Peripheral arterial disease associated with caries and periodontal disease.

BACKGROUND: Peripheral arterial disease (PAD) is an important cardiovascular disorder of the peripheral arteries. Chronic infections, such as periodontitis, may play an important role in the etiology and pathophysiology of PAD and other cardiovascular conditions. Recently, Streptococcus mutans has been found with high frequency in atheromatous plaques. The aim of this study is to evaluate the possible clinical and microbiologic association between PAD and periodontitis and dental caries. METHODS: Thirty patients with PAD and 30 control individuals were selected. PAD and its severity were established by the use of the ankle-brachial index (ABI). Clinical attachment loss (AL); probing depth; decayed, missing, and filled teeth (DMFT) index; and C-reactive protein (CRP) levels were evaluated. The presence of bacterial DNA from Streptococcus mutans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, Treponema denticola, and Aggregatibacter actinomycetemcomitans was identified by polymerase chain reaction in subgingival biofilm and serum. RESULTS: Patients with ≥30% AL ≥ 4 mm had six-fold increased risk of having PAD (odds ratio = 8.18; 95% confidence interval = 1.21 to 35.23; P = 0.031). There was statistical difference in the CRP (P = 0.0413) and DMFT index (P = 0.0002), with elevated number of missing teeth (P = 0.0459) in the PAD group compared with the control group. There were no significant differences in the frequency of bacteria in serum and subgingival plaque. CONCLUSION: There was a positive relationship between periodontitis based on AL and PAD determined by the ABI (odds ratio = 8.18).

New oral anticoagulants: will they replace warfarin?

Vitamin K antagonists, such as warfarin, are considered to be the treatment of choice to prevent thromboembolic events, but problems, such as the need for frequent dose adjustment and monitoring of coagulation status, as well as multiple drug and food interactions, make their use difficult for both physician and patient. Two new anticoagulants are now being considered as possible replacements of vitamin K antagonists. Dabigatran, an oral direct thrombin inhibitor has already been approved in the USA for prevention of stroke in patients with atrial fibrillation. Rivaroxaban, a factor Xa inhibitor, and dabigatran are licensed in Europe and Canada for short-term thromboprophylaxis after elective hip or knee replacement surgery. The advantages of these drugs are that they are safe and effective, require no monitoring, have a direct mode of action against only one clotting factor (thrombin or factor Xa), have limited drug interactions, and have rapid peak blood levels. Based on the fact that dabigatran has already been approved for use in the USA, it would appear that it has an advantage over rivaroxaban in becoming the replacement drug for vitamin K antagonists.

Weight gain following spinal cord injury: a pilot study.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To define the temporal course of weight gain in persons with new spinal cord injury (SCI), and to identify predictors of weight gain in this population. SETTING: A United States Department of Veterans Affairs (VA) SCI Unit. METHODS: A retrospective chart review in a VA SCI Unit was conducted. Participants (n = 85) included all persons with new SCI completing initial rehabilitation at the center between 1998 and 2006. Outcome measures were mean change in body mass index (BMI) between rehabilitation admission and final follow-up, time of greatest BMI change, and distribution of participants by BMI classification. These measures were also examined relative to SCI level, American Spinal Injury Association Impairment Scale (AIS) grade, primary mode of mobility, and age at rehabilitation admission. RESULTS: Mean BMI increased by 2.3 kg/m2 between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants transitioning from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up (P < 0.0005). CONCLUSIONS: These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.

The dental treatment of patients with joint replacements: a position paper from the American Academy of Oral Medicine.

