Human Papillomavirus (HPV) oral lesions surgical management with Nd:YAG laser versus blade and QMR scalpel: a single center experience in 251 cases.

HPVs are a large and varied group of viruses capable of infecting both animals and humans. They have evolved together with their respective hosts and are isolable in different and numerous species of birds, reptiles, marsupials and mammals. The present study aims to analyze and compare the epidemiological aspects of 251 HPV-associated benign lesions treated with three different surgical approaches. Between January 2004 and December 2019, 251 HPV-associated benign lesions (papillomas and / or condylomas) were treated at the Center of Medicina e Patologia Orale Laser Assistita of the University of Parma. After loco-regional anesthesia, the excisional biopsy was performed with A): 15C scalpel blade; B): molecular quantum resonance scalpel (RQM); C): Nd: YAG laser (1064 mn, 3.5W, 70Hz). The epidemiological analysis considered: gender, age, site of the lesion, surgical technique and recurrence. Our study did not show substantial differences in gender prevalence and the mean age of 50 years (minimum 8 years, maximum 85 years). Our study showed that HPV-associated lesions are localized in almost half of patients (47.9%) on the tongue or hard palate, less frequently on the cheeks (16.3%) and on the upper or lower lip (14,4) and in less than 10% of patients in the soft palate. Our study showed a low relapse rate (3%) for all three therapeutic approaches used, meaning that the cold blade, RQM scalpel and Nd: YAG laser can be successfully used to treat lesions associated with HPV, the laser approach has proved to be slightly more effective: probably thanks to the radicalization obtained through carbonization of the biopsy surrounding tissues. Since a small group of these viruses are the responsible agent of several types of human cancers (including squamous cell carcinoma of the oral cavity), early screening and treatment of HPV-associated lesions is essential to prevent the development of oncological diseases.

Correlation between temperature rise and auto-fluorescence: ex vivo study with Er:YAG laser, Quantum Molecular Resonance scalpel and Nd:YAG laser on hard and soft tissues.

Surgical techniques of soft and hard oral tissues highly benefited from new technologies such as the Quantic Molecular Resonance (QMR) lancet, the Neodymium-doped Yttrium Aluminum Garnet (Nd:YAG) laser and the Erbium-doped Yttrium Aluminum Garnet (Er:YAG) laser. Increasingly, these technologies replace scalpel, conventional electrosurgery and traditional rotary surgery instruments due to their proven advantages. Features such as reduction of the surgical time, more efficient bleeding control resulting in higher intra-operative visibility and improvement of postoperative course with better Quality of Life score (QoL) are highlighted in numerous studies published in the literature. The thermal rise of tissues during surgical incision, performed with other instruments rather than traditional cold blade scalpels, is not to be ignored by the operator and it must take into consideration first when choosing the surgical instrument and then throughout all the surgical act. Auto-fluorescence (AF) is a property possessed by every cell that exposed to a specific wavelength can absorbance or reflect with peculiar characteristics and its direct examination has been proposed as a non-invasive visual tool for investigation of suspicious changes in oral mucosa. At the limit of our knowledge, few studies have been published in the literature regarding tissue's temperature variations and the interest in Infra-Red temperature detection has been shown in various medicine fields and none of published studies investigated the possible correlation between temperature raise and AF variations. This ex vivo study aims to analyse and compare through the use of a thermal imaging camera and simultaneous detection of AF, the possible correlation between temperature increase and auto-fluorescence.

Salivary biomarkers for diagnosis of systemic diseases and malignant tumors. A systematic review.

