Unveiling denture-induced oral lesions: A comprehensive study on classification and pain assessment

BACKGROUND

Denture-induced oral Lesions (DIOLs) often manifests shortly after the placement or adjustment of new or realigned dentures, frequently resulting in severe pain and discomfort.

OBJECTIVES

This study aimed to classify DIOLs placing a particular emphasis on assessing the associated pain.

METHODS

A prospective case study was conducted involving 126 patients who were fitted with a total of 193 dentures of various types at the Hadassah School of Dental Medicine. All patients underwent comprehensive intra-oral examinations within 1-8 weeks following denture delivery, completed symptom questionnaires and had their medical records reviewed. Key variables documented included age, gender, overall health status, denture type, and a detailed description of the DIOLs. The description encompassed factors such as lesion location, shape, colour, size, border characteristics, ulcerative appearance, membrane coverage, 3D morphology (elevated, immersed and flat) and patient-reported Verbal Pain Score (VPS) when touching the DIOLs, when wearing the denture, and when not wearing the denture.

RESULTS

Notably, 25.4% of denture wearers required no adjustments, while 14.4% necessitated more than three revisions. A majority (71.8%) of DIOLs cases were associated with mandibular complete dentures, primarily situated on the alveolar ridge. The mean VPS indicated a pain intensity of 7 ± 2.1, with temporary dentures in both jaws causing the most discomfort. Implant-supported overdentures were particularly painful when placed in the mandible. Additionally, VPS scores were higher among older individuals and those with prior prosthetic experiences. A significant correlation was observed between pain intensity and presence of chronic health condition (0.036).

CONCLUSIONS

This study revealed distinct characteristics of DIOLs and highlighted the multifactorial nature of pain experienced following the development of DIOLs. Insights into the influence of patient and denture characteristics on DIOLs and pain intensity can guide healthcare professionals in optimising patient comfort and satisfaction.

Impact of dementia status on intravenous thrombolysis and endovascular treatment for acute ischemic stroke: Retrospective study

INTRODUCTION

Individuals with dementia are underrepresented in interventional studies for acute ischemic stroke (AIS). This research gap creates a bias against their treatment in clinical practice. Our goal was to compare the safety and efficacy of intravenous-thrombolysis (t-PA) and endovascular treatment (EVT) in individuals with or without pre-AIS dementia.

METHOD

A retrospective study of AIS patients receiving t-PA or EVT between 2019 and 2022. Patients were classified as dementia on a case-by-case review of baseline assessment. Additional variables included demographic, vascular risk factors, AIS severity and treatment. Outcomes of interest were intracerebral hemorrhage, mortality in 90-days, and the difference in modified rankin scale (mRS) before AIS and in 90-days follow-up. Outcomes were compared across non-matched groups and following propensity-score matching.

RESULTS

Altogether, 628 patients were included, of which 68 had pre-AIS dementia. Compared to non-dementia group, dementia group were older, had a higher rate of vascular risk factors, higher pre-stroke mRS and higher baseline NIHSS. Individuals with dementia had higher rates of mortality (25% vs.11%,p < 0.01) on non-matched comparison. All cohort and restricted t-PA EVT matched analysis showed no difference in any outcome. Regression analysis confirmed that AIS severity at presentation and its treatment, not dementia, were the chief contributors to patients' outcomes.

DISCUSSION

Our results indicate that pre-AIS dementia does not impact the efficacy or safety of EVT or t-PA for AIS. We thus call for more inclusive research on stroke therapy with regards to baseline cognitive status. Such studies are urgently required to inform stroke guidelines and enhance care.

Effect of time delay in inter-hospital transfer on outcomes of endovascular treatment of acute ischemic stroke

Background

Endovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome.

Methods

We present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT.

Results

Among a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients).

Conclusion

Our results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.

Intracranial stenting for large vessel intracranial atherosclerotic disease: Retrospective study

BACKGROUND

Intracranial atherosclerotic disease (ICAD) is a common cause for stroke and can be defined as symptomatic (stroke) or asymptomatic. Current guidelines recommend against intracranial stenting (ICS) for patients with ICAD; treatment of patients who failed the best medical therapy is still debatable.

METHODS

We introduce a preliminary retrospective analysis of our tertiary stroke center during 2018-2022 of patients that were treated with ICS either in acute phase or elective (eICS). Study endpoints were stroke, functional outcome (modified Rankin Score [mRS] at 3 months), and serious adverse events.

