Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome.

The components of the human body are closely interdependent; as a result, disease conditions in some organs or components can influence the development of disease in other body locations. The effect of oral health upon health in general has been investigated for decades by many epidemiological studies. In this context, there appears to be a clear relationship between deficient oral hygiene and different systemic disorders such as cardiovascular disease and metabolic syndrome. The precise relationship between them is the subject of ongoing research, and a variety of theories have been proposed, though most of them postulate the mediation of an inflammatory response. This association between the oral cavity and disease in general requires further study, and health professionals should be made aware of the importance of adopting measures destined to promote correct oral health. The present study conducts a Medline search with the purpose of offering an update on the relationship between oral diseases and cardiovascular diseases, together with an evaluation of the bidirectional relationship between metabolic syndrome and periodontal disease. Most authors effectively describe a moderate association between the oral cavity and cardiovascular diseases, though they also report a lack of scientific evidence that oral alterations constitute an independent cause of cardiovascular diseases, or that their adequate treatment can contribute to prevent such diseases. In the case of metabolic syndrome, obesity and particularly diabetes mellitus may be associated to an increased susceptibility to periodontitis. However, it is not clear whether periodontal treatment is able to improve the systemic conditions of these patients.

Study of serum CTX in 50 oral surgical patients treated with oral bisphosphonates.

OBJECTIVES: To determine whether there is a relationship between the total BP dose administered and the variations in serum CTX concentration. STUDY DESIGN: The study included 50 patients requiring dental implant surgery and treated with oral BPs, seen in an Oral Surgery and Implantology Unit between January 2007 and June 2009. The patients were divided into two groups: those in which the medication was not suspended before obtaining the laboratory test sample, and those patients referred from other dental clinics in which BPs was suspended before reporting to our Unit. The total drug dosage administered and the total dose per kilogram body weight were evaluated for comparison with serum CTX. The data obtained were correlated to the osteonecrosis risk table developed by Marx et al. in 2007. RESULTS: There were no significant differences between the two groups in relation to the total administered dose and the dose in mg/kg b.w. Likewise, in both groups no relationship was observed between the serum CTX value and the total administered dose or the dose in mg/kg b.w. No differences were found between the two patient groups regarding chemical osteonecrosis risk based on the criteria of Marx et al. CONCLUSIONS: No relationship was observed between the oral BP dose administered (total dose or expressed in mg/kg b.w.) and serum CTX concentration, and suspension of the medication did not influence the serum CTX levels.

Changes in smoking habit among patients with a history of oral squamous cell carcinoma (OSCC).

OBJECTIVE: To determine the changes in smoking habit among patients with oral squamous cell carcinoma (OSCC) diagnosed and treated in the Service of Stomatology (Valencia University General Hospital. Valencia, Spain). MATERIAL AND METHODS: The study involved 123 patients with a history of OSCC interviewed by telephone on their smoking habits at the time of the diagnosis and modifications in habits subsequently. The mean age at diagnosis was 60 years and 9 months (standard deviation, SD +/- 12 years and 2 months). Males predominated (61.8%) over females (38.2%). The mean time from the diagnosis of OSCC to the survey was 4 years and 6 months (SD +/- 3 years and 6 months). RESULTS: Almost one-half of the patients (45.5%) were active smokers at the time of the diagnosis, with a mean duration of the habit of 34.9 years (SD +/- 12 years and 7 months). In turn, 19.5% of the patients were ex-smokers at diagnosis, with an average of 13 years and 9 months (SD +/- 9 years and 4 months) from smoking cessation to the development of cancer. A total of 57.1% of the smokers abandoned the habit at diagnosis, 8.9% continued to smoke to the same extent as before, and 33.9% reduced smoking. CONCLUSION: A full 44.4 % of our patients diagnosed with OSCC continued to smoke despite warnings of the risks, and although the majority claimed to have reduced their smoking habit, interventional strategies would be indicated to help ensure complete smoking cessation.

Retinoids and proliferative verrucous leukoplakia (PVL). A preliminary study.