BACKGROUND: Saliva evaluation could be a possible alternative to blood and/or tissue analyses, for researching specific molecules associated to the presence of systemic diseases and malignancies. The present systematic review has been designed in order to answer to the question "are there significant associations between specific salivary biomarkers and diagnosis of systemic diseases or malignancies?". MATERIALS AND METHODS: The Preferred Reporting Item for Systematic Reviews and Meta-analysis (PRISMA) statement was used to guide the review. The combinations of "saliva" and "systemic diseases" or "diagnosis" or "biomarkers" or "cancers" or "carcinoma" or "tumors", were used to search Medline, Scopus and Web of Science databases. Endpoint of research has been set at May 2019. Studies were classified into 3 groups according to the type of disease investigated for diagnosis: 1) malignant tumors; 2) neurologic diseases and 3) inflammatory/metabolic/cardiovascular diseases. Assessment of quality has been assigned according to a series of questions proposed by the National Institute of Health. Level of evidence was assessed using the categories proposed in the Oxford Center for Evidence-Based medicine (CEMB) levels for diagnosis (2011). RESULTS: Seventy-nine studies met the inclusion and exclusion criteria. Fifty-one (64%) investigated malignant tumors, 14 (17.5%) neurologic and 14 (18.5%) inflammatory/cardiovascular/metabolic diseases. Among studies investigating malignant tumors, 12 (23.5%) were scored as "good" and 11 of these reported statistically significant associations between salivary molecules and pathology. Two and 5 studies were found to have a good quality, among those evaluating the association between salivary biomarkers and neurologic and inflammatory/metabolic/cardiovascular diseases, respectively. CONCLUSIONS: The present systematic review confirms the existence of some "good" quality evidence to support the role of peculiar salivary biomarkers for diagnosis of systemic diseases (e.g. lung cancer and EGFR).

Absorption and diffusion of a 645 nm diode laser beam in the bone. An ex vivo study.

The present preliminary ex vivo study aims to assess the possible interaction between complex biological systems and laser light, through irradiation of different hard tissue samples. A 645 nm wavelength diode laser was adopted to perform the present evaluation. Due to known similarities to human tissues, swine tissue samples were used. Two samples of cortical bone measuring 4.4 mm and 4.7 mm of thickness and 2 samples of spongeous bone measuring 2.45 mm and 2.9 mm were harvested for the analysis of hard tissues. Mean absorption values were as follows: 128.82 mW standard deviation 8.74 for 2.45 mm spongeous bone sample; 132.34 mW standard deviation 7.66 for 2.9 mm spongeous bone sample; 140.59 mW standard deviation 5.97 for 4.4 mm cortical bone sample and 152.20 mW standard deviation 3.36 for 4.7 mm mucosa and cortical bone sample. Red-light laser with 645nm wavelength has the ability to reach cells in each layer of measured tissues.

Effects of zoledronic acid and dexamethasone on early phases of socket healing after tooth extraction in rats: A preliminary macroscopic and microscopic quantitative study.

BACKGROUND: The exact pathogenesis of medication-related osteonecrosis of the jaw (MRONJ) is still unknown. The aim of this paper was to investigate the effects of zoledronic acid and dexamethasone on the early phases of socket healing in rats subjected to tooth extractions. MATERIAL AND METHODS: Thirty male Sprague-Dawley rats were divided into 2 groups: pharmacologically treated group (T, n=20) and non-pharmacologically treated group (C, n=10). T group rats received 0.1 mg/Kg of zoledronic acid (ZOL) and 1 mg/Kg of dexamethasone (DEX) three times a week for 10 consecutive weeks. C group rats were infused with vehicle. After 9 weeks from the first infusion, first maxillary molars were extracted in each of the rats. Quantitative macroscopic and microscopic analysis was performed to evaluate socket healing 8 days after extraction. RESULTS: Pharmacologically treated rats showed significant inhibition of bone remodeling. Connective tissue/alveolar bone ratio, osteoclast number and woven bone deposition were significantly reduced in group T compared to group C. Conversely, the proportion of necrotic bone was higher in group T compared to group C (0.8% and 0.3%, respectively. P=0.031). ZOL plus DEX do not cause gross effects on socket healing at a macroscopic level. CONCLUSIONS: Our findings confirmed that exposure to ZOL plus DEX impairs alveolar wound repair. Inhibition of osteoclastic resorption of socket walls after tooth extraction and the inability to dispose of the necrotic bone may be considered the initial steps of MRONJ onset.

The association between burning mouth syndrome and sleep disturbance: A case-control multicentre study.

OBJECTIVES: To investigate the quality of sleep and the psychological profiles of a large cohort of Italian patients with burning mouth syndrome (BMS) and to clarify the relationships between these variables and pain. METHODS: In this case-control study, 200 patients with BMS vs an equal number of age- and sex-matched healthy controls, recruited in 10 universities, were enrolled. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), Numeric Pain Intensity Scale (NRS) and Total Pain Rating Index (T-PRI) were administered. Descriptive statistics, including the Mann-Whitney U test and hierarchical multiple linear regression analysis, were used. RESULTS: Poor sleep quality (PSQI ≥ 5) was present in 78.8% (160) patients with BMS. BMS patients had statistically higher scores in all items of the PSQI and ESS than the healthy controls (p < .001). A depressed mood and anxiety correlated positively with sleep disturbance. The Pearson correlations were 0.570 for the PSQI vs HAM-D (p < .001) and 0.549 for the PSQI vs HAM-A (p < .001). Pain intensity (NRS) poorly correlated to sleep quality; the Pearson correlation was 0.162 for the PSQI vs NRS (p = .021). CONCLUSIONS: The BMS patients showed a poor sleep quality, anxiety and depression, as compared with the controls, highlighting the relationships between oral burning, sleep and mood.

