Clinico-therapeutic management of osteoradionecrosis : a literature review and update

In the management of head and neck cancer, radiotherapy is usually a coadjuvant to surgery, or is applied on a palliative basis. The most important complication of such radiotherapy is osteoradionecrosis, which manifests as an area of exposed necrotic bone in the maxillae or mandible that fails to heal during at least three months. In most cases osteoradionecrosis gradually progresses, becoming more extensive and painful, and its late manifestations comprise infection and pathological fracture. The present study provides a literature review and update on the risk factors underlying osteoradionecrosis, its clinical and diagnostic particulars, prevention, and most widely accepted treatment options, as well as new possibilities relating to clinical management of the disorder. Lastly, a new early management protocol is proposed based on the current consensus criteria relating to maxillary osteonecrosis secondary to treatment with bisphosphonates, together with the adoption of new therapies supported by increased levels of evidence. © Medicina Oral S. L

Manifestaciones orales del paciente con artritis reumatoide

La artritis reumatoide (AR) es una enfermedad sistémica crónica inflamatoria que se caracteriza por una reacción autoinmune que afecta de forma primaria a las articulaciones, y si permanece sin tratamiento puede comprometer la función de estas. Esta AR puede producir manifestaciones a nivel orofacial como afectación de la articulación temporomandibular, xerostomía, síndrome de Sjögren secundario con sus respectivas manifestaciones y periodontitis entre otras. En muchos estudios de la literatura se han identificado una posible relación entre la enfermedad periodontal (EP) y la AR, donde se ha visto que los pacientes con AR pueden tener una mayor incidencia de EP y viceversa. Asimismo, también se ha propuesto que la severidad de la EP es mayor en estos pacientes. Sin embargo, hay autores que no encuentran tales relaciones existiendo cierta controversia en la literatura sobre el tema. Al estudiar la relación entre las dos enfermedades, la mayoría de estudios apoyan la idea de que la periodontitis y la AR se relacionan entre sí, proponiéndose que un estado de inflamación en el individuo podría ser el vínculo de unión entre la EP y la AR. A su vez se cree algunos mediadores de la inflamación como citoquinas, antígenos HLA –DR, hormonas e incluso las bacterias periodontales son elementos que formarían parte de la relación entre ambas enfermedades. Objetivo general En primer lugar, desearíamos confirmar la asociación entre artritis reumatoide y enfermedad periodontal, y si es así, determinar el grado de severidad de periodontitis y los posibles factores causales de la misma en el paciente con artritis reumatoide. De igual forma, se conoce la relación entre esta enfermedad y la xerostomía, por lo que queremos comprobar también la asociación entre artritis reumatoide y el grado de secreción salival. Objetivos concretos 1. Comprobar si existen diferencias entre el índice CAOd en pacientes con artritis reumatoide y pacientes del grupo control sin artritis reumatoide. 2. Ver si los pacientes con artritis reumatoide tienen mayor prevalencia que la población general (grupo control) de enfermedad periodontal, mediante las variables clínicas: el índice de placa, índice de sangrado, profundidad de bolsa y pérdida de inserción. 3. Comprobar si la severidad en la enfermedad periodontal (si se comprueba) está relacionada con la severidad de la artritis reumatoide. 4. Comparar las tasas de flujo salival en reposo (STR), saliva total estimulada (STE) y saliva parotídea estimulada (SPE) entre pacientes con artritis reumatoide y en pacientes de un grupo control sin artritis reumatoide. 5. Evaluar la correlación entre la proporción de interleuquina 6 (IL-6) en saliva con el resto de parámetros periodontales y factores de perfil del paciente artrítico. 6. Se propone la construcción de un modelo predictivo diagnóstico para determinar la probabilidad de padecer AR en función a las variables orales estudiadas y de la IL-6 con el que cuantificar el impacto de los aspectos periodontales y de saliva. Se diseño un estudio prospectivo de casos y controles en el que en una primera fase del estudio se estudiaron las variables orales y periodontales (CAOD, índice de placa, índice de sangrado, bolsas periodontales, pérdida de inserción), y se realizaron sialometrías en toda la muestra completa formada por 146 pacientes, 73 con artritis reumatoide y otros 73 individuos sin ella. En una segunda fase, se seleccionaron 30 pacientes de cada grupo de forma aleatoria para hacer un estudio cualitativo de la saliva donde se