Relationship between dental occlusion and functional dependence in elderly Caucasians.

OBJECTIVE: To determine whether a relationship exists between the number of functional masticatory units (FMUs) and the level of functional dependence of elderly. SUBJECTS AND METHODS: The study group comprised 502 elderly Caucasians living in nursing homes in north-west Spain and Portugal. The number of FMUs was counted on direct visual inspection. The degree of dependence was assessed using the Barthel index. The results were validated in a group of 156 elderly. Statistical analysis of the results was performed using a generalised linear model (GLM), a logistic GLM, a ROC-GLM curve and a confusion matrix. RESULTS: The number of FMUs significantly affected the Barthel index score (explained deviance = 27.5%). The number of FMUs was significantly associated with a lower probability of dependence, both for women (explained deviance = 31%) and for men (explained deviance = 33%). The model based on FMUs showed a good discriminatory capacity for dependence (AUC = 0.84 in women and 0.82 in men). The predictive capacity of the dependence model based on FMUs was very high (sensitivity = 0.9 in women and 0.8 in men). CONCLUSIONS: In institutionalised elderly Caucasians, the number of FMUs is significantly associated with the Barthel index score and could be a predictive factor for dependence.

A Dramatic Case of Odynophagia.

We report the case of a 77-year-old male with a history of aortic stenosis and interstitial lung disease, who debuted 3 years ago with an outbreak of necrotic and very painful canker sores. The severity of the lesions and their refractory response to treatment led to several hospital admissions and multiple consultations to different specialists (ENT, rheumatology, dermatology, ophthalmology, cardiology, and internal medicine). During this time, the patient received central parenteral nutrition with an episode of catheter-related septicemia, and he came to require psychiatric assistance for autolytic ideation. Numerous diagnostic tests were performed with inconclusive results, including biopsy of the lesion (histological study, immunohistochemistry for CD68 + , CD4 + , CD8 + , CD20 + , MCT +, and cytomegalovirus, PAS, Grocott-Gomori and Zielh-Neelsen staining, and in situ hybridization for Epstein Barr virus). Numerous treatments were unsuccessfully tested until thalidomide was administered, thus completely remitting lesions but leaving retractable scarring sequelae. Since then, the patient has had two recurrences, coinciding with the reduction of thalidomide dosages, which were controlled by increasing the dose of the immunomodulator. Recurrent necrotizing major aphthous stomatitis (Sutton's disease) is a clinical variant of recurrent aphthous stomatitis that may have a dramatic course. Unfortunately, the lack of etiopathogenetic uniformity precludes any specific treatment. In severe cases, immunomodulators, including thalidomide, may represent a valid therapeutic option.

A breath ammonia analyser for monitoring patients with end-stage renal disease on haemodialysis.

OBJECTIVE: Breath ammonia measurement has attracted increasing interest for clinical diagnosis and metabolic status monitoring. This pilot study aims to evaluate a simple detection method to measure breath ammonia levels in haemodialysis patients. MATERIALS AND METHODS: The study group comprised 44 adults undergoing haemodialysis and a control group of 44 age- and sex-matched individuals with a glomerular filtration rate >90 mL/min. To measure breath ammonia concentration, we designed a device based on that used to monitor atmospheric air, which uses a specific colorimetric tube. A single operator took two readings from each haemodialysis patient (one predialysis and one postdialysis) and one reading from each control. The results were compared with the urea concentrations in blood and saliva. RESULTS: Breath ammonia concentration correlated significantly with blood urea both predialysis (P < 0.001; R2 = 0.55) and postdialysis (P = 0.009; R2 = 0.25), as well as with predialysis saliva urea concentration (P < 0.001; R2 = 0.24). Ammonia was not detectable in breath of any of the control group. CONCLUSIONS: The collection of breath samples in polyvinyl fluoride bags and their subsequent analysis using colorimetric tubes is a simple, noninvasive method that enables variations in breath ammonia concentration to be measured rapidly in haemodialysis patients. Using this method, we found that the breath ammonia concentration correlated significantly with the blood urea concentration before and after haemodialysis.