OBJECTIVE: A study is made of the efficacy and adverse effects of retinoid therapy applied to the white lesions of proliferative verrucous leukoplakia (PVL). MATERIAL AND METHODS: The results of retinoid therapy were evaluated in 17 patients diagnosed with PVL. Topical retinoids were used in 5 patients, in the form of two daily applications of 0.1% 13-cis-retinoic acid in orabase for an average of 6.17+/-3.13 months. Systemic retinoids were used in 11 patients, with the administration of 25 mg/day of acitretin in tablet form for an average of 5.41+/-2.02 months. One patient successively received the topical and systemic retinoid formulations. The course and results were evaluated on a blind basis by two investigators. The adverse effects of the medication were also assessed. RESULTS: Clinical improvement was recorded for 7 lesions (38.8%) (six involving systemic treatment and one as a result of topical application). Clinical worsening was recorded in the same proportion (5 lesions with systemic therapy and two with topical treatment), while four lesions (22.4%) showed no changes (one lesion with systemic therapy and three with topical treatment). Adverse effects were documented in all the patients administered the systemic formulation, versus in only one patient administered topical retinoids. The most frequent problems were desquamation and pruritus. CONCLUSION: Although topical or systemic retinoic acid produces some improvement in about one-third of all patients with PVL, further studies are needed to assess the efficacy and safety of these products, in view of the important percentage of individuals who worsen despite therapy, and the frequent appearance of adverse effects.

Retrospective study of a series of 850 patients with temporomandibular dysfunction (TMD). Clinical and radiological findings.

OBJECTIVE: To define the clinical and radiological characteristics of the four most common presentations of temporomandibular dysfunction-myofascial pain (MFP), disc displacement with reduction (DDWR), disc displacement without reduction (DDWoR), and osteoarthrosis (OR)-and to identify the differences among them. MATERIAL AND METHODS: The study comprised a series of 850 patients (121 males and 729 females) seen between May 2003 and December 2006 in Valencia University General Hospital (Valencia, Spain) for temporomandibular joint disease (TMJD). An analysis was made of the possible etiological factors (stress, traumatisms, sleep disturbances, parafunctional habits, reason for consultation), possible pain sensations in response to palpation of the masticatory muscles, joint sounds, etc. A panoramic X-ray study was made on a routine basis, and in some patients (n = 54) the study was completed with a magnetic resonance imaging scan of the temporomandibular joints and related tissues. The differences between qualitative variables were examined by means of the chi-square test with R x C contingency tables and the Z-test, while quantitative variables were contrasted by analysis of variance (ANOVA) and post hoc testing (Scheffe). RESULTS: The variables showing statistically significant differences among the four diagnostic categories were: patient age, sleep disturbances, stress, parafunctional habits, nibbling on hard objects and "other parafunctions", reason for consultation, mandibular movements, "non-evaluable" molar and canine relationship, ligament hyperlaxity, and panoramic X-ray alterations.

MRI of mandibular osteonecrosis secondary to bisphosphonates.

OBJECTIVE: Bisphosphonates are a group of drugs used in the treatment of oncology patients with bone metastases. However, in the past few years, osteonecrosis of the jaw has been reported as a serious complication of such treatment. The objective of this study was to examine the use of MRI in the assessment of bone lesions caused by this disease. MATERIALS AND METHODS: Fourteen patients were studied who had been treated with i.v. bisphosphonates and had developed focal lesions of osteonecrosis of the jaw. These patients were referred by the stomatology department of Hospital General Universitario de Valencia. We evaluated both the morphology and the behavior of the lesions in T1, STIR, and after the administration of gadolinium. RESULTS: Twenty-six focal lesions were detected clinically and 36 were detected radiologically. All the clinically detected focal lesions were visible on MRI. There were 15 focal lesions detected radiologically that were not detected on clinical examination. In all patients, it was possible to assess bone involvement and involvement of the bone marrow, soft tissues, sinuses, and mandibular canal as well as the presence of adenopathy. CONCLUSION: MRI is an effective tool in the assessment of osteonecrosis of the jaw. The significance of focal lesions detectable on radiologic examination but without clinical correlation and their progression over time remains to be determined.

Cardiovascular diseases in dental practice. Practical considerations.

