The dental implications of bisphosphonates and bone disease

In 2002/2003 a number of patients presented to the South Australian Oral and Maxillofacial Surgery Unit with unusual non-healing extraction wounds of the jaws. All were middle-aged to elderly, medically compromised and on bisphosphonates for bone pathology. Review of the literature showed similar cases being reported in the North American oral and maxillofacial surgery literature. This paper reviews the role of bisphosphonates in the management of bone disease. There were 2.3 million prescriptions for bisphosphonates in Australia in 2003. This group of drugs is very useful in controlling bone pain and preventing pathologic fractures. However, in a small number of patients on bisphosphonates, intractable, painful, non-healing exposed bone occurs following dental extractions or denture irritation. Affected patients are usually, but not always, over 55 years, medically compromised and on the potent nitrogen containing bisphosphonates pamidronate (Aredia/Pamisol), alendronate (Fosamax) and zolendronate (Zometa) for non-osteoporotic bone disease. Currently, there is no simple, effective treatment and the painful exposed bone may persist for years. The main complications are marked weight loss from difficulty in eating and severe jaw and neck infections. Possible preventive and therapeutic strategies are presented although at this time there is no evidence of their effectiveness. Dentists must ask about bisphosphonate usage for bone disease when recording medical histories and take appropriate actions to avoid the development of this debilitating condition in their patients.

A novel CEA vaccine stimulates T cell proliferation, γIFN secretion and CEA specific CTL responses

Carcinoembryonic antigen (CEA) is a cell surface protein over-expressed by a wide range of tumours. The mouse anti-idiotypic antibody, 708, mimics CEA and can induce both antibody and T cell responses that specifically recognise this antigen. Sequence analysis of 708 revealed homology with a previously identified HLA-A3 T cell epitope in CEA but not to other closely related molecules. 708 was chimerised to a human IgG1 to allow Fc targeting of APCs and was deimmunised to remove unwanted T cell epitopes. The chimerised and deimmunised, but not the mouse 708, could stimulate CTL, proliferation and gammaIFN responses in vitro in normal (HLA-A3, DR1) individuals. Furthermore, the CTLs killed tumour cells expressing CEA suggesting that this deimmunised antibody could be a useful vaccine for solid tumours.

Tranexamic acid mouthwash--a prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions

This prospective randomized study analyses the use of a prescribed 4.8% tranexamic acid post-operative mouthwash over 2 days vs 5 days to prevent bleeding in patients taking warfarin who require dental extractions. Eighty-five patients therapeutically anticoagulated with warfarin for various conditions, ranging in age from 21 to 86 years and requiring dental extractions, were randomly divided into two groups. Group A postoperatively received a 4.8% tranexamic acid mouthwash to be used over a 2-day period. Group B received the same mouthwash and instructions postoperatively, to be taken over 5 days. All procedures were performed on an ambulatory basis under local anaesthetic by the same surgeon. Patients were reviewed 1, 3, and 7 days postoperatively to assess bleeding. Eighty-two of the 85 patients encountered no postoperative problems. Two patients in group A and one in group B had minor postoperative bleeds that required minor ambulatory intervention to control. This study shows that a 2-day postoperative course of a 4.8% tranexamic acid mouthwash is as equally effective as a 5-day course in controlling haemostasis post-dental extractions in patient's anticoagulated with warfarin.

Current concepts of the management of dental extractions for patients taking warfarin

BACKGROUND

Controversy has surrounded the correct management of patients therapeutically anticoagulated with warfarin who require dental extractions. The risk of bleeding must be weighed up against the risk of thromboembolism when deciding whether to interfere with a patient's warfarin regimen. An improved understanding of the importance of fibrinolytic mechanisms in the oral cavity has resulted in the development of various local measures to enable these patients to be treated on an outpatient basis.

METHODS

A review of the literature was undertaken. This was supplemented by the authors' clinical trials and extensive clinical experience with anticoagulated patients.

RESULTS

Various protocols for treating patients taking warfarin have been reviewed and summarized and an overview of the haemostatic and fibrinolytic systems is presented. A protocol for management of warfarinized patients requiring dental extractions in the outpatient setting is proposed.

CONCLUSIONS

Patients therapeutically anticoagulated with warfarin can be treated on an ambulatory basis, without interruption of their warfarin regimen provided appropriate local measures are used.

Cognitive rehabilitation as a component of early intervention in Alzheimer's disease: a single case study

Early intervention in Alzheimer's disease (AD) should focus on psychological and social needs as well as the provision of medication. One possible component of early intervention programmes for people with early-stage AD is cognitive rehabilitation aimed at fostering the development of strategies for coping with memory problems. The likely relevance of cognitive rehabilitation in early-stage AD is supported by neuropsychological and experimental learning studies, but further work is required to develop clinically relevant interventions, which can be applied in the real-life setting. This paper presents a single case intervention study in which a 66-year-old man with early-stage AD learned the names of 13 members of his support group using a mnemonic strategy coupled with either expanding rehearsal or repeated presentation, or both, within an errorless learning paradigm. Recall scores improved from a mean of 2.31% at initial baseline to 91.46% following intervention, and gains were largely maintained at follow-up. There was no evidence of any increase in depression, anxiety or caregiver strain during the intervention. The results support the view that cognitive rehabilitation interventions may form a valuable component of comprehensive early intervention programmes for people with AD.