVE: A common response to health-related symptoms is to treat oneself in lieu of or prior to seeking formal health care. Among the more extreme forms of dental self-care is dental self-extraction. To our knowledge, no study of the incidence of this behavior has been conducted. The objective of this study was to determine if one form of dental self-care, dental self-extraction, is a real phenomenon, and if so, to determine its incidence. METHODS: The Florida Dental Care Study is a longitudinal study of changes in oral health, whose subjects participated for an interview and clinical examination at baseline and 24 months after baseline. RESULTS: Of the 739 persons who participated through 24 months 176 lost one or more teeth. Of these 176 persons, 13 (7%) extracted one or more of their own teeth. The clinical status at baseline of the self-extracted teeth was consistent with the ability to self-extract. CONCLUSION: The phenomenon of dental self-extraction is real and is not limited to residents of developing nations or geographically isolated areas. Because of the potential for prolonged bleeding or bacterial endocarditis in certain population groups, community health clinicians and officials should be cognizant of this behavior.

Germectomy or delayed removal of mandibular impacted third molars: the relationship between age and incidence of complications.

PURPOSE: To analyze and compare complications and side effects after removal of 1,500 mandibular impacted third molar teeth in three age groups. MATERIALS AND METHODS: The sample comprised 868 patients, 462 women and girls and 406 men and boys aged 9 to 67 years. The patients were divided according to age into the following three groups: group A, aged 9 to 16 years; group B, aged 17 to 24 years; group C, older than 24 years of age. RESULTS: The incidence of complications and side effects was 2.6% in group A, 2.8% in group B, and 7.4% in group C. All complications were temporary except in one instance of mandibular nerve paresthesia that occurred in a group C patient, in whom symptoms were still present 25 months after surgery. CONCLUSION: This study showed no significant difference in the complication rate between groups A and B, but complications significantly increased in group C.

Adult day case tonsillectomy: a safe and viable option.

Day case tonsillectomy, in general, is not considered a routine procedure. Many otolaryngologists would not perform this operation on an out-patient basis due to the risk of reactionary haemorrhage after discharge from hospital. A prospective trial of carefully selected adult patients undergoing day case tonsillectomy was performed. Each was given a questionnaire to assess post-operative morbidity including pain, time required to return to normal diet and comments on the ambulatory aspect of their surgery. The results of 48 patients are analysed. None of these had haemorrhage within 24 h of their operation. Twenty patients (42%) were happy to have the procedure performed in this way whilst 19 (39%) found it tolerable. Two patients had to be admitted overnight as they had not recovered enough to be discharged. It is concluded that adult day case tonsillectomy in selected patients is a safe and viable option.