Coronary heart disease is the principal cause of death in the industrialized world. Its most serious expression, acute myocardial infarction, causes 7.2 million deaths each year worldwide, and it is estimated that 20% of all people will suffer heart failure in the course of their lifetime. The control of risk cardiovascular factors, including arterial hypertension, obesity and diabetes mellitus is the best way to prevent such diseases. The most frequent and serious cardiovascular emergencies that can manifest during dental treatment are chest pain (as a symptom of underlying disease) and acute lung edema. Due to the high prevalence and seriousness of these problems, the dental surgeon must be aware of them and should be able to act quickly and effectively in the case of an acute cardiovascular event. In patients with a history of cardiovascular disease, attention must center on the control of pain, the reduction of stress, and the use or avoidance of a vasoconstrictor in dental anesthesia. In turn, caution is required in relation to the antiplatelet, anticoagulant and antihypertensive medication typically used by such patients.

Dental management in renal failure: patients on dialysis.

Chronic renal failure is an important health care problem throughout the world, with an incidence of 337, 90, 107 and 95 new cases per million inhabitants/year in the United States, Australia, New Zealand and the United Kingdom, respectively. These figures moreover invariably tend to increase. During the progression of renal damage, clinical manifestations are noted in practically all body organs and systems, and 90% of all affected patients experience oral symptoms. The existing management options range from simple measures based on changes in diet and life style, to different forms of dialysis (hemodialysis and peritoneal dialysis), and also kidney transplantation. Given the multiple oral manifestations of chronic renal failure, and the different repercussions of its treatment upon the oral cavity, these patients require special considerations and precautions in the face of dental treatment. Consultation with the nephrologist is essential before any dental treatment is carried out, in order to determine the condition of the patient, define the best moment for dental treatment, introduce the necessary pharmacological adjustments, or to establish other important aspects for preventing complications in the dental clinic. The present study reviews the characteristics of the disease, the existing therapeutic options, and the considerations of relevance for the dental professional.

A review of temporomandibular joint disease (TMJD). Part II: Clinical and radiological semiology. Morbidity processes.

The clinical signs and symptoms of greatest semiologic value in temporomandibular joint disease (TMJD) are muscle pain, joint pain, limitations in mandibular movement, and joint sounds. Imaging studies of the joint are very useful for establishing the diagnosis and for discarding other disease processes, though in many cases diagnostic error results from the detection of a large proportion of patients with alterations in the imaging studies but with no associated clinical manifestations. Panoramic X-rays and magnetic resonance imaging are the most commonly used complementary techniques for diagnosing TMJD. MRI may be regarded as the imaging technique of choice, particularly when studying the soft tissues. Biochemical evaluation of the joint synovial fluid has improved our understanding of TMJD pathogenesis, though to date such parameters have not been extended to clinical practice. Myofascial pain with positive painful palpation of the masticatory muscles; joint disc displacements with reduction characterized by the presence of opening or opening and closing clicks; disc displacements without reduction characterized by limitations in oral aperture; and osteoarthritis / osteoarthrosis characterized by the auscultation of friction sounds during mandibular movement, are the morbidity processes most often seen in the context of TMJD. The present study offers a review of the semiology and morbidity processes of the temporomandibular joint.

Oral lesions and immune reconstitution syndrome in HIV+/AIDS patients receiving highly active antiretroviral therapy. Epidemiological evidence.

OBJECTIVE: To determine whether opportunistic oral infections associated to HIV infection (OOI-HIV) are found in HIV+/AIDS patients with immune reconstitution related to highly active antiretroviral therapy (HAART). METHODS: From among 1100 HIV+/AIDS patients (Service of Internal Medicine, Carlos Haya Hospital, Malaga, Spain) subjected to review of the oral cavity between January 1996 and May 2007, we identified those examined in 1996 and which were again examined between 1997 and 2007, and were moreover receiving HAART. The following data were collected: age, gender, form of contagion, antiretroviral therapy at the time of review, number of CD4+ lymphocytes/ml, and viral load (from 1997 onwards). We identified those subjects with an increase in CD4+ lymphocytes/ml associated to HAART, and classified them as subjects with quantitative evidence of immune reconstitution (QEIR). Among these individuals with QEIR we moreover identified those with undetectable viral loads (QEIR+VL), and differentiated those patients with an increase in CD4+ lymphocytes >500/ml (QEIRm+VL). In each group we determined the prevalence of OOI-HIV, following the diagnostic recommendations of the EC-Clearinghouse (CDC-Atlanta, USA - WHO). In addition, we analyzed the prevalence of OOI-HIV in the different groups in relation to the duration of HAART. RESULTS: A total of 86 subjects were included (44 females and 42 males; 19 heterosexuals, 34 male homosexuals, and 33 intravenous drug abusers). Forty-two patients showed QEIR: 21 belonged to the QEIR+VL group, and 17 conformed the QEIRm+VL group. The prevalence of OOI-HIV per group was as follows: QEIR = 54.8%; QEIR+VL = 33%; QEIRm+VL = 35%. The most prevalent lesion in all groups was erythematous candidiasis. OOI-HIV increased with the duration of HAART (p = 0.008), and were seen to be dependent upon late appearance of the mycotic lesions (after 24 months under HAART). CONCLUSIONS: It is suggested that opportunistic oral infections associated to HIV infection form part of the clinical picture of immune reconstitution inflammatory syndrome, though such infections are of late onset.