valoró la IL-6 y como afectaban tanto las variables periodontales como las salivales de forma múltiple a la enfermedad. Encontramos un aumento significativo en las medias de placa bacteriana, profundidad de bolsas periodontales, porcentaje bolsas moderadas, pérdida de inserción clínica en los pacientes con AR. Asímismo, observamos una disminución significativa en las medias de bolsas fisiológicas, saliva total en reposo y saliva parotídea estimulada para estos pacientes. Todos estos datos se encontraban en sintonía con lo publicado anteriormente en la literatura, aunque había controversia en cuanto a la placa bacteriana al haber algunos autores que no encontraban estas diferencias. Obtuvimos que los parámetros que mas influían para poder decir que había diagnóstico positivo de artritis, explicando casi un 60% de la probabilidad de tener la enfermedad, eran: la placa bacteriana, las bolsas 1-3 mm., las bolsas de 4-5 mm., la pérdida de inserción y la SPE. El índice de placa era el parámetro más diferenciador de la artritis respecto al grupo de los sanos con un odds o riesgo de presentar artritis que se elevaba casi 7 veces. Creemos que este dato podría ir en la línea de las teorías que hablan de las infecciones periodontales como posibles desencadenantes de la AR en pacientes susceptibles. También se observó que la pérdida de inserción elevaba el riesgo de padecer AR en torno a 4 veces, coincidiendo con otros autores que pensaban que que las enfermedades periodontales se relacionan con la AR. En varios estudios se demostró la elevación de los niveles de IL-6 en pacientes con AR respecto a controles. Incluso, en alguno de ellos encuentran una asociación entre la elevación de este parámetro y la severidad clínica de la artritis. En nuestro estudio se ha podido comprobar un aumento de IL-6 en saliva de los pacientes con AR en relación a los individuos sin AR. Ya que la obtención de saliva es mas sencilla y no invasiva, se podrían realizar estudios en el futuro en el sentido de utilizar la medida de este parámetro en saliva como un posible marcador de la enfermedad. Conclusiones 1. Los pacientes con artritis reumatoide no tienen en nuestro estudio un mayor índice CAOD que los pacientes que no presentan la enfermedad. 2. El índice de placa de Sillness y Löe se presentaba claramente aumentado en los pacientes con artritis reumatoide, indicando una franca deficiencia de la higiene bucodental de estos pacientes. 3. El índice de sangrado gingival no presentaba diferencias entre los pacientes con artritis reumatoide y sin ella. 4. Los pacientes con artritis reumatoide presentan mayor profundidad de bolsas periodontales y mayor predominio de bolsas periodontales medianas (4-5mm) que los pacientes sin artritis. 5. Los valores de pérdida de inserción clínica estaban elevados en los pacientes con artritis reumatoide frente al grupo control. 6. Los pacientes con artritis reumatoide presentan una mayor prevalencia de enfermedad periodontal que los pacientes del grupo control. 7. Las tasas de flujo salival en reposo y parotídea (STR y SPE) se encontraban disminuidas en los pacientes con artritis reumatoide, sin embargo, no se encontraron diferencias en cuanto a la tasa de flujo salival estimulada (STE). 8. El factor periodontal que mas explicaba el riesgo de padecer artritis reumatoide en nuestra muestra de pacientes fue la placa bacteriana con un odds ratio de 6,77. 9. La interleuquina-6 (IL-6) presentó valores claramente elevados en saliva en los pacientes con AR frente a los pacientes sin artritis.Rheumatoid arthritis (RA) is a systemic, chronic and inflammatory pathology characterized by an autoimmune reaction that primarily affects joints, and if not treated can compromise their function. RA can cause manifestations at the orofacial level, like affectation of the temporomandibular joint, xerostomy, secondary Sjögren syndrome, along with its respective manifestations, and periodontal disease, to cite some examples. Many studies within the literature have identified a possible relationship between periodontal disease (PD) and RA, where patients with RA may have higher incidence of PD and vice versa. Also, it has also been proposed that the severity of PD is higher in these patients. However, there are many authors that have not found such relationships, and some controversy remains in the literature concerning this subject. While studying the relationship between both pathologies, most of the studies support the idea that periodontal disease and RA are related with each other, suggesting that an inflammatory state in the individual could be the link between them. It is also believed that some mediators of the inflammatory process like citokines, HLA-DR antigens, hormones and even periodontal