Early tooth loss in end-stage renal disease patients on haemodialysis.

OBJECTIVE: This article sets out to evaluate the prevalence and aetiopathogenesis of edentulism in patients on haemodialysis. SUBJECTS AND METHODS: The study group comprised 44 adult patients with end-stage renal disease (ESRD) on haemodialysis. A control group was formed of 44 individuals matched for age and sex and with a glomerular filtration rate >90 ml min(-1) . All participants underwent intra-oral examination, gathering information on dental and periodontal status, and a saliva sample was taken to determine saliva debit and its biochemical composition. RESULTS: The average number of missing teeth was higher in ESRD patients than in controls (P = 0.018). Six (13.6%) fully edentulous individuals were detected in the study group and 1 (2.2%) in the control group. Some of the clinical and biochemical variables with statistically significant differences between the study group and the control group showed a significant relationship with the number of missing teeth, but the depth of the periodontal pockets presented the highest coefficient of determination (OR = 3511.1; 95%CI = 82.2-6834.3; P < 0.001; R(2)  = 0.827). CONCLUSIONS: Premature tooth loss is common in haemodialysis patients. Although the aetiology and pathogenesis of this finding has still not been fully clarified, it appears that severe periodontal disease may play a relevant role.

Morphometry of the hard palate in Down's syndrome through CBCT-image analysis.

OBJECTIVES: To define the morphometry of the hard palate in Down's syndrome (DS) on cone beam computed tomography (CBCT) images. SETTING AND SAMPLE POPULATION: Santiago de Compostela University (Spain). The study group included 40 white DS individuals aged 10 to 40 years (mean = 18.8 ± 7.3 years), 25 males and 15 females. The control group consisted of 40 individuals matched for age and sex were selected. MATERIAL & METHODS: Nine measurements were taken on the CBCT images. Axial plane: anteroposterior length (aAPL) and arch length (aARL); sagittal plane: anteroposterior length (sAPL), maximum height (sMH) and sagittal arch (sAR); coronal plane: interdental width (cIDW), height (cHE), skeletal width (cSW) and coronal arch (cAR). RESULTS: aAPL, aARL, sAPL, sMH, sAR, cMH and cAR were comparable in the two groups. cIDW and cSW were greater in controls than in DS. We found no statistically significant differences between males and females with DS. In the controls, sAPL and sAR were greater in males than females. In DS, age only had a statistically significantly increasing effect on aAPL and sAPL. In the controls, age significantly affected sAR and cHE. CONCLUSION: The hard palate is narrower in DS than in controls, but the anteroposterior measurements and the height of the vault are comparable in both groups.

HCV clearance from saliva of HIV-HCV-coinfected patients on treatment with interferon plus ribavirin.

OBJECTIVE: To determine hepatitis C virus (HCV) RNA clearance from blood and saliva of HIV-HCV-coinfected patients undergoing combined therapy with pegylated interferon plus ribavirin (PEG-IFN-RIB). SUBJECTS AND METHODS: Study group was formed of 60 HIV-infected patients with chronic hepatitis C who were starting treatment with PEG-IFN-RIB. Blood and saliva samples were taken at baseline, at the end of treatment and 24 and 48 weeks later. A nested RT-PCR technique was used to detect HCV-RNA in saliva. RESULTS: HCV-RNA was detected in saliva at baseline in 64.7% of patients. Thirty-four patients completed follow-up. The response rate (undetectable HCV-RNA) in blood was 79.4% at the end of treatment; 55.8% at 24 weeks after the end of treatment and 50% at 48 weeks. HCV was detected in saliva of 13 (38.2%) patients at the end of treatment and in 18 (52.9%) patients at 24 and 48 weeks later. Concordance of HCV clearance from blood and saliva reached its maximum value at 48 weeks after the end of treatment (odds ratio, 112.51). CONCLUSION: In HIV-HCV-coinfected patients responders to PEG-IFN-RIB, the salivary glands do not appear to be a sanctuary site for HCV, although viral clearance from saliva may be slower than from blood.

