The role of hyperbaric oxygen in osteoradionecrosis-a prophylactic insight.

BACKGROUND: Osteoradionecrosis (ORN) is an uncommon and debilitating consequence of head and neck radiotherapy and hyperbaric oxygen therapy (HBOT) has been advocated for prophylaxis prior to performing dentoalveolar procedures. The aim of this study was to evaluate a prophylactic HBOT protocol and describe the outcomes of susceptible individuals. METHODS: A retrospective audit of adults who attended the Oral and Maxillofacial Surgery department at the Royal Adelaide Hospital (South Australia) who received dental extractions with a history of radiotherapy to the jaws from 2008 to 2020. Data including demographic information and outcomes of osteoradionecrosis and delayed healing was recorded. RESULTS: A total of 121 individuals were eligible for case note review; 68.6% of individuals were male and 55.4% were aged over 67 years. Osteoradionecrosis occurred in 9.1% of individuals and delayed healing for 3.3%; fifteen individuals (12.4%) were unable to complete the HBOT protocol. The individuals who were diagnosed with ORN had a significant association with age (P = 0.006) and binary analysis showed alcohol consumption to be a significant predictor. CONCLUSIONS: Prophylactic HBOT protocol had a lower proportion of individuals diagnosed with ORN and those who were diagnosed were more likely to be younger males and have current alcohol consumption.

Necrotizing fasciitis as a complication of odontogenic infection: a review of management and case series.

BACKGROUND: The aims of the present study were to establish the incidence of head and neck necrotizing fasciitis (NF) in the Adelaide Oral and Maxillofacial Surgery Unit; review the current literature regarding the management of head and neck NF; and determine the evidence for the role of hyperbaric oxygen therapy in the management of NF. METHODS: A retrospective audit of all patients admitted to the Royal Adelaide Hospital Oral and Maxillofacial Surgery Unit 2006-2015 with severe odontogenic infections was carried out. Patient demographics were recorded and treatment details were collected and analysed. RESULTS: A total of 672 patients were admitted for management of severe odontogenic infections. Of these, three were identified as NF. One case was treated using hyperbaric oxygen as an adjunct to conventional surgical and medical management. Two cases were managed using aggressive surgical management alone. Two patients survived. The incidence of head and neck NF in South Australia is 48/100 000 infections per year. CONCLUSIONS: The first-line treatment of severe odontogenic infections remains conventional surgical and medical management; however, hyperbaric oxygen therapy may have an additional role in the management of NF and other rare severe infections in medically complex patients.

Does increased sunlight exposure work as a strategy to improve vitamin D status in the elderly: a cluster randomised controlled trial.

SUMMARY: Sunlight exposure by improving vitamin D status could be a simple public health strategy in reducing falls among frail elder people. In a randomised controlled trial, adherence to sunlight exposure was low (median adherence, 26%) and no effect of increased UV exposure on falls risk was observed (incidence rate ratio (IRR) 1.06, P = 0.73). INTRODUCTION: This study aimed to determine whether increased sunlight exposure was effective to improve vitamin D status and reduce falls in the elderly. METHODS: In a cluster randomised controlled trial (NCT00322166 at ClinicalTrials.gov), 602 residents aged 70 or more (mean age, 86.4 years; 71% female) were recruited from 51 aged care facilities in Northern Sydney, Australia. Participants were randomised by facility to receive either increased sunlight exposure (additional 30-40 min/day in the early morning) with (UV+) or without (UV) calcium supplementation (600 mg/day) or neither (control) for a year. The co-primary endpoints were change in serum 25 hydroxy vitamin D (25OHD) and falls incidence after 12 months. RESULTS: Adherence to sunlight exposure was low (median adherence, 26%; IQR, 7%-45%). Serum 25OHD levels were low at baseline (median, 32.9 nmol/L) and increased only slightly depending on the number of sunlight sessions attended over 12 months (P = 0.04). During the study, 327 falls occurred in 111 (54%) subjects in the control group, 326 falls in 111 (58%) subjects in the UV only group and 335 falls in 108 (52%) subjects in the UV+ group. By intention-to-treat analysis, there was no significant effect of increased UV exposure on falls risk (IRR, 1.06; 95% CI, 0.76-1.48; P = 0.73). However, in 66 participants who attended ≥130 sessions per year (adherence, ≥50% of 260 sessions-five per week), falls were significantly reduced (IRR, 0.52; 95% CI, 0.31-0.88; P = 0.01) compared with the control group. CONCLUSIONS: Increased sunlight exposure did not reduce vitamin D deficiency or falls risk in frail older people. This public health strategy was not effective most likely due to poor adherence to the intervention.