bacteria are elements that could play a role between both illnesses. Global objective In first place, we want to confirm the association between RA and PD, and if existant, determine the degree of severity of periodontal disease in RA patients and its possible causal factors, especially those that are controllable and can be identified. Second, the relationship between this disease and xerostomy is well known, so we also want to test the possible association between RA and the degree of saliva secretion. Concrete objectives 1. Test if there are differences in the CAOd index between patients with RA and patients from the control group, not affected by RA. 2. Evaluate if patients with RA have more prevalence of PD than the main population (control group) by means of the following clinical variables: plaque index, bleeding index, pocket depth and loss of attachment. 3. Investigate if PD’s severity (if verified) is related with the severity of RA. 4. Compare unstimulated whole saliva flux (UWS), stimulated whole saliva (SWS) and stimulated parotid saliva (SPS) between patients with RA and patients from the control group. 5. Explore the correlation between interleukin 6 (IL-6) proportion in saliva and the rest of the arthritic patient’s specific factors and periodontal parameters. 6. The creation of a diagnostic predictive model to determine the probability of undergoing RA under the studied oral variables, and of another model to predict the effect of periodontal and saliva parameters over IL-6. A cases and controls prospective study was designed, in which, in a first phase, oral and periodontal variables were measured (CAOD, plaque index, bleeding index, pocket depth and loss of attachment), and sialometries were practiced over the whole sample, consisting in 146 patients: 73 affected by RA and 73 not affected. In a second phase, 30 patients were haphazardly selected from each group in order to realize a qualitative study of the saliva, were IL-6 was measured and how both saliva and periodontal variables multiply affect the disease was evaluated. Bacterial plaque, periodontal pocket depth, percentage of moderate periodontal pockets and loss of attachment means were significantly higher in the RA patient group than in the control group, while physiological periodontal pockets, UWS, SPS means were significantly lower. These results were consistent with the findings of most previous research, despite the controversy concerning bacterial plaque raised by some authors that did not observe these differences. We found that the most relevant factors for a positive diagnostic of arthritis, explaining almost 60% of the probability of undergoing the disease, were: bacterial plaque, 1-3 mm. pockets, 4-5 mm. pockets, loss of attachment, and SPS. The most differentiating parameter between RA patients and the control group was plaque index, which elevated by almost 7 times the odds of suffering arthritis. We believe these findings support the theory that periodontal infection is a potential cause of RA in predisposed patients. Loss of attachment was also observed to increase around 4 times the odds of undergoing RA, consistently with other authors’ research, which suggested RA was related with periodontal disease. Several studies demonstrated IL-6 levels were higher in RA patients than in the control group. Moreover, many of these studies found an association between the increase in this parameter and arthritis’ clinical severity. Consistently, we observed higher levels of IL-6 in RA patients than in healthy patients. Because sampling saliva is simple and practically un-invasive, IL-6 measurement in saliva should be considered as a possible marker for this disease. Conclusions 1. RA patients did not present a higher CAOD index than healthy patients in our study. 2. Sillnes an Löe plaque indexes were clearly higher in RA patients, indicating decreased dental hygiene in these patients. 3. Bleeding index did not present significant differences between RA patients and the control group. 4. RA patients present deeper periodontal pockets and a preponderance of medium depth periodontal pockets (4-5 mm.) than healthy patients. 5. Clinical attachment loss was higher in RA patients than in the control group. 6. Patients undergoing RA present greater prevalence of periodontal disease than healthy ones. 7. Unestimulated whole saliva and stimulated parotid saliva (UWS and SPS) were diminished in patients with RA, nevertheless, no differences were found for stimulated whole saliva (SWS). 8. The most differentiating parameter between RA patients and the control group was plaque index, with an odds ratio of 6,77. 9. Interleukin-6 (IL-6) levels were clearly higher in RA patients than in healthy patients