A new indicator of the oral hygiene habits of disabled persons: relevance of the carer's personal appearance and interest in oral health.

OBJECTIVE: To investigate whether there is a relationship between the oral hygiene habits of individuals with severe disability the carer's personal appearance and interest in oral health. PATIENTS AND METHODS: The study group was formed of 60 disabled persons and their respective carers who came for the first time to consultation in the Special-Needs Dentistry Unit of the University of Santiago de Compostela, Spain. All the carers answered a standardised questionnaire of 28 questions divided into four sections: disabled individual's demographic data, disabled individual's general medical details, social aspects of the carer (personal appearance of the carer and interest in oral health), and disabled individual's oral hygiene habits. The personal appearance of the carers and their interest in the disabled individual's oral health were evaluated using independent scales designed specifically for the study, with five binary items in each scale. RESULTS: The carer's personal appearance and interest in the disabled individual's oral health showed a statistically significant relationship with the individual's oral hygiene habits, particularly with respect to the frequency and duration of toothbrushing, need for physical restraint during toothbrushing, use of a manual toothbrush and use of toothpaste. CONCLUSIONS: The carer's personal appearance and interest in the disabled individual's oral health are good indicators of the oral hygiene habits of an individual with severe disability. Consideration should be given to the inclusion of these aspects as a complementary element of the dental record.

A novel mutation in the OFD1 (Cxorf5) gene may contribute to oral phenotype in patients with oral-facial-digital syndrome type 1.

BACKGROUND: Oral-facial-digital syndrome (OFDS) type 1 (OFD1) is an X-linked dominant condition associated with embryonic male lethality. It almost always affects the oral cavity, face, and digits. It is considered to be a ciliopathy caused by mutations in the OFD1 gene. A variety of mutations have been described, and a genotype-phenotype correlation has been suggested. OBJECTIVE AND METHODS: The proband was an 8-year-old Spanish girl with suspected OFD1. We extended the pedigree to three proband's generations, performing a thorough physical examination and screening for OFD1 mutations in nine individuals. RESULTS: The proband, her mother, and her sister showed oral findings consistent with OFD1. Ultrasound evaluation revealed the existence of renal cysts only in the proband's mother. The rest of the family (all male) had no relevant morphological abnormalities. A single-base deletion in exon 16 of OFD1 (c.2183delG) leading to a frameshift was detected in the proband, her mother, and her sister. CONCLUSION: Because all three women had a similar oral phenotype, this new mutation might be involved in the development of the OFD1 oral manifestations. In cases of OFDS, physical examination (including the oral cavity and renal function) and genetic screening of the probands and their relatives are mandatory.

Case report of segmental odontomaxillary dysplasia with cutaneous manifestations.

BACKGROUND: Segmental odontomaxillary dysplasia is an uncommon nonhereditary growth disorder that affects the maxilla, gums and ipsilateral dentition. The disorder is diagnosed mainly based on dental (over-retention of primary teeth, dental agenesis and diastemas) and bone findings (bone sclerosis, irregular trabeculation of immature bone and reduced maxillary sinus). This paper provides a case report. CASE REPORT: A 5-year-old child with skin manifestations including hypertrichosis, facial erythema and pigmented nevus was diagnosed with type II segmental odontomaxillary dysplasia based on clinical, radiographic and histopathological analysis. CONCLUSION: The skin findings can help with the suspicion of segmental odontomaxillary dysplasia, although the definitive diagnosis is typically established by a paediatric dentist based on clinical and radiological findings.

Evaluation of chlorhexidine substantivity on salivary flora by epifluorescence microscopy.

