[Tuberculosis in the dental office. Epidemiology, clinical view and prevention]. / Tuberculose in de tandartspraktijk. Epidemiologie, klinisch beeld en preventie.

The expectation that tuberculosis would be eliminated in the Netherlands by about 2030 has been negatively adjusted due to a variety of factors. The incidence of pulmonary and extrapulmonary tuberculosis has even increased. The risk for oral health care providers to be exposed to tuberculosis has also increased. A questionnaire among dentists revealed that knowledge concerning tuberculosis is limited. On the basis of a review of the literature, an overview is given of the pathways of tuberculosis infection, the immunology of tuberculosis, clinical signs of tuberculosis, resistance to tuberculosis, diagnostic tools for tuberculosis, and the therapy and prevention of tuberculosis. Emphasis is placed especially on manifestations of oral tuberculosis and the prevention of tuberculosis in dental practice.

[An inventory of knowledge on tuberculosis among dentists in the Netherlands]. / Inventarisatie van de kennis over tuberculose onder tandartsen in Nederland.

By the nature of his work, a dentist has a higher risk of tuberculosis infection than the average Dutch population. Thus, the question arises whether dentists do have sufficient knowledge on tuberculosis. In order to determine their knowledge, an inventory was conducted among a sample of dentists in the Netherlands. Analysis of the dentists' response to 19 correct or incorrect statements revealed that their knowledge level on tuberculosis was rather low, did not vary with regard to gender, and was independent of the region where they were practising and of their explicit medical interest. The dentists indicated a desire for education on tuberculosis.

[Miscommunication during the treatment of a medically compromised patient]. / Miscommunicatie bij de behandeling van een medisch gecompromitteerde patiënt.

A 42-year-old patient with cardiac problems had periodontal disease. The required periodontal treatment was only carried out after a period of 6 months. During this time, the patient was at risk of endocarditis due to a bacteraemia, a problem which was not recognized by any of the oral healthcare providers. When treating a patient who is at risk of developing endocarditis, the guidelines of the Dutch Heart Foundation (Nederlandse Hartstichting) must be observed. Deviation from the guidelines is only permissible under appropriate conditions. If treatment is being carried out by a team, then there is not only a question of shared responsibility, but also of shared liability. Adequate communication and record-keeping are vital in cases of patients who are medically compromised.

[Antibiotic prophylaxis for patients with joint prostheses]. / Antibioticaprofylaxe bij patiënten met een kunstgewricht.

In The Netherlands only patients with reduced defence mechanism are considered for antibiotic prophylaxis, and only in case of a total hip replacement. The extend to which the American indications will be applied in Europe, is at this moment unknown. It becomes more and more clear that the risk from providing prophylaxis is greater than the risk of a joint infection.

[Local anesthesia and patients presenting with medical pathologies; the use of anamnesis in the prevention of medical complications in the dental office]. / Anesthésie locale et patients présentant des pathologies médicales; utilité de l'anamnèse dans la prévention des complications médicales au cabinet dentaire.

The treatment of medically compromised patients is becoming a frequent event in general dental practice as a consequence of the longer presence of natural teeth, an increase in life expectation and a shift towards more ambulatory medical treatment of patients with chronic diseases. Since the dentist is responsible for a correct approach of these patients, it is important that he has knowledge of interactions between medical conditions, compensating mechanisms and medical treatment and the impact of dental treatment on this. In this context, medical history taking is useful. The medical history should be taken as correct as possible, with careful interpretation of the information. Necessary preventive measures should be known.

Acute medical complications in 277 general dental practices.

BACKGROUND: Due to the aging of the population on one hand and both medical and dental innovations on the other, the number of medical complications which occur during dental treatment is expected to rise. In order to prevent such complications, dental practitioners have used a medical risk-related history which includes risk determination and preventive measures (together the MRRH system). In this study, the medical complications which occurred in their practice have been compared with those recorded by a control group. METHODS: First, a tested registration form was used. In addition, the group using the MRRH system had previously attended a 1-day introductory course de voted to the MRRH system. Furthermore, a power analysis was used to determine the group sizes. The registration period was set at 1 year, during which the dentists sent in monthly reports. Only patients over the age of 18 were included, after having given their oral consent. An independent diagnosis was given of all registered medical complications by two different internists. RESULTS: A total of 208 medical complications were reported: 45 complications were reported by the 62 dentists who used the MRRH system (reference group) and 163 by the 215 dentists of the control group. First, it should be noted that some reports did not register vital signs; this is reflected in categories such as "no diagnosis," "collapse eci," and "others." Second, the study has revealed that the reference group has registered the heart rate and the frequency of breathing of patients more frequently than the control group. Also, a relatively lower percentage of complications was recorded within the reference group due to the intravenous injection of local anesthetics. CONCLUSIONS: The number of medical complications recorded in the two groups shows little variation. There is a considerable difference, however, in the nature of these complications.

