Design of clinical trials for chronic diseases: implications for periodontal disease

In order to make effective use of the statistical theory of design of clinical trials for chronic diseases such as periodontal disease, certain issues must be considered. Any clinical trial requires that the disease definition be well-specified; that patient eligibility be explicit; that the observation times be explicit; that the duration and endpoint of therapy be specified; that the duration of subsequent followup observation be specified; and that the unit of observation (e.g., tooth, set of teeth, patient) be defined. In a chronic disease, the potential biases that can readily be introduced by self-selection of patients who enter the trial and/or who return for subsequent observation become more important, because subjects are required to remain on treatment and/or observation for prolonged periods. Further, the cyclical nature of some chronic diseases may require special attention to baseline definitions of active disease and disease outcome. These issues are illustrated with examples from clinical trials of hypertension, breast cancer screening, and Polycythemia Vera. Implications for periodontal disease are discussed.     

中老年患者与第三磨牙相关的口腔疾病

本研究对口腔内科门诊中35岁以上、至少保留1个第三磨牙者440例进行调查。结果表明因第三磨牙龋病、牙髓根尖病及其相关病变(包括第二、三磨牙间食物嵌塞、第二磨牙远中面龋及与第三磨牙相关的粘膜病)就诊者182例;1158颗第三磨牙中以垂直位者多见,占53.97％;第三磨牙龋坏机率高于其他磨牙及双尖牙(p<0.001);在与第三磨牙相关的粘膜病中以过角化(110例)和创伤性溃疡(35例)为多见,且显示出慢性刺激对白斑与扁平苔藓发生有促进作用。提示保留至中老年的第三磨牙潜在致病性的存在;所以除完全正位萌出且易清洁或对义齿修复有帮助者均应及早拔除。从而进一步丰富了人们对中老年人口腔状况尤其是第三磨牙的认识。     

Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases

Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-α), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.     

Oral medicine and the elderly

A focus often exists in dental practice on the maintenance and management of the dentition and the periodontium, however, conditions of the oral mucosa and orofacial pain can cause significant problems for older patients. Oral mucosal conditions are more prevalent in older patients and many orofacial pain disorders, such as burning mouth syndrome and trigeminal neuralgia, are more common in patients over the age of 50 years. Although these conditions may not be routinely managed in general practice, identification of these patients in primary care and appropriate referral will lead to more prompt and effective treatment. CLINICAL RELEVANCE: Dental practitioners need to be able to identify what is considered to be within the normal physiological limits of the ageing oral tissue and hence what is abnormal and requires further investigation to facilitate appropriate referral.     

Oral verrucous hyperplasia: histologic classification, prognosis, and clinical implications

Background:  Oral verrucous hyperplasia (OVH) is a premalignant lesion that may transform into an oral cancer.
Methods:  Sixty consecutive OVH cases were collected from 2003 to 2004. Clinicopathological features and the 5-year malignant transformation rate of these 60 OVH lesions were evaluated and analyzed.
Results:  We found that 84% of OVH lesions occurred in patients between 40 and 69 years of age. The most common site for OVH lesions was the buccal mucosa (48%), followed by the tongue (20%), palate (18%), gingiva (7%), and labial mucosa (7%). Approximately 91% of OVH patients were areca quid chewers and 89% were smokers. When 60 OVH lesions were classified into 30 plaque-typed and 30 mass-typed OVH lesions, the mass-typed OVH lesions had a higher malignant transformation rate of 17% (5/30) than the plaque-typed OVH lesions (3%, 1/30) during a mean follow-up period of 59 ± 7 months. The mean time for malignant transformation was 22 ± 11 months. Of the 6 OVH lesions with malignant transformation, 2 underwent total surgical excision and 4 did not receive any form of therapy.
Conclusions:  We conclude that OVH lesions occur more commonly on the buccal mucosa and are highly associated with the areca quid chewing and cigarette smoking habits. The overall 5-year malignant transformation rate of 60 OVH lesions was 10%. The mass-typed OVH lesions had a higher malignant transformation rate than the plaque-typed OVH lesions and thus should receive an immediate treatment, such as total surgical excision or photodynamic therapy, after the histopathologic diagnosis.     