Implant dentistry in Australian undergraduate dental curricula: knowledge and competencies for the graduating dentist.

AIMS: The aim of this paper is to define the key competencies (knowledge, skills, attitudes and values) in the field of implant dentistry, necessary for graduating general practitioners in Australia. The authors have produced a headline reference guide to outline the necessary educational outcomes which can be targeted by the undergraduate curricula in dental schools of Australian universities. This paper focuses on competencies and aims to clarify curricula 'endpoints' rather than processes. The process towards achieving these outcomes and the instructional methods and strategies might vary among universities. The authors acknowledge that there are different ways to reach the targeted learning outcomes and that there is a diversity of curricular approaches, structures and methodologies among Australian dental schools, which are enriching and desirable educationally. Specific educational strategies also with regards to the teaching of implant dentistry have been addressed in previous work and will not be covered in this paper. This paper will not address extracurricular courses, special degrees or training after graduation.

Comparison of genome screens for two independent cohorts provides replication of suggestive linkage of bone mineral density to 3p21 and 1p36.

Low bone mineral density (BMD) is a major risk factor for osteoporotic fracture. Studies of BMD in families and twins have shown that this trait is under strong genetic control. To identify regions of the genome that contain quantitative trait loci (QTL) for BMD, we performed independent genomewide screens, using two complementary study designs. We analyzed unselected nonidentical twin pairs (1,094 pedigrees) and highly selected, extremely discordant or concordant (EDAC) sib pairs (254 pedigrees). Nonparametric multipoint linkage (NPL) analyses were undertaken for lumbar spine and total-hip BMD in both cohorts and for whole-body BMD in the unselected twin pairs. The maximum evidence of linkage in the unselected twins (spine BMD, LOD 2.7) and the EDAC pedigrees (spine BMD, LOD 2.1) was observed at chromosome 3p21 (76 cM and 69 cM, respectively). These combined data indicate the presence, in this region, of a gene that regulates BMD. Furthermore, evidence of linkage in the twin cohort (whole-body BMD; LOD 2.4) at chromosome 1p36 (17 cM) supports previous findings of suggestive linkage to BMD in the region. Weaker evidence of linkage (LOD 1.0-2.3) in either cohort, but not both, indicates the locality of additional QTLs. These studies validate the use, in linkage analysis, of large cohorts of unselected twins phenotyped for multiple traits, and they highlight the importance of conducting genome scans in replicate populations as a prelude to positional cloning and gene discovery.

Men and osteoporosis.

BACKGROUND: While strict criteria have been developed for defining osteoporosis in women (bone mineral density measurements more than 2.5 standard deviations below the mean for young adult normal women, i.e. t-score value < -2.5), there still remains a controversy regarding the definition in men. Spinal fractures occur in 5% and hip fractures in 6% of men older than 50 years. There are significant differences between men and women with respect to the pathogenesis of osteoporosis, underlying medical conditions and postfracture sequelae. OBJECTIVE: To provide an overview of the pathogenesis, diagnosis and prevention of osteoporosis in men. DISCUSSION: Osteoporosis is increasingly recognised. Data from the Dubbo Osteoporosis Epidemiology Study suggests that 30% of men in Australia aged over 60 years will suffer from an osteoporotic fracture. It is estimated that 30-60% of men presenting with spinal fractures will have another illness contributing to their bone loss. Osteoporotic fractures in men are associated with higher morbidity and mortality than in women. Lifestyle changes together with daily calcium supplementation should be implemented and vitamin D3 should be considered in men with osteopenia.

Corticosteroid induced osteoporosis. Guidelines for treatment.