Dental treatment of patients with coagulation factor alterations: an update.

Hemostasia is a defense mechanism that protects vascular integrity, avoids blood loss, and maintains blood fluidity throughout the circulatory system. The biochemical processes leading to blood clot formation are complex, and alterations can appear at any point within the chain of events. While a range of alterations can affect the coagulation factors, some are more common than others in the general population, including congenital (hemophilia A and B, Von Willebrand's disease) and acquired disorders (anticoagulant drugs). Such diseases require special consideration in the context of dental treatment, and therefore must be known to dental professionals. Interconsultation with the hematologist will provide orientation on the characteristics of the disease and on the best approach to treatment, including the need for replacement therapy, the application of local hemostatic measures, the modification of anticoagulant therapy, etc. In any case, the most important concern is the prevention of bleeding complications by compiling a detailed clinical history, with adequate planning of treatment, and taking special care to avoid soft tissue damage during the dental treatment of such patients. The dental surgeon must enhance awareness among patients and their relatives of the importance of correct oral hygiene, which will help avoid the need for invasive dental treatments and will reduce the number of visits to the dentist.

Use of nonsteroidal antiinflammatory drugs in dental practice. A review.

Nonsteroidal antiinflammatory drugs (NSAIDs) are drugs commonly prescribed in dental practice for the management of pain and swelling. Of these substances, paracetamol and ibuprofen are the most widely used. Their mechanism of action is based on the inhibition of cyclooxygenase, and therefore of prostaglandin synthesis. All of these drugs present a similar mechanism of action, as a result of which their side effects are also similar. The most frequent range from mild (e.g., nausea or vomiting) to serious gastric problems (such as gastric bleeding or perforation). Other side effects include an increased risk of vascular accidents (particularly acute myocardial infarction), renal toxicity secondary to a decrease in perfusion, and the risk of abnormal bleeding tendency due to the antiplatelet effect of these drugs. Their use is contraindicated in the third trimester of pregnancy, due to the induction of premature ductus arteriosus closure. The present study reviews the information currently available on NSAIDs, with special emphasis on those aspects related to dental practice.

Review of temporomandibular joint pathology. Part I: classification, epidemiology and risk factors.

Pathology of the temporomandibular joint (TMJ) affects an important part of the population, though it is not viewed as a public health problem. Between 3-7% of the population seeks treatment for pain and dysfunction of the ATM or related structures. The literature reports great variability in the prevalence of the clinical symptoms (6-93%) and signs (0-93%), probably as a result of the different clinical criteria used. In imaging studies it is common to observe alterations that have no clinical expression of any kind. Radiographic changes corresponding to osteoarthrosis are observed in 14-44% of the population. Age is a risk factor, though with some particularities. In elderly patients there is an increased prevalence of clinical and radiological signs, though also a lesser prevalence of symptoms and of treatment demands than in younger adults. Approximately 7% of the population between 12 and 18 years of age is diagnosed with mandibular pain-dysfunction. Temporomandibular dysfunction (TMD) is more frequent in females. No clear relationship has been established between occlusal alterations and TMJ disease. Only disharmony between centric relation and maximum intercuspidation, and unilateral crossbite, have demonstrated a certain TMJ disease-predictive potential. Both local and systemic hyperlaxity has been postulated as a possible cause of TMD. Parafunctional habits and bruxism are considered risk factors of TMD with odds ratios (ORs) of up to 4.8. Psychophysiological theory holds stress as a determinant factor in myofascial pain. Genetic factors and orthodontic treatment have not been shown to cause TMD.

