Four-year cross-sectional study of bleeding risk in dental patients on direct oral anticoagulants

OBJECTIVE

New oral anticoagulants, or "direct oral anticoagulants" (DOACs), have been used worldwide in recent years. An evidence-based enigma regarding dental patients using DOACs still exists.

METHOD AND MATERIALS

This was a 4-year, cross-sectional study on individuals receiving DOAC therapy, treated in a single maxillofacial center. A bleeding event was the outcome parameter. Potential contributing risk factors were evaluated.

RESULTS

Of a total of 111 patients, 72 underwent a total of 305 oral procedures in 115 sessions. The overall frequency of bleeding events was 6.1% per session. One "major" (0.9%) and six "minor" (5.2%) events were recorded. The management was simple, local hemostasis. Statistically significant association was found between bleeding events and (1) history of spontaneous hemorrhage and (2) surgical procedures involving soft tissue manipulation. Withdrawal of DOAC therapy was not associated with decreased postoperative bleeding events.

CONCLUSION

The risk of bleeding in dental patients using DOACs is low with no major consequences. The data support not stopping DOACs prior to dental treatment, regardless of the complexity or the extent of the procedure. Dosage adaptation is recommended in patients with a history of spontaneous hemorrhage.

Can Differences in Vascularity Serve as a Diagnostic Aid in Fibro-Osseous Lesions of the Jaws?

PURPOSE

Different lesions in the fibro-osseous group share microscopic features; thus, establishing a definitive diagnosis based on microscopic features alone can be a challenge. There is a need for additional microscopic tools to aid in differentiating these lesions. This study compared parameters related to vascularity among 3 lesions in the fibro-osseous group: fibrous dysplasia (FD), central ossifying fibroma (COF), and cemento-osseous dysplasia (COD).

MATERIALS AND METHODS

This study was a cross-sectional analysis of biopsied lesions retrieved from 3 medical centers over a 14-year period. The primary predictor variables were the vascularity parameters (number, perimeter, and area). The outcome variables were diagnoses of FD, COF, and COD. Diagnosis was based on clinical, microscopic, and radiologic correlations. From each histopathologic slide, 5 representative fields were captured with a computerized digital camera. The number of blood vessels was counted, and the surface area and vascular perimeter were measured by tracing the perimeter of each vessel. Data were statistically analyzed using analysis of variance with logarithmic transformation and a Tukey adjustment.

RESULTS

Sixty-six cases were included in the study (26 in FD group, 26 in COF group, and 14 in COD group). The mean number of vessels showed only a tendency to be larger in the FD group compared with the COF and COD groups (5.4 ± 2.6, 3.7 ± 2.3, and 3.6 ± 1.7, respectively), but the results did not reach the threshold for significance. The mean vascular perimeter was 1,385.8 ± 859.2 pixels in the FD group and 742.6 ± 661.8 in COF group after logarithmic transformation (P = .012). The perimeter in the COD group was smaller (941.1 ± 502) compared with that in the FD group, but the difference did not reach the threshold for significance. The mean area was 25,061 ± 24,875.6 in the FD group and 11,773.8 ± 21,734.4 in the COF group after logarithmic transformation (P = .004). The perimeter in the COD group was smaller (13,011.1 ± 8,338.3) compared with the FD group, but the difference did not reach the threshold for significance.

CONCLUSION

The vascular content of the FD group was markedly higher than of the COF group. These vascular changes can aid in differentiating these lesions microscopically.

[Bone augmentation of the extremely atrophic anterior mandible, using allogeneic block grafts, via submental approach]