BACKGROUND: Last year, Australian Family Physician published 'Guidelines for Management of Postmenopausal Osteoporosis', which were developed by Osteoporosis Australia. Recently, significant advances in our understanding of the treatment of corticosteroid osteoporosis have occurred. OBJECTIVE: The following guidelines, also developed by Osteoporosis Australia, and supported by the National Asthma Campaign, are to help general practitioners identify those patients at risk of this problem and to provide information about current treatment strategies. DISCUSSION: Corticosteroids are widely used and effective agents for the control of many inflammatory diseases. Corticosteroid osteoporosis is a common problem associated with the long term high dose use of these medications.

Corticosteroid osteoporosis.

Corticosteroids are widely used and effective agents for the control of many inflammatory diseases, but corticosteroid osteoporosis is a common problem associated with their long term high dose use. Prevention of corticosteroid osteoporosis is preferable to treatment of established corticosteroid bone loss. Several large double-blind controlled clinical trials in patients with corticosteroid osteoporosis have recently been published that provide new insights into its treatment. Based upon available evidence, the rank order of choice for prophylaxis would be a bisphosphonate followed by a vitamin D metabolite or an oestrogen type medication. Calcium alone appears to be unable to prevent rapid bone loss in patients starting corticosteroids, especially with prednisolone doses at 10 mg a day or greater. If an active vitamin D metabolite is used, calcium supplementation should be avoided unless dietary calcium intake is low. Hormone replacement therapy should be considered if hypogonadism is present. Since vertebral fracture is a common and important complication of high dose corticosteroid therapy, these findings suggest that rapid bone loss and hence fractures, can be prevented by prophylactic treatment. Although the follow-up data is limited, it is likely that such therapy needs to be continued beyond 12 months whilst patients continue significant doses of corticosteroid therapy.

Postmenopausal osteoporosis treatment guidelines.

BACKGROUND: Several years ago, Osteoporosis Australia published Guidelines for the management of osteoporosis. Since then significant advances in our understanding of the treatment of osteoporosis have been published. The importance of this is heightened as early diagnosis is now possible with precise methods of bone density measurement. OBJECTIVE: This article presents updated guidelines developed on behalf of Osteoporosis Australia for the treatment of postmenopausal osteoporosis to help general practitioners identify those women at risk and to review current treatment strategies. DISCUSSION: Osteoporosis and its associated problems are major health concerns in Australia, especially with an ageing population. While important principles of management are still considered to be maximising peak bone mass and prevention of postmenopausal bone loss by oestrogen therapy, new clinical trial data about drugs such as raloxifene and the bisphosphonates have recently become available and the relative role of various agents is gradually becoming clearer.

Osteoporosis prevention and treatment.

Patients with low bone density or any prior low trauma fracture should be considered for therapeutic intervention. Oestrogen replacement therapy remains the first choice for prevention of bone loss in early postmenopausal women with low bone density. In postmenopausal women with existing fractures, the rank order of treatments is firstly alendronate, secondly raloxifene and thirdly less potent bisphosphonates, such as etidronate, or active vitamin D metabolites, such as calcitriol. For men with osteoporosis, if hypogonadism is present, it should be treated with testosterone replacement therapy. Despite limited data, a bisphosphonate should then be considered in conjunction with calcium. Supplementation with simple vitamin D should be considered in elderly patients who are housebound or live in institutions, as they are at risk of vitamin D deficiency and osteomalacia.

Corticosteroid osteoporosis.

Corticosteroids are widely used in the treatment of patients with chronic inflammatory diseases. Since the most rapid bone loss occurs in the first 12-24 months after commencing high dose corticosteroids, it is important to consider two different therapeutic situations, (a) prevention in patients starting corticosteroids and (b) treatment of patients on chronic corticosteroids who will already have some significant degree of corticosteroid related bone loss. An adequate calcium intake is recommended and any contributing factors to osteoporosis should be treated. A bone density will give information about the future risk of osteoporotic fracture and the need for active pharmacological treatment. Patients commencing high dose long-term corticosteroid therapy should be treated prophylactically with a bisphosphonate and/or active vitamin D metabolites (alphacalcidol or calcitriol) and the treatment may need to be continued for 1-2 years. Patients on chronic corticosteroids may improve their bone density by treatment with bisphosphonates and vitamin D metabolites (including the calciferols). In postmenopausal women, concomitant use of estrogen replacement therapy is also appropriate. It is important in a patient on long-term therapy to review the need for continuing treatment or the possibility of dosage reduction.