A 5-year retrospective longitudinal study on the incidence and the risk factors of osteonecrosis of the jaws in patients treated with zoledronic acid for bone metastases from solid tumors.

BACKGROUND: The aim of this study was to evaluate the incidence and the risk factors of osteonecrosis of the jaw (ONJ) in a group of patients treated with zoledronic acid (ZA) for bone metastases from solid tumors and enrolled in a preventive dental program. MATERIAL AND METHODS: This 5-year retrospective longitudinal study included all consecutive oncological patients who underwent at least one infusion with ZA between 2004 and 2011 for bone metastases due to solid neoplasms. RESULTS: Of the 156 patients enrolled in the study, 17 developed ONJ (10.89%). At the multivariate analysis, severe periodontal disease (P=0.025), tooth extraction (P<0.0001) and starting the preventive dental program after the beginning of ZA therapy (P=0.02) were the only factors which showed a significant association with the occurrence of ONJ. CONCLUSIONS: This study demonstrated the importance of beginning dental prevention before zoledronic acid exposure in reducing ONJ occurrence, especially in the long term. The results of this research show that control of periodontal disease and an increase in the time between tooth extraction and the first ZA administration are recommended in order to reduce the risk of ONJ development.

Type of surgical treatment and recurrence of oral leukoplakia: A retrospective clinical study.

BACKGROUND: Oral leukoplakia (OL) is the most typical potentially malignant disorder of the oral mucosa. We aimed to evaluate the clinical outcome of oral leukoplakia treated with several types of lasers and with the use of quantic molecular resonance (QMR) lancet, in terms of recurrence rate. MATERIAL AND METHODS: Eighty-seven previously untreated OL (52 occurring in females and 35 in males, mean age of 59.4 ± 13.9 years) were consecutively submitted to surgical treatment at University Hospital of Parma, Italy, and Hospital de Valongo, Portugal, (1999 to 2012). Interventions were subclassified into 5 groups according to the instrument used for the surgical removal of OL (cold blade - 17; Nd:YAG 1064nm laser - 14; Er:YAG 2940nm laser - 33; CO2 10600nm laser - 15; and QMR scalpel - 8). The mean follow-up period after treatment was 21.6 months (range 1-151 months). The outcome of treatment was scored through the same clinical protocol in the two participating units. Statistical analysis were carried by univariate analysis using chi-square test (or Pearson's test when appropriate). RESULTS: Recurrences were observed in 24 cases of OL (27.6%). Malignant transformation occurred in one patient (1.1%) after a period of 35 months. Statistical comparison of the 5 surgical treatment modalities showed no differences in clinical outcomes nor in the recurrence rate of OL. However, when Er:YAG laser group was compared with traditional scalpel, a significantly better outcome in cases treated with Er:YAG laser (P = 0.015) was highlighted. CONCLUSIONS: Our results suggests that Er:YAG laser could be a promising option for the treatment of OL.

Non-invasive visual tools for diagnosis of oral cancer and dysplasia: A systematic review.

BACKGROUND: Gold standard for the diagnosis of oral dysplasia (OD) and oral squamous cell carcinoma (OSCC) and malignant lesions is the histological examination. Several adjunctive diagnostic techniques have been proposed in order to increase the sensitivity (SE) and specificity (SP) of conventional oral examination and to improve the diagnostic first level accuracy. The aim of this study is to perform a systematic review on non-invasive tools for diagnosis of OD and early OSCC. MATERIAL AND METHODS: Medline, Scopus, Web of Knowledge databases were searched, using as entry terms "oral dysplasia AND diagnosis" / "oral cancer AND diagnosis". Data extracted from each study included number of lesions evaluated, histopathological diagnosis, SE, SP, positive and negative predictive values (PPV and NPV), diagnostic accuracy (DA) and the main conclusions. RESULTS: After title and abstract scanning of 11.080 records, we selected 35 articles for full text evaluation. Most evaluated tools were autofluorescence (AF), chemiluminescence (CL), toluidine blu (TL) and chemiluminescence associated with toluidine blue (CLTB). CONCLUSIONS: There is a great inhomogeneity of the reported values and there is no significant evidence of superiority of one tool over the other. Further clinical trials with a higher level of evidence are necessary in order to assess the real usefulness visual diagnostic tools.