Clinical evaluation of dental and periodontal status in a group of oncological patients before chemotherapy.

OBJECTIVE: To evaluate the dental status of 88 cancer patients before chemotherapy. MATERIAL AND METHODS: Eighty-eight patients with cancer in different body locations were studied and compared with a control group. Dental plaque was assessed by means of the Silness and Löe index, dental status with the DMFT index, and periodontal status with the modified CPI index. RESULTS: In the oncological patients the mean Silness and Löe index was 1.28-/+0.11. Patients showed multiple missing teeth (mean number 7.55-/+0.80); the mean number of decayed teeth was 2.10-/+0.36; and the mean number of filled teeth was 2.27-/+0.37. As to periodontal status, the mean modified CPI index was 1.45-/+0.11. In the control group, the mean Silness and Löe index was 0.94-/+0.00. The mean number of decayed teeth was 1.21-/+0.25; the mean number of missing teeth was 4.97-/+0.67; and the mean number of filled teeth was 4.82-/+0.44. The mean modified CPI index was 1.29-/+0.10. CONCLUSIONS: Oncological patients in our study showed more dental plaque versus healthy patients and more decayed and missing teeth. However, patients in the control group showed more filled teeth than cancer patients. Periodontal status as determined by the modified CPI index was similar in both patient groups.

Treatment of recurrent aphthous stomatitis. A literature review.

Recurrent aphthous stomatitis (RAS) is the most common chronic disease of the oral cavity, affecting 5-25% of the population. The underlying etiology remains unclear, and no curative treatment is available. The present review examines the existing treatments for RAS with the purpose of answering a number of questions: How should these patients be treated in the dental clinic? What topical drugs are available and when should they be used? What systemic drugs are available and when should they be used? A literature search was made of the PubMed, Cochrane and Scopus databases, limited to articles published between 2008-2012, with scientific levels of evidence 1 and 2 (metaanalyses, systematic reviews, phase I and II randomized clinical trials, cohort studies and case-control studies), and conducted in humans. The results obtained indicate that the management of RAS should be based on identification and control of the possible predisposing factors, with the exclusion of possible underlying systemic causes, and the use of a detailed clinical history along with complementary procedures such as laboratory tests, where required. Only in the case of continuous outbreaks and symptoms should drug treatment be prescribed, with the initial application of local treatments in all cases. A broad range of topical medications are available, including antiseptics (chlorhexidine), antiinflammatory drugs (amlexanox), antibiotics (tetracyclines) and corticosteroids (triamcinolone acetonide). In patients with constant and aggressive outbreaks (major aphthae), pain is intense and topical treatment is unable to afford symptoms relief. Systemic therapy is indicated in such situations, in the form of corticosteroids (prednisone) or thalidomide, among other drugs. Key words:Recurrent aphthous stomatitis, treatment, clinical management.

Clinical and microbiological diagnosis of oral candidiasis.

INTRODUCTION: Candidiasis or oral candidiasis is the most frequent mucocutaneous mycosis of the oral cavity. It is produced by the genus Candida, which is found in the oral cavity of 53% of the general population as a common commensal organism. One hundred and fifty species have been isolated in the oral cavity, and 80% of the isolates correspond to Candida albicans, which can colonize the oral cavity alone or in combination with other species. Transformation from commensal organism to pathogen depends on the intervention of different predisposing factors that modify the microenvironment of the oral cavity and favor the appearance of opportunistic infection. The present study offers a literature review on the diagnosis of oral candidiasis, with the purpose of establishing when complementary microbiological techniques for the diagnosis of oral candidiasis should be used, and which techniques are most commonly employed in routine clinical practice in order to establish a definitive diagnosis. MATERIALS AND METHODS: A Medline-PubMed, Scopus and Cochrane search was made covering the last 10 years. RESULTS: The diagnosis of oral candidiasis is fundamentally clinical. Microbiological techniques are used when the clinical diagnosis needs to be confirmed, for establishing a differential diagnosis with other diseases, and in cases characterized by resistance to antifungal drugs. Biopsies in turn are indicated in patients with hyperplastic candidiasis. Staining (10% KOH) and culture (Sabouraud dextrose agar) are the methods most commonly used for diagnosing primary candidiasis. Identification of the individual species of Candida is usually carried out with CHROMagar Candida®. For the diagnosis of invasive candidiasis, and in cases requiring differentiation between C. albicans and C. dubliniensis, use is made of immunological and genetic techniques such as ELISA and PCR. Key words:Clinical, oral candidiasis, microbiology.