BACKGROUND: In February 2009, the American Academy of Orthopaedic Surgeons (AAOS) published an information statement in which the organization "recommends that clinicians consider antibiotic prophylaxis [AP] for all total joint replacement patients prior to any invasive procedure that may cause bacteremia." The leadership of the American Academy of Oral Medicine (AAOM) thought that there was a need to respond to this new statement. METHODS: The authors reviewed the literature on this subject as it relates to the AAOS's February 2009 information statement. The draft of the resulting report was reviewed and approved by the leadership of the AAOM and several dentists in North America who have expertise on this subject. RESULTS: The risk of patients' experiencing drug reactions or drug-resistant bacterial infections and the cost of antibiotic medications alone do not justify the practice of using AP in patients with prosthetic joints. CONCLUSIONS: The authors identified the major points of concern for a future multidisciplinary, systematic review of AP use in patients with prosthetic joints. In the meantime, they conclude that the new AAOS statement should not replace the 2003 joint consensus statement. CLINICAL IMPLICATIONS: Until this issue is resolved, dentists have three options: inform their patients with prosthetic joints about the risks associated with AP use and let them decide; continue to follow the 2003 guidelines; or suggest to the orthopedic surgeon that they both follow the 2003 guidelines.

Detection of periodontal bacterial DNA in serum and synovial fluid in refractory rheumatoid arthritis patients.

AIM: To identify periodontal bacterial DNA (PBDNA) by PCR in subgingival dental plaque (SDP), serum and synovial fluid (SF) of rheumatoid arthritis (RA) with periodontal disease (PD) patients and to explore the possible PBDNA transport pathways from mouth to joints. METHODS: This cross-sectional prolective study involved 19 subjects with RA and PD. Informed consent, health and dental questionnaires were obtained. SDP, SF and serum samples were obtained, and leucocytes were isolated from blood. DNA was extracted and PCR assays to detect main PD species were carried out. Cultures on agar plates and broth, from each sample, were performed. RESULTS: Hundred percentage of patients showed PBDNA in SDP and SF and 83.5% in serum. Prevotella intermedia (89.4% and 73.6%) and Porphyromonas gingivalis (57.8% and 42.1%) were the species most frequently detected in SDP and SF, respectively. In SDP, 4.05 different bacterial species were found followed by 1.19 in serum and 2.26 in SF. Culture onto agar plates and broth did not show any bacterial growth, leucocytes were not positive to PBDNA by PCR. CONCLUSION: This study suggests that PBDNA could have a role on the RA aetiology. The possible pathway of transport of PBDNA from mouth to joints could be via the free form of DNA.

Periodontal disease and heart disease: are they related?

This article reviews the literature (with an emphasis on articles published from 2005-2008) regarding a possible association between periodontal disease and cardiovascular disease. Both clinical studies and review papers were included. A number of studies continue to demonstrate such an association; however, none of the studies to date have shown a cause-and-effect relationship between the diseases. Based on the findings of this literature review, dentists still should apply the recommendations made by the American Heart Association in its 2004 statement.

Methamphetamine abuse and "meth mouth".

Dental management for the patient who abuses drugs is always a challenge. The numbers of patients abusing methamphetamines appears to be increasing. The dentist needs to be aware of the clinical presentation and medical risks presented by these patients and to attempt to get the patient to seek professional help. Additionally, special attention will be necessary for the high prevalence and severity or oral manifestations including: rampant caries, enamel erosion, xerostomia, bruxism and muscle trismus.

Antibiotic prophylaxis in dentistry: an update.

Antibiotics are used in dentistry to treat an existing infection therapeutically or to prevent an infection prophylactically. To prevent a perioperative infection (primary prophylaxis), prophylactic antibiotics may be administered when a surgical device, such as a prosthetic cardiac valve, is placed. They also may be administered to patients who have an existing medical condition or have received a previously placed device to reduce the risk of infection from a bacteremia (secondary prophylaxis). Although it is common to prescribe secondary prophylaxis for many dental conditions, there is a general lack of scientific evidence of its effectiveness and accumulating evidence suggests that such prescriptions may be unnecessary. In the past, antibiotic prophylaxis has been used for conditions with no proven benefit. Risks associated with antibiotics include allergic reactions (for example, anaphylaxis), development of antibiotic-resistant bacteria, development of superinfections, pseudomembranous colitis, cross-reactions with other drugs, and death. The costs involved with the use of antibiotics can be significant as well. This article reviews the current status of secondary antibiotic prophylaxis use in dentistry.