Comparison of two different laser wavelengths' dental bleaching results by photo-Fenton reaction: in vitro study.

The purpose of this study was to perform a preliminary in vitro test on the possible use of two different laser wavelengths, 405 and 532 nm, to improve the dental bleaching results. To perform the test, the degradation of a dye, rhodamine B, under the effects of hydrogen peroxide was used. One hundred and twenty vials were divided into four groups of 30 samples each and, while three of them were irradiated with different wavelengths, 365 nm (reference), 405 nm and 532 nm, the fourth was the non-irradiated control group. Each of the four groups was further divided into three subgroups of 10 cuvettes (n = 10) each. The three subgroups included a group with a rhodamine (RH) solution, a rhodamine and hydrogen peroxide (RH + HP) solution and a rhodamine plus hydrogen peroxide and ferrous gluconate (RH + FR) solution. When hydrogen peroxide was present, only UVA irradiation was able to produce significant results, whereas when the photo-Fenton reaction occurred, all the three wavelengths were able to produce a significant degradation of rhodamine B, with better results for longer wavelengths in comparison with short wavelengths. Within the limitations of this in vitro study, the light of the two laser devices, even remaining less effective than UV activation, showed its ability to improve the performance of bleaching agents based on Fenton photocatalysis, whereas when used in combination with hydrogen peroxide only, the 405-nm laser displayed a small effect and the 532-nm laser produced no effects.

Postoperative discomfort in oral soft tissue surgery: a comparative perspective evaluation of Nd:YAG Laser, quantic molecular resonance scalpel and cold blade.

AIM: The aim of this paper was to compare pain, health-related quality of life (HRQoL) and need for painkillers during the postoperative course of oral soft tissue surgery performed with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, quantic molecular resonance (QMR) scalpel and cold blade. METHODS: One-hundred and sixty-three similar surgical interventions were subclassified as follows: group 1 (G1), 77 cases performed with Nd:YAG laser; group 2 (G2), 45 cases performed with QMR scalpel and group 3 (G3), 41 cases performed with cold blade. Pain was evaluated using a Visual Analogue Scale (VAS), a Numeric Rating Scale (NRS) and a Verbal Rating Scale-6 (VRS-6) on the same day of surgery (day 0), and at 1, 3 and 7 days after surgery. The HRQoL was evaluated on day 7 using a 0-45 score range questionnaire. On day 7, painkillers taken were recorded. RESULTS: No statistically significant differences could be highlighted in the VAS and NRS scores at day 1, 3 and 7. A trend toward significance at day 0 was evident, with a VAS and NRS average scores lower in G1 than G2 and G3. With regard to VRS-6, the scores resulted statistically lower in G1 than G2 and G3 at day 1 and 3. The HRQoL in G1 was statistically lower than G3. CONCLUSION: Our study demonstrates that the use of new technologies in oral soft tissue surgery is associated to a reduction of postoperative discomfort. The better HRQoL and the lower postoperative pain observed in laser-treated patients may be associated to the possible bio-modulating effect of the laser.

Oral proliferative verrucous leucoplakia: are there particular features for such an ambiguous entity? A systematic review.

Proliferative verrucous leucoplakia (PVL) is a distinct, particularly aggressive form of oral leucoplakia. Given the low prevalence of PVL, data are sparse and are mostly from case reports, case series and only a few case-control studies, meaning that the literature is able to provide only weak evidence. The present systematic literature review aims to collate the available evidence on the following issues: patient demographics, aetiology, lesion location(s), malignant potential, location and histopathological features of transformed lesions, disease-specific survival rates and treatment response. Electronic databases were searched for studies in the English language reporting original data from at least 10 patients with PVL on the target issues of the present review. The retrieved data were merged and a descriptive analysis performed. The 20 studies selected indicated that PVL does not seem to be correlated with the major risk factors for oral carcinoma (tobacco, alcohol and/or areca nut/betel leaf chewing). The disorder affects mainly adult/elderly women and has a very high malignant transformation rate, particular site distribution and particular location and histopathological features of transformed lesions. The present results may be limited by some articles being unintentionally excluded as they were not found during the electronic search, a lack of worldwide accepted diagnostic criteria for PVL, and overlapping data from multiple studies performed in a limited number of centres. Despite these potential drawbacks, the present results demonstrate that PVL does have particular features.