OBJECTIVE: To evaluate the in vivo antimicrobial activity of chlorhexidine (CHX) in saliva 7 h after its application using an epifluorescence microscopy technique. SUBJECTS AND METHODS: Fifteen volunteers performed a single mouthrinse with sterile water (SM-water) and with 0.2% CHX (SM-0.2% CHX). Saliva samples were taken at 30 s and 1, 3, 5 and 7 h after each application. The bacterial suspension was mixed with the SYTO 9/propidium iodide staining and observed using an Olympus BX51 microscope. The mean percentage of viable bacteria was calculated for each sample. RESULTS: In comparison with baseline values, the frequency of viable bacteria decreased significantly at 30 s after the SM-0.2% CHX (P < 0.001) and presented significant antibacterial activity up to 7 h after the mouthrinse (P < 0.001). In comparison with SM-water, the prevalence of viable bacteria was significantly lower at 30 s after the SM-0.2% CHX (P < 0.001) and showed a significant antibacterial effect up to 7 h after the mouthrinse (P < 0.001). CONCLUSIONS: Epifluorescence microscopy permits evaluating the antimicrobial activity of CHX on the salivary flora in real-time. Fluorescence assays could be particularly useful to analyse simultaneously the effect of antimicrobials that alter the cytoplasmic membrane integrity on different oral ecosystems.

Changes in salivary composition in patients with renal failure.

OBJECTIVE: To our knowledge, none of the articles has been published in the literature which analyse the alterations of saliva in different stages of chronic renal failure (CRF). The objective of this study has been to analyse the flow, pH and biochemical composition of saliva in patients with moderate-severe CRF (M-S CRF) and with terminal renal failure (TRF). DESIGN: The study group was formed of 50 CRF patients: 22 with M-S CRF and 28 with TRF included in a haemodialysis programme. A control group with similar characteristics was established (n=64). Saliva samples were taken from both patients and controls to determine the salivary pH and biochemical composition. RESULTS: Whole salivary flow was similar in patients and controls. Salivary concentrations of creatinine, urea, sodium, potassium, chloride and alpha-amylase were significantly higher in patients than in controls. Calcium concentration was significantly lower in patients than in controls. Creatinine, urea and potassium concentrations were significantly higher in patients with M-S CRF than in those with TRF. The salivary pH was significantly higher in patients than in controls. CONCLUSIONS: Salivary composition in patients with CRF is conditioned by the stage of renal failure. The relationship between these biochemical parameters and the oral health status has still not been definitively clarified.

The incidence of bacteraemia associated with tracheal intubation.

Expert committees on bacterial endocarditis prophylaxis have provided differing opinions on whether tracheal intubation is an 'at-risk' manipulation. We studied the incidence of bacteraemia after orotracheal and nasotracheal intubation. The study group comprised 110 patients who underwent surgery under general anaesthesia. Venous blood samples were collected from each patient at baseline and 30 s after intubation. Samples were processed with conventional microbiological techniques. Bacteraemia after tracheal intubation was detected in 13 patients (11.8%); six after orotracheal intubation and seven after nasotracheal intubation. Staphylococci and streptococci were the most commonly isolated bacterial species. Seven isolates (54%) were resistant to oxacillin. The incidence of bacteraemia was similar after orotracheal (12.0%) and nasotracheal intubation (11.7%). The recommendation for bacterial endocarditis prophylaxis with flucloxacillin when performing nasotracheal intubation, as put forward by the British Society for Antimicrobial Chemotherapy, needs further consideration.

Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremia.

OBJECTIVE: To investigate the prevalence, duration, and etiology of bacteremia following dental extractions performed after a single administration of chlorhexidine mouthwash. DESIGN AND SETTING: A randomized, controlled trial performed in a university hospital. METHODS: A series of 106 patients with mental and behavioral disabilities who underwent dental extractions under general anesthesia were randomly assigned to a control group or chlorhexidine group. The exclusion criteria applied were use of antibiotics in the previous 3 months, use of oral antiseptics, any type of congenital or acquired immunodeficiency, and disease that predisposes the patient to infections or bleeding. The chlorhexidine group had 0.2% chlorhexidine mouthwash administered for 30 seconds before any dental manipulation. Blood samples were collected at baseline, 30 seconds, 15 minutes, and 1 hour after the dental extractions. Subculture and further identification of the isolated bacteria were performed by conventional microbiological techniques. RESULTS: The prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96% and 79%, respectively, at 30 seconds (P=.008), 64% and 30% at 15 minutes (P<.001), and 20% and 2% at 1 hour (P=.005). The most frequently identified bacteria were Streptococcus species in both the control and chlorhexidine groups (64% and 68%, respectively), particularly viridans group streptococci. CONCLUSION: We recommend the routine use of a 0.2% chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremia.