RESULTS

Thirty-three stents were implanted, 21 in acute group and 12 in the eICS group. Most patients (75%) were treated with a new generation self-expandible stent. One patient had peri-procedural stroke and four patients had transient ischemic event or stroke during follow-up. There were eight cases of death (all acute group patients, seven of which occurred in the posterior circulation). Fifteen patients (62%) had favorable clinical outcomes (mRS 0-2 for pre-stroke), of which 10/10 (100%) in the eICS, the other two eICS patients had pre-morbid mRS 3 with no clinical change.

CONCLUSIONS

The evolution of new devices for ICS and the accumulating interventional experience might open a new era. As no other effective alternative treatment options exist for preventing recurrent stroke, stenting is still common practice in many tertiary centers either urgently or as elective procedure for refractory cases.

Delayed CTP-Derived Deep Venous Outflow: A Novel Predictor of Striatocapsular Infarction after M1 Thrombectomy

BACKGROUND AND PURPOSE

Isolated striatocapsular infarction occurs commonly in patients with ischemic stroke following M1 thrombectomy. We aimed to explore the correlation between CTP-derived parameters of deep venous outflow at presentation and subsequent striatocapsular infarction in a retrospective cohort of such patients.

MATERIALS AND METHODS

TTP and peak enhancement were measured on CTP-derived time-attenuation curves of the internal cerebral and thalamostriate veins bilaterally. The difference in TTP (ΔTTP) and the relative decrease in venous enhancement between the ischemic and normal sides were calculated. NCCT performed 24 (SD, 12) hours postthrombectomy was used to determine tissue fate in the caudate head, caudate body, lentiform nucleus, and internal capsule. Striatocapsular ischemia (striatocapsular infarction-positive) was defined as infarction and striatocapsular injury as either infarction, contrast enhancement, or hemorrhagic transformation in ≥1 of these regions. A striatocapsular ischemia score was calculated (0 = no ischemic region, 1 = 1 ischemic region, 2 = ≥2 ischemic regions).

RESULTS

One hundred sixteen patients were included in the analysis. Sixty-one patients had striatocapsular infarction (striatocapsular infarction-positive). The mean thalamostriate ΔTTP was 1.95 (SD, 1.9) seconds for patients positive for striatocapsular infarction and 0.79 (SD, 2.1) for patients negative for it (P = .010). Results were similar for striatocapsular injury. The mean thalamostriate ΔTTP was 0.79 (SD, 2.1), 1.68 (SD, 1.4), and 2.05 (SD, 2) for striatocapsular infarction scores of 0, 1, and 2, respectively (P = .030).

CONCLUSIONS

CTP-derived thalamostriate ΔTTP is an excellent surrogate marker for striatocapsular infarction in patients post-M1 thrombectomy. The novel approach of extracting venous outflow parameters from CTP has numerous potential applications and should be further explored.

Unique challenges in naval military dentistry

Divers are regularly exposed to a unique and changing environment that dentists must consider when treating such patients. This review focuses around two case studies encountered in naval dentistry: (i) diving barotrauma (pressure-induced injury related to an air space); and (ii) scuba diving mouthpiece-related oral conditions. Each condition is described by its effect on the oral cavity and in particular the teeth. Then we generally review the latest literature on the different effects of scuba diving on the diver's head, face and oral regions and emphasize methods of dental disease prevention, diagnostic tools and treatment guidelines.

Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy

BACKGROUND AND PURPOSE

The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex.

MATERIALS AND METHODS

We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery.

RESULTS

The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients.

CONCLUSIONS

Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.

Worse Outcome in Patients with Acute Stroke and Atrial Fibrillation Following Thrombolysis

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and a common cause of ischemic stroke. Stroke patients with AF have been shown to have a poorer neurological outcome than stroke patients without AF.

OBJECTIVES

To determine the impact of pre-existing AF on residual degree of disability in patients treated with IV thrombolysis.

METHODS

In this case-control study, data of 214 stroke patients (63 with AF and 151 without AF) were collected from the National Acute Stroke Israeli Registry, a nationwide quadrennial stroke database. Stroke severity and outcome were compared using the National Institute of Health Stroke Scale (NIHSS) on admission and the modified Rankin Scale (mRS) on admission and discharge. Demographics and stroke characteristics were also compared between the groups.