Edentulous patients with advanced resorption of the mandible (atrophic mandible) suffer major discomfort when using dentures. Furthermore, placing dental implants is impossible due to lack of sufficient bone volume. In the past, several methods of bone grafting to the anterior mandible have been proposed. Most of them were unpredictable in either the short or long-term. In 2002 a technique for bone grafting of the anterior mandible via a submental approach was published. A wide reflection of the soft tissue was followed by implant placement. Autogenous particulate posterior iliac crest bone graft was used. The presence of the implants did not allow for contraction of the soft tissue and bone resorption. The addition of bone volume to the chin improved the facial aesthetics of the patients due to a fuller appearance of the chin and tightening of the skin of the neck. The submental approach changes the spatial orientation of the surgeon and placement of implants in the correct location and angle become challenging. Placement of the implants too far buccally was a prosthetic problem. A major disadvantage of autogenous bone grafting is the necessity to operate a donor site. The increasing experience in use of allogenic bone grafts with resorbable collagen membranes, allowed us to modify the submental approach for bone grafting of the anterior atrophic mandible, avoiding a donor site surgery. We chose to perform the bone graft as a first stage surgery, in which, via a submental approach allogenic bone blocks were adapted and fixated to the anterior mandible with titanium screws, xenograft and resorbable collagen membranes were used. A few months (>4) were allowed for graft consolidation and then a second stage surgery was performed, via an intraoral approach dental implants were placed. In this way we avoided loss of orientation and had a familiar setting for implant location and angulation. Five patients with atrophic mandibles were treated using this surgical protocol. Based on cone beam CT imaging, average bone height in the anterior mandible prior to treatment was 5.52 mm. After bone graft, the average gain in bone height was 12.74 mm. No major post-operative complications were noted. After bone graft consolidation, 4 or 5 dental implants were placed, most of the implants used were longer than 11.5 mm. 22 implants were placed, out of which 21 integrated (95.5%). Some of the patients were rehabilitated with overdentures and locators and some with PFM bridges. All patients were followed up for more than a year and no implant failure was recorded. Bone grafting to the anterior mandible using allogenic blocks with collagen membranes via a submental approach with second stage implant placement seems to be a viable solution for rehabilitation of the atrophic mandible.

[Perceived attractiveness and other characteristics of different male facial types before and after orthognathic surgery]

Orthognathic intervention has not only profound implications on the individual's function and esthetics, but also on the perception of his surrounding environment. In this study, frontal and profile photographs of 3 groups of men (a control group with normal profile and prognathic and retrognathic profiles, before and after orthognathic surgery) were shown in random order to a group of 83 women, who were asked to rate the pictures according to attractiveness and several personality traits on an analog scale. Results show that men with normal profiles got the most positive scores on all categories. Men with prognathic profiles were perceived as more aggressive and assertive, while men with retrognathic profiles were perceived as less intelligent and reliable. After orthognathic intervention both retrognathic and prognathic groups had a significant improvement in their scores, which were closer to the normal profile group.

The clinical characteristics of benign oral mucosal tumors

Objectives: To investigate the clinical characteristics and pre-biopsy provisional diagnoses of benign oral mucosal tumors. Material and Methods: A 10- year retrospective analysis of all benign tumors of the oral mucosa, from a university- affiliated oral and maxillofacial surgery department. Results: 146 benign tumors were included. The mean age was 49.6 years, with an approximately equal gender distribution. The most prevalent tumor types were lipomatous tumors (27.4%), vascular (23.3%), and salivary gland tumors (16.5%). Tongue, labial and buccal mucosa were the most frequently involved sites. The vast majority (98.6%) presented as non-ulcerated masses. Only 2 (1.4%) presented as ulcerated masses. The clinical provisional diagnosis correctly classified lesions as non-malignant in 93.3%. In only 9 (6.7%) suspicion of malignancy was included in the provisional diagnosis. However, benign neoplasia was unsuspected in 42.1% of tumors. These cases were clinically classified as reactive. Conclusions: Benign tumors were most likely to be clinically correctly classified as non-malignant, but even in the setting of experienced oral surgeons, neoplasia was unsuspected in more than 40% of cases. This data strongly supports the need to biopsy every oral mucosal mass, since inaccurate clinical evaluation of the lesion’s biological nature was a frequent event.

Key words:Malignant, benign, reactive, ulcerated mass, non-ulcerated mass, clinical diagnosis.