Cemento-ossifying fibroma of the mandible: presentation of a case and review of the literature

Introduction: Cemento-ossifying fibroma is a benign fibro-osseous maxillary tumor belonging to the same category as fibrous dysplasia and cement-ossifying dysplasia. The aim of present study was report a case of cement-ossifying mandibular fibroma and offers a review of the literature on this disorder. Case report: A 41-year-old woman presented for conventional dental treatment. A control panoramic X-ray study revealed a rounded, mixed-type image in the mandible, located in the periapical zone from tooth 4.3 to 3.3. The patient presented no symptoms and had no medical history of interest. A sample of the lesion was obtained for histopathological study, which yielded a definitive diagnosis of cemento-ossifying fibroma. Discussion: The World Health Organization classifies cemento-ossifying fibroma as a fibro-osseous neoplasm included among the non-odontogenic tumors derived from the mesenchymal blast cells of the periodontal ligament, with a potential to for fibrous tissue, cement and bone, or a combination of such elements. These are slow-growing lesions, and are more frequent in women between the third and fourth decades of life. Although the underlying cause is not known, there have been reports of past trauma in the area of the lesion. Due to the good delimitation of the tumor, surgical removal and curettage is the treatment of choice

Hospital dental practice in special patients

Dental patients with special needs are people with different systemic diseases, multiple disorders or severe physi - cal and/or mental disabilities. A Medline search was made, yielding a total of 29 articles that served as the basis for this study, which offers a brief description of the dental intervention protocols in medically compromised patients. Dental treatment in patients with special needs, whether presenting medical problems or disabilities, is sometimes complex. For this reason the hospital should be regarded as the ideal setting for the care of these individuals. Be - fore starting any dental intervention, a correct patient evaluation is needed, based on a correct anamnesis, medical records and interconsultation reports, and with due assessment of the medical risks involved. The hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made, and we moreover have the possibility of performing treatments under general anesthesia. In this context, ambulatory major surgery is the best approach when considering general anesthesia in patients of this kin

Association between obesity and periodontal disease. A systematic review of epidemiological studies and controlled clinical trials

Obesity is a very prevalent chronic disease worldwide and has been suggested to increase susceptibility of periodontitis. The aim of this paper was to provide a systematic review of the association between obesity and periodontal disease, and to determine the possible mechanisms underlying in this relationship. A literature search was carried out in the databases PubMed-Medline and Embase. Controlled clinical trials and observational studies identifying periodontal and body composition parameters were selected. Each article was subjected to data extraction and quality assessment. A total of 284 articles were identified, of which 64 were preselected and 28 were finally included in the review. All the studies described an association between obesity and periodontal disease, except two articles that reported no such association. Obesity is characterized by a chronic subclinical inflammation that could exacerbate other chronic inflammatory disorders like as periodontitis. The association between obesity and periodontitis was consistent with a compelling pattern of increased risk of periodontitis in overweight or obese individuals. Although the underlying pathophysiological mechanism remains unclear, it has been pointed out that the development of insulin resistance as a consequence of a chronic inflammatory state and oxidative stress could be implicated in the association between obesity and periodontitis. Further prospective longitudinal studies are needed to define the magnitude of this association and to elucidate the causal biological mechanisms

Possible association between obesity and periodontitis in patients with Down syndrome