Subcutaneous emphysema related to air-powder tooth polishing: a report of three cases.

Subcutaneous emphysema is a rare complication of dental procedures and can occasionally give rise to potentially life-threatening complications. We describe three cases of subcutaneous emphysema diagnosed in the same dental clinic. All cases occurred during tooth or implant cleaning using air polishing (KavoProphyflex® ) with a sodium bicarbonate powder (Air-N-Go Classic® ). The diagnosis was based on clinical findings and was confirmed radiologically. The cervical and facial regions were affected in all three cases, and spread to the mediastinum occurred in one case. All the episodes resolved within 3-5 days. Tooth cleaning using air polishing combined with an abrasive powder is a risk factor for subcutaneous emphysema, especially when the powder and device are from different manufacturers. Radiological assessment must be performed to rule out involvement of deep tissue planes.

Cone Beam Computed Tomography evaluation of palatal bone thickness for miniscrew placement in Down's syndrome.

OBJECTIVES: To quantify palatal bone thickness (PBT) in Down's syndrome (DS) patients in order to identify the best areas for miniscrew placement. DESIGN: The study group was formed of 40 DS patients (25 male and 15 female) with a mean age of 18.4±6.3 years (range, 9-40 years). A control group of 40 non-syndromic age- and sex-matched individuals was selected. Maxillary CBCT images were available for all participants. Coronal sections of the hard palate were selected at 4, 8, 16 and 24mm posterior to the distal wall of the incisive foramen. PBT measurements were performed at 20 selected points on these coronal sections at the midline and at 3 and 6mm to right and left of the suture. RESULTS: Overall, PBT was similar in DS and controls and it was not affected by age or sex. In both groups PBT decreased progressively with increasing distance from the posterior wall of the nasopalatine foramen in an anteroposterior direction, except along the median palatal suture. PBT along the suture was lower in DS than in controls in all the paracoronal image planes (P=0.02, 0.007, 0.01 and 0.02 at 4mm, 8mm, 16mm and 24mm, respectively, from the incisive foramen). PBT at the most anterior paramedian locations was also lower in DS than in controls (P=0.02 and 0.03, respectively, 3mm to the right and left of midline). CONCLUSIONS: In DS individuals, the most suitable area for miniscrew placement in terms of bone volume is the median palatal suture, irrespective of age or sex, as occurs in the general population, followed by the paramedian sites closest to the incisive foramen.

Oral bisphosphonate-related osteonecrosis of the jaws in dental implant patients: a case series.

Bisphosphonates have been associated with a serious adverse reaction known as bisphosphonate-related osteonecrosis of the jaws (BRONJ). The aim of this study was to describe its clinical characteristics in patients with dental implants who were taking bisphosphonates orally. We made a retrospective multicentre study in 3 hospitals in Galicia, Spain. The medical records and clinical and radiological follow-up of the oral cavity were reviewed for those patients given bisphosphonates and diagnosed with BRONJ after the placement of dental implants within the previous 3 years. The series comprised 9 white patients (mean age 66 years). The bisphosphonates were alendronate (n=6), ibandronate (n=2), and risedronate (n=1), and the most common indication was osteoporosis (n=7). The mean interval between the initiation of treatment and the onset of BRONJ lesions was 60 months. Most of the lesions were located around the mandibular implants (n=8). The mean interval between placement of dental implants and the onset of BRONJ was 34 (range 1-96) months. After treatment 7/9 patients recovered completely. The prevalence of BRONJ secondary to treatment with bisphosphonates taken orally after placement of dental implants may be higher than expected in a particular geographical region, but to date specific risk factors have not been identified. Clinical characteristics and the outcomes of treatment of lesions are similar to those seen in patients with BRONJ that is unrelated to placement of dental implants.