Introductory notes regarding a European Medical Risk Related History questionnaire (EMMRH) designed for use in dental practice.

The Medical Risk Related History (MRRH) has been in use for several years in the Netherlands. Since 1994 the MRRH system has been subject to research in nine European countries. Legal and ethical demands in all participating countries have been listed, and a national epidemiological analysis of pathology interfering with dental treatment has been undertaken for every participant.

Stress in elective dental treatment: epinephrine, norepinephrine, the VAS, and CDAS in four different procedures.

This study focuses on progressive stress during defined, elective dental treatments, expressed in VAS, CDAS, and catecholamine excretion in urine. Fourteen male patients had avoided dental treatment for years; all were classified as ASA risk score I. The different dental sessions were: first visit after many years; check-up (nonpainful and nontraumatic); drilling and restoring under local anesthetics; drilling and restoring without local anesthesia; and extractions. Urine collection was performed directly before and after the sessions to measure epinephrine and norepinephrine concentrations. Anticipation stress was registered in the VAS, CDAS, and epinephrine excretion. Progressive stress was reflected in epinephrine increase, which discriminated between the different elective dental treatments.

Characteristics of Prevotella intermedia-specific CD4+ T cell clones from peripheral blood of a chronic adult periodontitis patient.

Periodontitis is a chronic destructive inflammatory disease associated with periodontopathic bacteria. In addition, autoantigens such as collagen and heat shock proteins (hsp) have been suggested to play a role. Established periodontal lesions are characterized by dense infiltrations of immune cells such as cytokine-producing CD4+ and CD8+ T cells. CD4+ T cells specific for Prevotella intermedia can be isolated from lesional gingiva, suggesting an active role for CD4+ T cells in the response to this bacterium. We therefore investigated the characteristics of a panel of 13 P. intermedia-specific CD4+ T cells generated from the peripheral blood of a patient with chronic adult periodontitis. All 13 P. intermedia-specific CD4+ T cells recognized the antigens in the context of HLA-DR. The T cell clones were mainly classified as Th0, producing comparable amounts of interferon-gamma (IFN-gamma) and IL-4, and Th2, producing high amounts of IL-4 and almost no IFN-gamma. None of the P. intermedia-specific T cell clones recognized antigens of the periodontopathic bacteria Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis and of the autoantigens collagen and hsp. The reactivity profile of the T cell clones to size-fractionated cell envelope antigens of P. intermedia indicated that P. intermedia-specific CD4+ T cell clones recognize probably five different antigen specificities in the context of the MHC class II molecules, DR7 or DR15. These results suggest that a broad panel of cell-associated protein antigens play a role in the induction of P. intermedia-specific CD4+ T cell response.

Detecting the medically compromised patient in dentistry by means of the medical risk-related history. A survey of 29,424 dental patients in The Netherlands.

BACKGROUND: This study focuses on the detection of medically compromised dental patients in the Netherlands by means of a validated patient-administered medical risk-related history (MRRH). Due to social changes and scientific innovations in the past decade, more medically compromised patients will be needing special dental treatment. METHODS: The medical problems of 29,424 dental patients (age 18 years and over) from 50 dental practices in the Netherlands were registered by means of the MRRH. The patients were classified according to the ASA risk-score system, which was modified for dental treatment. An inventory of the number and nature of medical problems and the modified ASA risk score was drawn up in relation to dental treatment and age. RESULTS: The average age of the patients was 37.1 +/- 13.5 years. According to the current guidelines, dental treatment must be modified if the patient has an ASA score of III or IV. A relatively high percentage of patients ages 65-74 (23.9%) and 75 or over (34.9%) did have an ASA score of III or IV. Furthermore, the medical problems were classified into 10 categories, and the relationship to age was examined. The conditions that increased with age were hypertension and cardiovascular, neurological, endocrinological, infectious, and blood diseases. CONCLUSIONS: For the dental practice, these results mean that the MRRH can play an important role in adapting dental treatment to the specific needs of patients. This is especially important in the case of elderly patients.

[Medical accidents in the dental practice. Survey of 471 dentists in the Netherlands]. / Medische accidenten in de tandartspraktijk. Rapportage door 471 tandartsen in Nederland.