Effects of high-intensity focused ultrasound on nerve conduction.

The effects of various exposures (intensity, duration) of high-intensity focused ultrasound (HIFU) on sciatic nerve conduction were investigated in vivo in rats. The objective was to identify HIFU exposures that produce biological effects ranging from partial to complete conduction block, indicating potential use of HIFU as an alternative to current clinical methods of inducing nerve conduction block. In the study, 26 nerves were exposed and treated with 5-s applications of 5.7-MHZ HIFU with acoustic intensities of 390, 2,255, 3,310, and 7,890 W/cm(2) (spatial peak, temporal peak). Compound muscle action potentials (CMAPs), in response to electrical stimulation of the nerve proximal to the HIFU site, were recorded from the plantar foot muscles immediately before and after HIFU treatment and 2 and 4 h after treatment. Furthermore, a preliminary long-term investigation was performed on 27 nerves with the same four sets of HIFU parameters. CMAPs were measured at the survival endpoint for each animal (7 or 28 days after treatment). For nerves treated with the three lower exposures, CMAPs decreased initially within 4 h or 7 days after HIFU treatment and then recovered to their baseline level at 28 days after treatment. For the highest exposure, however, CMAPs remained absent even 28 days after treatment. These exposure-dependent effects of HIFU on nerve function suggest its future potential as a novel treatment for severe spasticity and pain.

Pharmacologic management of type 2 diabetes: a review for dentistry.

Over the last 40 years, diabetes mellitus has increased sixfold in the United States. Reported cases increased by more than 6.0% in 2006. Type 2 diabetes accounts for approximately 90% of all cases and is becoming more common in children and adolescents. The cause of Type 2 diabetes involves both genetic and environmental factors. The recent increase in the incidence and prevalence of Type 2 diabetes is related largely to obesity. Type 2 diabetes is managed by lifestyle interventions, drug therapy, and control of risk factors for cardiovascular disease. Patients with renal failure can be treated by transplantation of a kidney and pancreas. Islet cell transplantation is available, but long-term results have not been good. Pharmacologic treatment is accomplished with several classes of oral drugs. This article reviews the literature to provide recent innovations in the pharmacologic management of Type 2 diabetes mellitus.

Pharmacologic management of type 1 diabetes: a review for dentistry.

The incidence of diabetes mellitus has increased dramatically in the United States over the last 40 years. In 2006, reported cases of diabetes mellitus increased by 6.0%. The vast majority of these increased cases involve Type 2 diabetes, which is becoming much more common in children, adolescents, and young adults. This article reviews the pharmacological treatments available for Type 1 diabetes, the monitoring necessary for diabetes patients, the regimens of intensive insulin therapy that have replaced conventional therapy, and the complications of insulin therapy. Alternate methods of insulin delivery and options for patients are discussed.

Image-guided high-intensity focused ultrasound for conduction block of peripheral nerves.

The objective of our work has been to investigate the use of ultrasound image-guided high-intensity focused ultrasound (HIFU) to non-invasively produce conduction block in rabbit sciatic nerves in vivo, a technique that could become a treatment of spasticity and pain. The work reported here involved the investigation of the duration of such conduction blocks after HIFU treatment and whether they resulted in axon degeneration. The right sciatic nerves of 12 rabbits were treated, under guidance of ultrasound imaging, with repeated 5-s applications of 3.2 MHz HIFU with in situ intensity of 1930 W/cm(2) (spatial-average, temporal-average) until conduction block was achieved. Survival endpoints were 0, 7, or 14 days after HIFU treatment, at which point the nerve conduction was assessed. Qualitative and quantitative histological analysis of nerve sections proximal and distal to the HIFU site was performed. Conduction block of all 12 nerves was achieved with average HIFU treatment time of 10.5+/-4.9 s (mean+/-SD). The volume of necrosis of adjacent muscle was measured to be 1.59+/-1.1 cm(3) (mean+/-SD). For all nerves, conduction block remained at the survival endpoint and the block resulted in degeneration of axons distal to the HIFU site, as confirmed by electrophysiological and histological methods. Potential clinical applications include treatment of spasticity in patients with spinal cord injury or pain in cancer patients.