Is oral bisphosphonate-related osteonecrosis of the jaw an endemic condition?

Since the introduction of bisphosphonates to treat diseases that affect bone remodelling, there has been an increasing number of cases of bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ). Epidemiological data regarding BRONJ vary widely between studies, and a number of potential methodological biases have been detected. In some small preliminary studies, single nucleotide polymorphisms associated with an increased risk of BRONJ among cancer patients have been identified. However, genetic susceptibility to oral BP-related BRONJ has not previously been discussed. We suggest that epidemiological variability could be related to the existence of a susceptibility factor particularly prevalent in the population of a well-defined geographical region. To support our hypothesis we performed a search for published case series, only including those with at least 10 patients detected in a single city or a delimited geographical region; this showed that 55% of reports came from Mediterranean countries such as Italy, Israel, Spain and France. The finding does not appear to be conditioned by publication bias. Furthermore, conditions such as classic Kaposi sarcoma and beta-thalassaemia, though not exclusive to the Mediterranean region, also have a high prevalence in that area. We speculate that some of the patients included in the selected US and Australian series may be of Spanish or Italian descent. With an ageing population, the prevalence of osteoporosis will increase, and the number of cases of oral BP-related BRONJ may rise exponentially. Identification of risk groups with susceptibility to BRONJ will arise caution when prescribing BPs and will allow new preventive and therapeutic strategies to be developed.

Osseointegrated dental implants in patients with intellectual disability: a pilot study.

PURPOSE: The objective of this study was to investigate if intellectual disability (ID) itself constitutes an absolute contraindication to oral rehabilitation with osseointegrated implants, or if adequately selected patients can benefit from this dental treatment technique. METHOD: We report a series of eight patients with non-syndromic ID and no associated neuromuscular disorders, craniofacial abnormalities, or serious systemic complications, in whom oral rehabilitation was performed using implant-supported prostheses, with a follow-up of one to three years. RESULTS: A total of 18 titanium implants were inserted and nine implant-supported prostheses were constructed. Follow-up examination showed that although the majority of implants presented a degree of peri-implant mucositis, all were osseointegrated and the prostheses were functional. CONCLUSIONS: Although there is very little literature on this subject, the results of this pilot study allow us to suggest that osseointegrated oral implants could constitute a therapeutic option for patients with ID. The success of oral rehabilitation depends fundamentally on appropriate patient selection. IMPLICATIONS FOR REHABILITATION: • Apart from the obvious difficulties related to eating and communication, edentulism is of great cosmetic importance in patients with ID in terms of social acceptance. • It has been suggested that patients with ID do not receive the same level of dental treatment as the general population. • The results of this pilot study allow us to suggest that osseointegrated oral implants could constitute a therapeutic option for patients with ID.

Correlation between dental maturation and chronological age in patients with cerebral palsy, mental retardation, and Down syndrome.

Determining a child's chronological age and stage of maturation is particularly important in fields such as paediatrics, orthopaedics, and orthodontics, as well as in forensic and anthropological studies. Some systemic conditions can cause abnormal physiological maturation, and skeletal maturation is usually more delayed than dental maturation. The aim of this study was to determine dental age in a group of patients with the most prevalent congenital or perinatally occurring physical and mental disabilities. The study group comprised 155 white Spanish children aged 3-17 years (35 with cerebral palsy, 83 with mental retardation and no associated syndromes or systemic conditions, and 37 with Down syndrome). The dental maturation indices described by Nolla and Demirjian were used to generate regression lines for the dental age of individuals in a control group (688 white Spanish children aged 3-17 years) and the formulae were then used to determine the dental age of patients in the study group. No significant differences were found between dental and chronological age in boys with cerebral palsy, mental retardation, or Down syndrome. In contrast, dental age (calculated from the linear regression model that included values for the Demirjian index) was significantly delayed compared with chronological age in girls with cerebral palsy or Down syndrome.