Oral infection, hyperglycemia, and endothelial dysfunction

Metabolic syndrome and type 2 diabetes (T2DM) resulting from sustained hyperglycemia are considered as risk factors for cardiovascular disease (CVD) but the mechanism for their contribution to cardiopathogenesis is not well understood. Hyperglycemia induces nonenzymatic glycation of protein-yielding advanced glycation end products (AGE), which are postulated to stimulate interleukin-6 (IL-6) expression, triggering the liver to secrete tissue necrosis factor alpha (TNF-alpha) and C-reactive protein (CRP) that contribute to CVD pathogenesis. Although the high prevalence of periodontitis among individuals with diabetes is well known by dental researchers, it is relatively unrecognized in the medical community. The expression of the same proinflammatory mediators implicated in hyperglycemia (i.e., IL-6, TNF-alpha, and CRP) have been reported to be associated with periodontal disease and increased risk for CVD. We will review published evidence related to these 2 pathways and offer a consensus.     

Oral and Maxillofacial Surgical simulation: efficacy for medical students

Oral and Maxillofacial Surgery (OMFS) is underrepresented in the medical curriculum with 90% of medical students reporting no exposure to the specialty in medical school. This can result in clinicians having problems recognising emergency presentations, and referrals being made inappropriately. OMFS trainees delivered an educational simulation course on common OMFS pathologies to medical students, with theory and hands-on, high-fidelity simulations that covered anatomy, emergency presentations, and the training pathway. Delegates were assessed immediately before, immediately after, and six-weeks after the course. There were significant improvements in knowledge six weeks after the course, with mean scores improving by 23% for knowledge of anatomy (p<0.01), 21% for emergency management of patients (p<0.01), and 22% for knowledge of the training pathway (p=0.04). There was a 58% increase in interest in OMFS and improved confidence for an oral examination. This study found that improvements in knowledge about concepts in OMFS were sustained and significant. Given the lack of representation of the specialty in medical school, high-fidelity simulation should be more widely adopted as an educational adjunct to help bridge the gap between taught theory and applied practice.     

Granulomatous diseases: Oral manifestations and recommendations

Granulomatous diseases may present with oral manifestations that are detectable by dental care providers. In certain cases, oral manifestations may precede systemic signs and symptoms. Dentists managing patients with these conditions may modify the dental treatment plan and possibly retain the support of other health professionals. This review gives an update on granulomatous diseases that can be faced by the dental practitioner.     

Oral piercing in athletes: implications for general dentists

General dentists need to be aware of the growing number of athletes who display various forms of body art. Intraoral piercing and tongue jewelry place athletes at greater risk for serious medical and dental consequences that are confounded when the athlete attempts to compete while wearing a mouthguard with the tongue jewelry in place. All body jewelry should be removed during sporting events. General dentists have a professional responsibility to: become more aware of the extent and implications associated with tongue piercing in athletes to discourage athletes from having the tongue pierced; be prepared to manage postpiercing intraoral and dental complications; provide proper advice for the care and use of a mouthguard in the presence of tongue jewelry; and develop educational strategies that address the medical and dental complications of intraoral piercing.     

Oral health disparities among the elderly: interdisciplinary challenges for the future

The elderly, like other population groups, have experienced varying levels of oral health among their diverse demographic subgroups. For those in poverty, experiencing social isolation, residing in long-term care institutions, and with complex medical illness, oral health care may be unreachable. Various models of training, education, and community, public, and professional collaboration have been proposed, yet few strategies have been implemented. Interdisciplinary approaches that bring interested partners together as equal stakeholders may create faster tracks in improving access to health care for those geriatric patients who lack it. This article explores past and present recommendations for interdisciplinary collaborations, reviews the current and future needs of the geriatric population, discusses educational models and content, and expresses the need for leadership to address oral health disparities in the elderly. Finally, strategies for making improvements in the existing oral health disparities are discussed.     

Metabolic syndrome: pathogenesis, medical care and dental implications

BACKGROUND: The dental literature contains little information about metabolic syndrome (MetS) and its dental implications. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 2000 through 2005, using the term "metabolic syndrome" to define its pathophysiology, medical treatment and dental implications. RESULTS: MetS is the co-occurrence of abdominal obesity, hyper-triglyceridemia, reduced high-density lipoprotein cholesterol levels, hypertension and impaired fasting glucose, which results from consumption of a high-calorie diet and decreased levels of physical activity superimposed on the appropriate genetic setting. Components of MetS synergistically promote the development of atherosclerosis, resulting in myocardial infarction and stroke. CLINICAL IMPLICATIONS: Deteriorating oral health status is associated with worsening of the atherogenic profile. Tooth loss often results in chewing difficulties because of inadequate occlusive surfaces and may lead to alterations in food selection and dietary quality. This, in turn, adversely affects body composition and nutritional status, both of which are related to vascular health. Dentists should develop treatment plans that preserve and restore the dentition, thus ensuring maximum masticatory efficiency and affording patients the optimum opportunity to consume food that will not foster atherogenesis.