Thyroid disorders. Part II: hypothyroidism and thyroiditis.

Part II of the series on thyroid disorders discusses hypothyroidism and thyroiditis that may be found in dental patients. An overview of the conditions is presented. Presenting signs and symptoms, laboratory tests used to diagnose hypothyroidism and thyroiditis, and their medical management is discussed. The dental management of patients with hypothyroidism is discussed in detail. The dentist by detecting the early signs and symptoms of hypothyroidism and thyroiditis can refer the patient for medical diagnosis and treatment and avoid potential complications of treating patients with uncontrolled disease. Patients with thyroiditis may have a short period of being hyperthyroid and it may be best to avoid routine dental treatment during that period. Patients with suppurative thyroiditis should not receive routine dental treatment during the acute stage of the disease. The end stage of Hashimoto's thyroiditis results in hypothyroidism. Central nervous system depressants, sedatives, or narcotic analgesics must be avoided in patients with severe hypothyroidism because significant respiratory depression may occur. In addition, myxedematous coma, particularly in elderly hypothyroid patients, can be precipitated by central nervous system depressants, infection, and possibly stressful dental procedures. In medically well-controlled patients the dental treatment plan is not affected and most dental procedures can be offered to these patients.

Thyroid disorders. Part III: neoplastic thyroid disease.

This paper is part III of the series on thyroid disorders. Thyroid tumors are the most common endocrine neoplasms. Most of these tumors are benign hyperplastic or colloid nodules or benign follicular adenomas. However, 5% to 10% of the lesions that come to medical attention are carcinomas. A major clinical challenge is establishing which nodules are hyperplastic, benign, or malignant. History, clinical findings, ultrasonography, and fine-needle aspiration biopsy are the mainstays for diagnosis. There are 3 main histologic types of thyroid cancer: differentiated, medullary, and anaplastic. Differentiated lesions are subdivided into papillary, follicular, and Hurthle cell carcinomas. In addition, primary lymphoma may occur in the thyroid gland and other cancers may metastasize to the thyroid. An important neoplastic syndrome, multiple endocrine neoplasia type 2 (MEN2), involves medullary carcinoma of the thyroid gland. In 2002 there were 10 cases of thyroid cancer per 100 000 population. During the past 10 years the rate of thyroid cancer has been increasing 5% per year. The overall 10-year survival for papillary carcinoma is 80% to 90%, follicular carcinoma 65% to 75%, and medullary carcinoma 60% to 70%. The prognosis for anaplastic carcinoma is very poor and 5-year survival is rare. The dentist by inspection and palpation of the neck in the area of the thyroid gland may detect single or multiple lesions that may be benign or malignant. Patients with identified nodules or enlarged thyroid glands should be referred for diagnosis and treatment. Patients with thyroid cancer will benefit from the early detection and treatment of their lesions as early detection can lead to a cure or prolongation of their life.

Thyroid disorders. Part I: hyperthyroidism.

The significant thyroid disorders that may be found in dental patients are presented in a series of 3 articles. This article (part I) deals with hyperthyroidism, part II with hypothyroidism and thyroiditis, and part III with neoplastic lesions of the thyroid. The signs and symptoms, laboratory tests used to diagnoses hyperthyroidism, and the medical management of patients with hyperthyroidism are presented in this paper. The dental management of patients with hyperthyroidism is discussed in detail. The dentist, by detecting the early signs and symptoms of hyperthyroidism, can refer the patient for medical diagnosis and treatment and avoid potential complications of treating patients with uncontrolled disease. These complications include the rare thyrotoxic crisis (thyroid storm) that may be precipitated by dental treatment, acute infection, or trauma in the patient with uncontrolled hyperthyroidism. Also, the use of epinephrine or other pressor ammines can cause a hypertensive crisis in the patient with uncontrolled hyperthyroidism. Patients will benefit from the early detection and referral by reducing the risks of the medical complications such as hypertension, cardiac arrhythmias, and congestive heart failure.