OBJECTIVE: To determine frequency and nature of medical accidents in Dutch dental practice in relation to type and time of treatment, with and without the use of the MRRH; frequency and nature of the professional assistance. METHOD: Dentists MRRH-users (n = 51) and control dentists (n = 420) recorded medical accidents by name, using a registration form, followed by an anonymous survey. RESULTS: 91 accidents were reported by name by 471 dentists. This contrasted with 300 accidents recorded by 380 dentists in an anonymous survey. No life threatening accidents were reported. Syncope and hyperventilation were frequent. Most of the accidents occurred during local anaesthesia or during treatment, as the procedure became more stressful. Two-third of the accidents could possibly have been prevented by means of a medical history. Medical assistance was requested in 6% of the cases. CONCLUSION: Life threatening disorders were not reported, possible because in the Netherlands no intravenous sedation or general anaesthetic is used in general dental practice.

Antigen-presenting properties of gingival fibroblasts in chronic adult periodontitis.

Chronic periodontitis is characterized by dense infiltrations of T lymphocytes in the connective tissue, which consists mainly of gingival fibroblasts. It is becoming increasingly clear that T lymphocytes and gingival fibroblasts are capable of influencing each other. For example, the T cell cytokine interferon-gamma (IFN-gamma) is able to induce MHC class II molecules on the surface of several cell types, including gingival fibroblasts. Histological sections of chronically inflamed gingival tissue showed a great number of CD4+ and CD8+ T cells that produced IFN-gamma, and in addition showed abundant expression of MHC class II molecules on gingival fibroblasts. Therefore, we investigated whether these gingival fibroblasts acquire the capacity to carry out MHC class II-restricted functions such as antigen presentation to local T cells. In this study, we show that IFN-gamma-treated gingival fibroblasts were able to function as antigen-presenting cells (APC) for superantigen-mediated T cell proliferation. However, these fibroblasts failed to present whole-cell antigens of periodontitis-associated bacteria. Moreover, gingival fibroblasts inhibited the presentation of the whole-cell antigens of these bacteria by professional APC. This inhibition could be overcome by the addition of IL-2. These results suggest that gingival fibroblasts play an important role in the local specific immune response in chronic inflammatory periodontal lesions by regulating the response of infiltrating T cells.

Effect of a protein-rich meal on urinary and salivary free amino acid concentrations in human subjects.

The aim of the present study was to investigate whether in healthy volunteers acute changes in plasma free amino acid composition after a protein-rich test meal are reflected in the urinary and salivary concentrations of the corresponding amino acids. The ingestion of a protein-rich meal elicited a significant increase of plasma and urine amino acid concentrations. The postprandial salivary amino acid excretion showed only minor changes. For several amino acids (alanine, arginine, asparagine, glycine, threonine and valine) significant relations were observed between the increase in concentration of these amino acids in venous plasma and urine. In whole saliva, only threonine and valine showed a significant relationship with the corresponding plasma concentration. Our data suggest that the urinary amino acid excretion of several amino acids has the potential for estimating short-term changes in plasma concentrations. Determination of salivary amino acid concentrations seems less appropriate for this purpose.

The validity of a medical risk-related history for dental patients in Belgium.

The aim of this study was to establish whether a patient-administered medical risk-related history (MRRH) for dental patients was valid. The MRRH, which was developed in the Netherlands, has now been tested in Belgium, where it was completed by total of 99 patients. Their answers were compared with the results of a verbal history, taken by a physician experienced in pre-assessment control. This verbal history was considered the 'gold standard'. The sensitivity and specificity of the medical questionnaire proved to be sufficiently high (88 per cent and 98 per cent respectively) and Cohen's Kappa displayed close agreement (0.87). These figures were only slightly lower than those obtained in Holland. The MRRH is valid for the registration of medical problems in dental patients but the answers need to be checked personally by the dental practitioner. Since the present trial was a limited one, the study will be expanded to nine countries in Europe.

Cardiovascular responses induced by dental treatment.

Changes in mean heart rate and mean systolic and diastolic blood pressure are induced in both the patient's anticipation of scheduled treatment and the actual dental treatment itself. Significant changes have been observed before application of a local anesthetic, during restorative treatment, during extractions, and when epinephrine-impregnated retraction cords were used. These cardiovascular responses may vary according to the local anesthetic used and the choice of vasoconstrictor. The individual changes in heart rate and blood pressure are affected by pain and such individual factors as age, gender, hypertension, dental experience, and psychological responses. Although for the most part the cardiovascular changes induced by dental treatment are limited and within the normal physiological variation, this review stresses the importance of eliminating pain and minimizing patient anxiety.