Thiazide diuretics and fractures: can meta-analysis help?

Published observational estimates of the effect of thiazide diuretics on osteoporotic fracture risk vary from a 70% reduction to a 60% increase but there have been no randomized controlled trials. The aims of this study were to use the technique of meta-analysis to attempt to resolve this conflict and to explore whether duration and/or dose of therapy has an effect on osteoporotic fracture risk. The data sources utilized were Medline and Excerpta Medica databases supplemented by reviews and back references. A total of 18 observational studies that looked at the relationship between diuretics and fracture were located, of which 13, involving 29,600 subjects, had extractable data on thiazides and fracture occurrence. Current thiazide users were protected against hip fracture (OR 0.82, 95% CI 0.73-0.91). Thiazide use of long duration may be protective (OR 0.82, 95% CI 0.62-1.08) but not short duration (OR 1.23, 95% CI 0.99-1.54). The size of this effect, which compares favorably to other interventions, indicates that a randomized controlled trial to resolve the problem of potential confounders and safety profile would require a minimum of 7000 person-years of observation in those at highest risk of fracture (women aged 80 or over) which is unlikely to be pursued at the present time. The results of this meta-analysis indicate that current thiazide users have a 20% reduction in fracture risk and that long-term use may reduce fractures by a similar amount.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of corticosteroid bone loss.

Prolonged corticosteroid therapy is known to result in an increased risk of osteoporotic fracture, probably as a consequence of enhanced bone resorption and depressed bone formation. We examined the effects of prophylactic treatment with 1,25-dihydroxyvitamin D3 (calcitonin) and nasal salmon calcitonin on corticosteroid-induced bone loss in 103 patients being treated with long-term corticosteroids for the first time in a randomized, double-masked prospective study. Patients were randomly allocated to one of three groups receiving either calcium supplementation alone, calcium plus calcitriol, or calcium plus calcitriol and nasal salmon calcitonin. Treatment was given for 12 months. Bone mineral density (BMD) was measured every 4 months by dual-photon absorptiometry in the lumbar spine and femoral neck. Calcium supplementation alone did not prevent bone loss at either site. In the lumbar spine calcitriol, with or without nasal calcitonin, significantly reduced bone loss (p < 0.0001). Neither calcitriol alone nor calcitriol with calcitonin prevented bone loss at the femoral neck. These data suggest that treatment with calcium and calcitriol, or with calcium and intranasal calcitonin, greatly reduced or prevented corticosteroid-induced bone loss in the lumbar spine.

Corticosteroid effects on proximal femur bone loss.

Prolonged high-dose corticosteroid therapy is known to result in an increased risk of osteoporotic fracture. Reductions in bone density have been demonstrated at the distal radius and lumbar spine in patients receiving corticosteroids; however there have been few studies of bone density in the hip (the most important site of osteoporotic fracture) in this context. To examine the effect of corticosteroids on the hip we measured bone mineral density (BMD) by dual-photon absorptiometry at three sites in the proximal femur as well as the lumbar spine in 32 patients aged 18-77 years who had been treated with corticosteroids (mean daily prednisone dose 12.7 mg) for up to 23 years. BMD was compared with the expected values using age regressions in normal subjects. BMD was significantly reduced in the femoral neck, Ward's triangle, and the trochanteric region (p less than 0.001 all sites). In the lumbar spine BMD was also significantly reduced (p less than 0.001). We also measured BMD serially in 29 patients receiving corticosteroids. BMD measurements were made in 12 patients who had already been treated with long-term corticosteroids at the time of first BMD measurement (chronic group) and from the commencement of corticosteroid therapy in 17 patients (acute group). The mean (+/- SEM) change in BMD (g/cm2 per year) in the lumbar spine and femoral neck were 0.006 +/- 0.006 and -0.021 +/- 0.007, respectively, for the chronic group and -0.02 +/- 0.005 and -0.039 +/- 0.006 for the acute group.(ABSTRACT TRUNCATED AT 250 WORDS)