Analysis of shade, temperature and hydrogen peroxide concentration during dental bleaching: in vitro study with the KTP and diode lasers.

Many dental bleaching techniques are now available, several of them using a laser source. However, the literature on the exact role of coherent light in the biochemical reaction of the whitening process is very discordant. The aims of this in vitro study were: (1) to compare two different laser sources, a KTP laser with a wavelength of 532 nm and a diode laser with a wavelength of 808 nm, during dental bleaching, and (2) to investigate the relationships among changes in gel temperature, tooth shade and hydrogen peroxide (HP) concentration during laser irradiation. Altogether, 116 bovine teeth were bleached using a 30% HP gel, some of them with gel only and others with gel plus one of the two lasers (532 or 808 nm) at two different powers (2 and 4 W). The KTP laser produced a significant shade variation with a minimal temperature increase. The diode laser led to a higher temperature increase with a greater reduction in HP concentration, but the change in shade was only statistically significant with a power of 4 W. At a power of 2 W, the KTP laser caused a greater change in shade than the diode laser. No significant correlations were found among temperature, HP concentration and shade variation. The KTP laser appears to provide better results with less dangerous thermal increases than the diode laser. This might call into question most of the literature affirming that the action of laser bleaching is by increasing the gel temperature and, consequently, the speed of the redox reaction. Further study is required to investigate the correlations between the parameters investigated and efficacy of the bleaching process.

Low energy KTP laser in oral soft tissue surgery: A 52 patients clinical study.

OBJECTIVES: Since 1962 laser appliances have been used for soft tissues surgery of oral cavity with significant advantages compared to the traditional instruments: excellent bleeding control, possibility to avoid the use of suture, good patient compliance thanks to a decrease of intra- and post-operative discomfort and biostimulating effect. Unfortunately, the wavelengths so far used have been seen to cause, in association with an excellent ablation capacity, heat damage of the tissues that can decrease healing process and cause a greater discomfort to patients. To evaluate the laser-assisted KTP laser surgery at low power in terms of characteristics of intervention and patients compliance. STUDY DESIGN: In this study, we describe the application of a new and recently introduced in dentistry wavelength, the KTP laser (532 nm), used with low power parameter (1 Watt - CW), evaluating the time of interventions and, by a Numerical Rating Scale, the intra and postoperative pain. RESULTS: KTP laser used at low power permits to obtain good pain control during operations that were carried out with only a topic anaesthetic (EMLA, Astratech), as shown in VAS tests. Good healing with limited or absent burning areas in treated portion of tissue. CONCLUSIONS: These preliminary study allows us to affirm that KTP laser with low parameters permits to perform oral surgery with good pain control and good wound healing. A greater number of clinical cases are however necessary to confirm the result obtained.

Food-specific IgG4 lack diagnostic value in adult patients with chronic urticaria and other suspected allergy skin symptoms.

BACKGROUND: Specific IgG4 dosing against food is proposed to the public by a lot of commercial laboratories as a reliable method to diagnose food intolerance. Actually, few data on IgG4 responses to foods in adults are available in the literature. In this study we evaluated the clinical utility of specific IgG4 dosing against food in adult patients with suspected food allergy/intolerance. METHODS: A case series of 73 adult patients with suspected food allergy and clinical manifestations of chronic urticaria or other allergy-supposed skin symptoms were tested for specific IgG4 against foods. An open food challenge was carried out for all IgG4-positive food. All positive open tests were controlled by double-blind placebo-controlled food challenge. RESULTS: Forty-five patients (62%) were IgG4 positive for a number of foods, mainly egg, milk, casein and wheat. None of the patients with IgG4-positive testing showed adverse reactions, neither immediate nor delayed, to the corresponding food. CONCLUSIONS: In adult patients, testing for specific IgG4 lacks clinical utility for the diagnosis of food allergy or intolerance. Dosing of IgG4 should not be part of the diagnosis and therapy of adult patients with allergy-like skin diseases.