Topical simvastatin improves the pro-angiogenic and pro-osteogenic properties of bioglass putty in the rat calvaria critical-size model

Objective was to describe the effect of bioactive glass putty with and without topical simvastatin on new bone formation in critical-sized defects of rat calvaria. A calvarial bone defect was created in 20 male Wistar rats and filled with bioactive glass alone (n = 10) or combined with simvastatin (n = 10). After 4 weeks, the defects were histomorphometrically evaluated for volume fraction (Vv) of woven bone, vessel density, bioglass quantity, and inflammation. Compared to the bioglass-only group, rats treated with simvastatin had greater Vv of blood vessels (3.3% ± 0.7 vs 1.6% ± 0.1, P = .0002) and new bone (2.3% ± 0.2 vs 1.8% ± 2.5, P = .003). The Vv of the bioglass remnants in the bioglass-only group was higher than in the group treated with simvastatin (2.4% ± 0.08 vs 1.7% ± 0.3, P < .0004). Chronic inflammation was noted in 1 rat from each group. Topical simvastatin seems to improve the pro-angiogenic and pro-osteogenic properties of bioglass putty in rat calvaria critical-size defects without significant inflammation.

HIF-1α, VEGF, and EGFR: contributing factors in the pathogenesis of necrotizing sialometaplasia

OBJECTIVES

Necrotizing sialometaplasia (NS) is an uncommon reactive lesion involving the minor salivary glands. This study aimed to investigate the expression of hypoxia-inducible factor alpha (HIF-1α), vascular endothelial growth factor (VEGF), and epithelial growth factor receptor (EGFR) in the pathogenesis of NS.

METHODS

Paraffin-embedded tissue sections from 10 cases of NS were immunohistochemically stained for HIF-1α, VEGF, and EGFR. A semiquantitative morphometric analysis was performed and compared with normal palatal salivary glands and traumatic ulcerations.

RESULTS

Hypoxia-inducible factor alpha staining was observed in most elements of the affected area, the acini and ducts of the involved salivary glands as well as in the inflammatory infiltrate, the endothelial cells, and stromal cells. HIF-1α was almost absent in the control glands (P < 0.0001). VEGF staining was positive in the stromal capillaries and in the inflammatory infiltrate. The expression was higher in cases of NS compared with the normal salivary glands (P < 0.001). EGFR was expressed in the surface epithelium, the pseudo-epitheliomatous hyperplasia, and the islands of squamous metaplasia. VEGF expression in traumatic ulcerations was lower than that in cases of NS.

CONCLUSION

This study provides molecular evidence to the role of hypoxia in NS; HIF-1α, the main regulator of hypoxia, was expressed in the infarcted salivary glands, EGFR in the metaplastic epithelium and VEGF in the stromal capillaries, all three components are the key factors induced by hypoxia.

Re-evaluation of common paradigms regarding the clinical appearance of oral mucosal malignancies

PURPOSE

To evaluate the clinical appearance and rate of ulceration of oral mucosal malignancies, and to investigate the accuracy of clinical provisional diagnoses.

METHODS

A 10-year retrospective analysis, which included diagnostic biopsies of malignant tumors of the oral mucosa. The clinical provisional diagnoses were compared with final diagnoses.

RESULTS

Two hundred and twenty-seven oral mucosal malignant tumors were included. Squamous cell carcinoma and its variants accounted for the majority (78%) of all malignant tumors. The most common clinical presentations were non-ulcerated (59.7%) and ulcerated masses (20.4%). Only 11.9% presented as indurate ulcers. The highest ulceration rate of all malignancies was recorded for SCC, with only about half of SCC and its variants ulcerated at the time of biopsy. 31.1% of all malignancies were not clinically suspected to be malignant and did not even include a request to rule out malignancy. There was a better agreement between the clinical provisional diagnoses and microscopic diagnoses in the SCC group than in other types of malignancy (P < 0.001).

CONCLUSION

Within this study sample, non-ulcerated masses rather than indurate ulcers are the most common clinical appearance of oral mucosal malignancies, and even for SCC, that showed the highest ulceration rate at presentation, half were non-ulcerated. Approximately, one-third of oral mucosal malignancies were not suspected to be malignant prior to biopsy. Thus, the level of suspicion currently reserved for mucosal ulcers and ulcerated masses should also be applied to non-ulcerated oral mucosal masses.

Metastatic tumors to the gingiva and the presence of teeth as a contributing factor: a literature analysis

BACKGROUND

Gingiva that is prone to inflammation may serve as a pre-metastatic niche for the attraction of circulating malignant cells. The aim of this study is to analyze cases of metastatic lesions to the gingiva compared with cases metastasizing to other oral mucosal sites. The pathogenesis of gingival metastases is discussed, with emphasis on the role of inflammation.