Melanoma: etiology, treatment, and dental implications.

Melanoma is one of the most serious skin cancers. It arises from neural crest-derived melanocytes located in the epidermis or dermis of the skin. Melanoma also can arise from melanocytes located in other regions of the body such as the eye, meninges, digestive tract, mucosal surfaces, or lymph nodes. There are no proven causes of melanoma but the most commonly associated factor is episodic exposure to the sun. Melanoma is a common cancer that has been increasing in incidence for the last 35 years. The median age at the time of diagnosis is 53 years. It is much more common in whites than in people of color. Five-year survival rates for melanoma of the skin have been increasing since 1976. There are four types of melanoma: superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral lintiginous melanoma. Clinical signs indicating possible melanoma are asymmetry, border irregularity, color variation, increase in diameter, elevation, ulceration, and bleeding of pigmented lesions. Histopathologic findings (tumor thickness, tumor invasion), surface ulceration, spread to lymph nodes, and distant metastases are used to project patient prognosis. Treatment consists of surgical excision, lymph node dissection, limb perfusion, regional chemotherapy infusion, radiation, intralesional immunotherapy, systemic chemotherapy, and/or interferon-alpha, depending on the staging of the melanoma. Oral melanomas are rare; however, approximately 20% of all melanomas are found in the head and neck region. The role of the dentist is to be alert for changes in pigmented lesions of the oral mucosa and skin of the head and neck. Lesions suspected of melanoma must be biopsied, which usually involves referral of the patient.

Gonorrhea: update.

Gonorrhea is a worldwide sexually transmitted disease (STD) caused by Neisseria gonorrhoeae. Gonorrhea is the second most often reported STD in the United States behind chlamydia. An estimated 600,000 people each year in the United States are infected. Only about half this number of cases are reported. From 1975 through 1997, the national gonorrhea rate declined 74.3%. After a small increase in 1998, the gonorrhea rate has decreased each year since 1999. In 2003 the South had the highest gonorrhea rate among the four regions of the country. Antimicrobial resistance remains an important consideration in the treatment of gonorrhea. In 2003 the Gonococcal Isolate Surveillance Project found about 16% of collected isolates were resistant to penicillin and/or tetracycline. Since 1998 the number of ciprofloxacin-resistant isolates has been increasing with 270 (4.1%) being reported in 2003. Oral gonorrhea is rare, nonspecific, and varied and may range from slight erythema to severe ulceration with a pseudomembranous coating. The patient with gonorrhea poses little threat of disease transmission to the dentist. However, patients who have or have had gonorrhea should be approached with a measure of caution because they are in a high-risk group for additional STDs. The CDC has published recommendations for standard precautions to be followed in controlling infection in dentistry that have become the standard for preventing cross-infection. Strict adherence to these recommendations will, for all practical purposes, eliminate the danger of disease transmission between dentist and patient. Dentists should be aware of local statutory requirements regarding reporting STDs to state health officials. Syphilis, gonorrhea, and AIDS are reportable diseases in every state. Local health departments or state STD programs are sources of information regarding this matter.

Methamphetamine abuse and "meth mouth".

Dental management for the patient who abuses drugs is always a challenge. The number of patients abusing methamphetamines appears to be increasing. The dentist needs to be aware of the clinical presentation and medical risks presented by these patients and to attempt to get the patient to seek professional help. Additionally, special attention will be necessary for the high prevalence and severity of oral manifestations including rampant caries, enamel erosion, xerostomia, bruxism, and muscle trismus.

Dental management of patients with Alzheimer's disease.

This article reviews the recent literature regarding the epidemiology, etiology, pathophysiology, diagnosis, and treatment of Alzheimer's disease. The dental management of patients with Alzheimer's disease is discussed in some detail.