Risk assessment of immediate systemic reactions from skin tests with ß-lactam antibiotics.

BACKGROUND: Some clinical studies have demonstrated that skin tests for ß-lactam antibiotics may cause more adverse reactions than skin tests for common allergens. OBJECTIVE: To assess the risk of systemic reactions from penicillin skin testing, based on a pre-test categorization of patients, in order to establish an appropriate strategy for preempting and dealing with cases. METHODS: A case series of 175 patients with a suspected allergy to penicillin was reviewed, and patients were classified as having a low or high probability of allergic sensitization to penicillin, according to their clinical history. For every group, the rate and the increase in the relative risk (RRI) of systemic reactions by skin testing were calculated. The results were compared to those reported in the available literature. RESULTS: In our case series of 175 patients, 52 were classified as having a high probability of being allergic to penicillin, according to their clinical history. Five systemic reactions to skin testing were observed, and these were exclusively in this group (9.61%, RRI = 479). In agreement with the literature, patients with a high likelihood of penicillin allergy showed an increase of up to 10% in the occurrence of systemic reactions at skin testing; in patients who had had severe allergic reactions, this figure was up to 20%. CONCLUSIONS: The RRI of systemic reactions by skin testing is proportional to the pre-test probability of a true immediate hypersensitivity reaction to ß-lactam antibiotics. In the present case series, only patients with high pre-test probability were at risk, and this group should therefore be skin tested and monitored in a hospitalization regimen, where resuscitation staff and access to an emergency room are immediately available.

Detection of survivin mRNA in healthy oral mucosa, oral leucoplakia and oral cancer.

BACKGROUND: Survivin is involved in modulation of cell death and cell division processes. Survivin expression in normal adult tissues has not been fully understood, although it is markedly lower than in cancer, where it is over-expressed. OBJECTIVE: To investigate survivin expression in normal, potentially malignant and cancerous oral mucosa. METHODS: We measured survivin mRNA levels by real-time RT-PCR in specimens of oral mucosa (15 from normal mucosa, 17 from potentially malignant lesions, 17 from neoplasms). Scores were compared using Kruskal-Wallis test and post hoc according to Conover. Chi-squared test was used for dichotomous data. RESULTS: The median relative levels of survivin mRNA resulted six for normal mucosa, eight for potentially malignant lesions, 13 for cancers: differences among these three groups were statistically significant, as between cancer and potentially malignant lesions. Expression in normal mucosa and potentially lesions group showed no significant difference. Low, but not marginal expression of survivin in normal mucosa is a new finding, and it could be explained with the higher sensibility of our methods. CONCLUSIONS: Survivin expression in oral potentially malignant lesions might indicate a progressive deregulation of expression paralleling oncogenesis, particularly during the first stages of process, suggesting a putative predictive role for survivin.

Intra-oral laser welding: an in vitro evaluation of thermal increase.

The neodymium:yttrium-aluminium-garnet (Nd:YAG) laser is currently used in dental laboratories to weld metals on dental prostheses. Recently, the use of Nd:YAG has been suggested so that dentists themselves can repair broken fixed, removable and orthodontic prostheses by welding metals directly in the mouth. This work aimed to evaluate, through a four k-type thermocouple system on calf jaws, the thermal increase in the biological structures close to the metal parts during laser welding. We put two hemispherical metal plates onto mandibular molars and then laser welded them at three points with a four k-thermocouple system to determine the thermal rise in the pulp chamber, sulcus, root and bone. This procedure was carried out on 12 samples, and the results were processed. The highest values of thermal increase were found in the pulp chamber, 1.5 degrees C; sulcus, 0.7 degrees C; root, 0.3 degrees C; and bone, 0.3 degrees C. This study showed that thermal increases in pulp chamber, sulcus, root and bone were biologically compatible and that intra-oral laser welding, at the parameters used in this work, seems to be harmless to the biological structures close to the welding and thermally affected zones.