METHODS

The English-language literature between 1916 and 2011 was searched for cases of metastatic lesions to the oral mucosa; only cases metastasizing in the oral mucosa, gingiva, and periodontium were included.

RESULTS

Two hundred seven cases were included. The gingiva was the most common site (60.4%), followed by tongue and tonsil. The most common primary sites were lung (24.2%), kidney (13.5%), skin (10.6%), and breast (8.7%). In 27%, the oral lesion was the first sign of a malignant disease. In most cases, the lesion appeared as an exophytic mass (96%) diagnosed clinically as a reactive gingival lesion. The presence of teeth was significantly associated with the development of gingival metastases: in 108 of 125 gingival metastases, the lesion was found adjacent to teeth (P <0.001; odds ratio = 8.2). The average life expectancy after diagnosis of the metastasis was 3.7 months.

CONCLUSIONS

The gingiva is the most common site for metastases to oral soft tissues, with strong association with the presence of teeth. This finding may be related to the role of inflammation in the attraction of metastatic cells to chronically inflamed gingiva.

The significance of surface ulceration as a sign of malignancy in exophytic oral mucosal lesions: myth or fact?

To compare the spectrum of pathologies in ulcerated versus non-ulcerated exophytic oral mucosal lesions and explore the significance of surface ulceration as an indication of malignancy. Retrospective analysis of exophytic lesions of the oral mucosa, 2009-2011. 713 biopsies of exophytic lesions of oral mucosa were included, of which 9.4% were ulcerated. Significant differences were found between ulcerated and non-ulcerated lesions. Of the ulcerated lesions 67.2% were reactive, 31.3% malignant and 1.5% benign, compared to 86, 8.4 and 5.6% respectively in non-ulcerated lesions (p < 0.0001). Malignancies were most prevalent in ulcerated lesions, in patients over 50. Malignancies presented the highest ulceration rate (36.8%, p < 0.001), compared to reactive (7.5%) and benign neoplasia (1.8%), however, the majority of oral mucosal malignancies (63.2%) presented as non-ulcerated masses. Squamous cell carcinoma presented the highest ulceration rate among malignancies, but even these were only ulcerated in 50% of cases. Non-epithelial malignancies were non-ulcerated in all cases. One-third of all malignancies were not suspected as such clinically, however, there was a better agreement between the clinical and microscopic diagnosis of malignancy in ulcerated lesions. Although the statistical likelihood of ulcerated masses to represent malignancy was higher than non-ulcerated lesions, especially in patients over 50, the majority of malignancies presented as non-ulcerated masses. Thus, all exophytic lesions should be submitted for microscopic analysis, and the status of ulceration should not be regarded neither as a factor in the decision to biopsy, nor a reliable indicator for malignancy.

Bone Remodeling in Onlay Beta-Tricalcium Phosphate and Coral Grafts to Rat Calvaria: Microcomputerized Tomography Analysis

This study was conducted to establish the efficiency of microcomputerized tomography (micro-CT) in detection of trabecular bone remodeling of onlay grafts in a rodent calvaria model, and to compare bone remodeling after onlay grafts with beta-tricalcium phosphate (TCP) or coral calcium carbonate. Ten rats received calvarial onlay blocks—5 with TCP and 5 with coral calcium carbonate. The grafts were fixed with a titanium miniplate screw and were covered with a collagen resorbable membrane. Three months after surgery, the calvaria were segmented, and a serial 3-dimensional micro-CT scan of the calvarium and grafted bone block at 16-micrometer resolution was performed. Image analysis software was used to calculate the percentage of newly formed bone from the total block size. Newly formed bone was present adjacent to the calvarium and screw in all specimens. The mean area of newly formed bone of the total block size ranged from 34.67%–38.34% in the TCP blocks, and from 32.41%–34.72% in the coral blocks. In the TCP blocks, bone remodeling was found to be slightly higher than in the coral blocks. Micro-CT appears to be a precise, reproducible, specimen-nondestructive method of analysis of bone formation in onlay block grafts to rat calvaria.