The present study was carried out to evaluate the possible association between obesity and periodontitis in patients with DS, and to explore which measure of obesity is most closely correlated to periodontitis. A prospective observational study was made to determine whether obesity is related to periodontal disease in patients with DS. The anthropometric variables were body height and weight, which were used to calculate BMI and stratify the patients into three categories: < 25(normal weight), 25-29.9 (overweight) and ? 30.0 kg/m2 (obese). Waist circumference and hip circumference in turn was recorded as the greatest circumference at the level of the buttocks, while the waist/hip ratio (WHR) was calculated. Periodontal evaluation was made of all teeth recording the plaque index (PI), pocket depth (PD), clinical attachment level (CAL) and the gingival index. We generated a multivariate linear regression model to examine the relationship between PD and the frequency of tooth brushing, gender, BMI, WHI, WHR, age and PI. Significant positive correlations were observed among the anthropometric parameters BMI, WHR, WHI and among the periodontal parameters PI, PD, CAL and GI. The only positive correlation between the anthropometric and periodontal parameters corresponded to WHR. Upon closer examination, the distribution of WHR was seen to differ according to gender. Among the women, the correlation between WHR and the periodontal variables decreased to nonsignificant levels. In contrast, among the males the correlation remained significant and even increased. In a multivariate linear regression model, the coefficients relating PD to PI, WHR and age were positive and significant in all cases. Our results suggest that there may indeed be an association between obesity and periodontitis in male patients with DS. Also, we found a clear correlation with WHR, which was considered to be the ideal adiposity indicator in this context

Cardiovascular disease versus periodontal disease: chronic systemic infection as a link

Objective : Analysis of the alleged connection between the periodontal and cardiovascular disease, with reference to periodontal pathogens as a risk factor for heart disease. Researching method : A research was carried out at Medline/Pubmed. Included criteria and researching strategy. The articles selection has been made taking into account key-terms appearing either in the title or in the summary. Experimental studies in animals, clinical prospective studies performed with a minimum sample size (>30) and studies written in English have been included. The rejected criteria were the following: clinical retrospective studies and/or studies carried out with a low sample size (n<30). Results : Within systemic diseases related to periodontal ones, the alleged link between periodontal and heart and circulatory disease has been one of the most investigated in recent times. Different authors consider the existence of a link between the diseases as such, inappropriate and implausible since both the diseases have risk factors in common (age, gender, smoking, diet, oral hygiene and diabetes). However, speculations about the origin of the diseases were raised when it was demonstrated that some bacteria species, bacteria proteins and lipopolysaccharide are present at the plaques of atherosclerosis that obstruct the coronary arteries. The mechanisms of this connection have been analyzed following an actualized review. Conclusion : Most of the experimental and clinical studies ensure that a positive association between periodontal disease and heart disease has been found, once the con-founder factors have been eliminate

Influence of anxiety and anesthetic vasoconstrictors upon hemodynamic parameters during dental procedures in controlled hypertensive and non-hypertensive patients

To determine the influence of dental anxiety and the vasoconstrictor used in local anesthesia upon different hemodynamic parameters - systolic (SBP) and diastolic blood pressure (DBP), heart rate (HR) and peripheral oxygen saturation (SatO2) - during den

Application of a capsaicin rinse in the treatment of burning mouth syndrome.

Objective: To examine the efficacy of a new topical capsaicin presentation as an oral rinse in improving the symptoms of burning mouth syndrome (BMS). Study design: A prospective, double-blind, cross-over study was made of 30 patients with BMS. There were 7 dropouts; the final study series thus comprised 23 individuals. The patients were randomized to two groups: (A) capsaicin rinse (0.02%) or (B) placebo rinse, administered during one week. After a one-week washout period,the patients were then assigned to the opposite group. Burning discomfort was scored using a visual analog scale(VAS): in the morning before starting the treatment, in the afternoon on the first day of treatment, and at the end of the week of treatment in the morning and in the afternoon. The same scoring sequence was again applied one week later with the opposite rinse. Results: The mean patient age was 72.65 ± 12.10 years, and the duration of BMS was 5.43 ± 3.23 years on average. Significant differences in VAS score were recorded in the capsaicin group between baseline in the morning (AM1)or afternoon (AA1) and the end of the week of treatment (AA7)(p=0.003 and p=0.002, respectively). Conclusion: The topical application of capsaicin may be useful in treating the discomfort of BMS, but has some limitations