Long-term tolerability of etoricoxib in different types of NSAID-intolerant subjects.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are a frequent cause of hypersensitivity reactions, therefore, in clinical practice, it's important to find safe and effective substances. OBJECTIVE: To evaluate the tolerability of etoricoxib and its subsequent actual use and safety at home. METHODS: Etoricoxib tolerance was assessed by single-blind-placebo-controlled oral challenges and its subsequent use was checked by a standardized telephone call. The test was performed in 139 subjects (83 single NSAID reactors and 56 multiple NSAID reactors). RESULTS: The drug was not tolerated in 4 cases (2.8%) causing wheals on the face area in 3 single reactors and a severe generalised reaction occurring three hours after the intake of a therapeutic dose in a multiple reactor. The phone calls showed that 64 (52.8%) patients did not take etoricoxib, mostly due to the fear of adverse effects; in 5 cases (4.2%), the practitioner prescribed a different NSAIDs. Only 52 (43%) subjects took etoricoxib after oral challenges; all tolerated the drug but 2 single reactors, who reported a very mild labial oedema. CONCLUSION: Our study confirmed the good long-term tolerability of etoricoxib in patients with a history of hypersensitivity to other NSAIDs without differences between single and multiple reactors. Nonetheless, in NSAID-intolerant subjects this drug should be first challenged in specialised centres due to the risk ofsevere reactions.

Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) therapy. A critical review.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an area of uncovered bone in the maxillo-facial region that did not heal within 8 weeks after identification by health care provider, in a patient who was receiving or had been exposed to Bisphosphonate Therapy (BPT) without previous radiation therapy to the craniofacial region. Low-grade risk of ONJ is connected with oral BPT used in the treatment of osteopenia, osteoporosis and Paget's disease (from 0.01% to 0.04%) while higher-grade risk is associated with intravenous (IV) administration in the treatment of multiple myeloma and bone metastases (from 0.8% to 12%). The management of BRONJ currently is a dilemma. No effective treatment has yet been developed and interrupting BPT does not seem to be beneficial. Temporary suspension of BPs offers no short-term benefit, whilst long term discontinuation (if systemic conditions permit it) may be beneficial in stabilizing sites of ONJ and reducing clinical symptoms. The use of oral antimicrobial rinses in combination with oral systemic antibiotic therapy -penicillin, metronidazole, quinolones, clindamycin, doxycycline, erythromycin- is indicated for Stages I and II of Ruggiero's Staging. The role of hyperbaric oxygen therapy is still unclear but some benefits of this treatment have recently been described in association with discontinuation of BPT and conventional therapy (medical or/and surgical). Surgical treatment, in accordance to the AAOMS Position Paper, is reserved to patients affected by Stage III of BRONJ even if in the last version (2009) a superficial debridement is indicated to relieve soft tissue irritation also in the stage II (lesions being unresponsive to antibiotic treatment). Aggressive surgical treatment may occasionally results in even larger areas of exposed and painful infected bone. Surgical debridement or resection in combination with antibiotic therapy may offer long-term palliation with resolution of acute infection and pain. Mobile segments of bony sequestrum should be removed without exposing unaffected bone. If pathological fractures or complete mandibular involvement are observed, if the medical condition of the patients allows it the affected bone portion may be resected and primary bone reconstruction or revascularization graft may be carried out. Ozone therapy in the management of bone necrosis or in extractive sites during and after oral surgery in patients treated with BPs may stimulate cell proliferation and soft tissue healing. Laser applications at low intensity (Low Level Laser Therapy - LLLT) have been reported in the literature for the treatment of BRONJ. Biostimulant effects of laser improve reparative process, increase inorganic matrix of bone and osteoblast mitotic index and stimulate lymphatic and blood capillaries growth. Laser can be used for conservative surgery, whereby necrotic bone is vaporized, until healthy bone is reached. The Er:YAG laser wavelength has a high degree of affinity for water and hydroxyapatite, hence both soft and bone tissues can be easily treated. An additional advantage of the Er:YAG laser is its bactericidal and possible biostimulatory action, accelerating the healing of both soft and bone tissues, in comparison to conventional treatments. Long-term, prospective studies are required to establish the efficacy of drug holidays in reducing the risk of BRONJ for patients receiving oral BPs even if it has been suggested that BPT may be discontinued for three months before the surgical procedures and bone turnover markers (CTx, NTx, PTH, 1,25-dihydroxy vitamin D) may be checked. However it must be recognized that interindividual variability, gender, age, physical activity, and seasonal and circadian variation exist that can result in difficulty in interpreting these assays and more research is needed. Laser application (LLLT and laser surgery) nowadays appears to be a promising modality of BRONJ treatment, being safe and well tolerated, and it permits the minimally invasive treatment of early stages of the disease.