Malignant transformation of proliferative verrucous leukoplakia to oral squamous cell carcinoma: a series of 55 cases.

In this study, we compared clinical differences between patients with proliferative verrucous leukoplakia (PVL) who did and did not develop oral cancer. This was a retrospective study of 55 PVL cases. All patients were followed for at least 1year, with a mean follow-up of 7.53 (SD=4.18) years. The mean age of the patients was 61.69 (SD=11.76) years. There were 36 (65.5%) females and 19 (34.5%) males. Group 1 included the 28 PVL patients who did not develop oral squamous cell carcinoma (OSCC) during the period. Group 2 included the 27 PVL patients who developed at least one OSCC during the period. The latter group was subdivided into patients with PVL who developed one (Subgroup 2a; n=16) or more than one (Subgroup 2b; n=11) OSCC during follow-up. There was no statistical difference in age or oral location of the PVL between Groups 1 and 2. Females had a greater tendency to develop cancer than males (58.3% vs. 31.6%). In Group 2, only six (22.2%) were smokers. There was no difference between Subgroups 2a and b in terms of age, gender, and oral location of the PVL. Subgroup 2b included fewer smokers, had higher gingival involvement rate, and lower frequency of PVL on the tongue. The PVL patients who develop oral cancers were more commonly female and non-smokers. Those patients who developed more than one OSCC were most likely to develop lesions of the gingiva.

Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome

The components of the human body are closely interdependent; as a result, disease conditions in some organs or components can influence the development of disease in other body locations. The effect of oral health upon health in general has been investigated for decades by many epidemiological studies. In this context, there appears to be a clear relationship between deficient oral hygiene and different systemic disorders such as cardiovascular disease and metabolic syndrome. The precise relationship between them is the subject of ongoing research, and a variety of theories have been proposed, though most of them postulate the mediation of an inflammatory response. This association between the oral cavity and disease in general requires further study, and health professionals should be made aware of the importance of adopting measures destined to promote correct oral health. The present study conducts a Medline search with the purpose of offering an update on the relationship between oral diseases and cardiovascular diseases, together with an evaluation of the bidirectional relationship between metabolic syndrome and periodontal disease. Most authors effectively describe a moderate association between the oral cavity and cardiovascular diseases, though they also report a lack of scientific evidence that oral alterations constitute an independent cause of cardiovascular diseases, or that their adequate treatment can contribute to prevent such diseases.In the case of metabolic syndrome, obesity and particularly diabetes mellitus may be associated to an increased susceptibility to periodontitis. However, it is not clear whether periodontal treatment is able to improve the sys-temic conditions of these patients

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Consensus statement on antimicrobial treatment of odontogenic bacterial infections.

The infection of the oral cavity is a common public health problem and constant cause for antibiotic prescription, with 10% of antibiotics used to treat this problem. However, few studies have so far aimed to determine its incidence. Added to this, its relationship with certain sytemic diseases (cardiac, endocrine, etc) confers this pathology vital importance. In spite of the frequency and importance of odontogenic infection, the current dispersion in criteria regarding key aspects in classification, terminology and therapeutic recommendations is noticeable. The main objective of this document, compiled as a consensus statement by specialists in microbiology and odontology, is to establish useful recommendations for all of those involved in the clinical management of this pathology. Special attention has been placed on the rise in bacterial resistance observed over the last years, specifically the proliferation of betalactamase producing strains. Another important factor causing the resistance to appear is lack of therapeutic compliance, specially what regards dosage and treatment duration. Therefore, this pathology constitutes a complex problem which requires the instauration of broad spectrum antimicrobials, well tolerated and a convenient posology so that patients receive the adequate dose over the necessary period. High doses of amoxicillin/clavulanate (2000 mg/125 mg) have showed good results and power to overcome resistance. Other agents such as metronidazole and clindamycin, followed by de claritromycin and azithromycin have also proved to be active against most of microorganisms responsible for odontogenic infection.