RESULTS

Stroke severity, as determined by NIHSS at admission, was higher in the AF group than the non-AF. In the group of patients who were treated with intravenous tissue plasminogen activator (tPA), more patients had favorable outcomes (mRS = 0-1 on discharge) in the non-AF group than in the AF group (P = 0.058, odds ratio = 2.217, confidence interval 0.973 to 5.05).

CONCLUSIONS

Our study suggests worse outcome in thrombolized patients with AF compared to non-AF stroke patients. Therefore, AF itself can be a poor prognostic factor for tPA sensitivity regarding the chance of revascularization and recovery after intravenous tPA.

[The influence of military underwater activity on the oral cavity]

The military dentists who serve in the navy, treat divers, among other patients. Divers are being exposed to a changing, unique environment on a regular basis. The aim of this article is to review latest literature on the different effects of scuba diving on the diver's head, face and oral regions and to emphasize methods of disease prevention, diagnostic tools and treatment guidelines. The review focuses on diving barotrauma (pressure- induced injury related to an air space) as well as scuba diving mouthpiece-related oral conditions, which include facial, jaw pain and headaches, decompression sickness and mouthpiece-related herpes infection. Each condition is described by its effect on the oral cavity and in particular the teeth.

Computed Tomography Perfusion-Based Decision Making for Acute Ischemic Stroke-Missing the Mismatch

The emerging use of mechanical thrombectomy for acute ischemic stroke treatment focuses on the importance of patient selection. Computed tomography perfusion (CTP) is one of widely used techniques. However, the accuracy and reliability of this modality is in debate among vascular neurologists. We present a case of an 80-year-old man admitted because of acute ischemic stroke. CT angiography demonstrated left proximal M2 occlusion. As CTP demonstrated signs of large ischemic core with no significant penumbra, mechanical thrombectomy was not performed following tPA administration. Twenty-four hours after thrombolysis, the patient was neurologically intact. Both non-contrast CT and magnetic resonance imaging (MRI) demonstrated small stroke involving the left caudate. Differences between CTP and MRI diffuse-weighted imaging were previously described. However, in the presented case, these differences were brought to extreme, precluding endovascular treatment. In our opinion, this case emphasizes why CTP should not be used for patient exclusion among patients in the early time frame for intervention. Such patients should be evaluated by MRI or by clinical-radiological mismatch only. CTP may have a role in selecting patients for endovascular intervention in borderline circumstances such as prolonged time window, wake-up stroke, etc.

Color Vision Deficiency and Functional Disorders Among Israeli Male Adolescents Between 2007 and 2013

Color vision deficiency has been associated with educational difficulties among male children, as well as attention-deficit hyperactivity disorder (ADHD). We examined the association of color vision deficiency with functional conditions, including ADHD, irritable bowel syndrome, enuresis and somatoform disorders, in a large population of male adolescents. We included all Israeli male adolescents that underwent medical and cognitive examinations during conscription between the years 2007 and 2013. The prevalence of ADHD, irritable bowel syndrome, enuresis, and somatoform disorders among color vision deficiency patients was compared to a control group. The study included 305 964 males aging 17 ± 0.6, of which 7584 (2.5%) had color vision deficiency. Using a multivariable analysis, the probability for irritable bowel syndrome, enuresis, and somatoform disorders among color vision deficiency patients was increased by 1.41, 1.94, and 3.87, respectively (P < .05). No significant association was found between ADHD and color vision deficiency. Color vision abnormalities are associated with functional disorders in male adolescents, including irritable bowel syndrome, enuresis, and somatoform disorders.

Is Male Migraine Associated With Color Vision Deficiency? Findings Among Israeli Adolescents Between 2007 and 2013

OBJECTIVE

Accumulating clinical and experimental evidence has shown that migraine patients tend to suffer from color vision abnormalities. The aim of this study was to examine whether color vision deficiency is associated with male migraine in a large population of adolescents.

METHODS

The study population included all Israeli male adolescents who underwent medical and cognitive examinations as part of their recruiting process between the years 2007 and 2013. Migraine prevalence among patients with color vision deficiency was compared to that of males without substantial color vision abnormalities.

RESULTS

The study population included 305 964 male adolescents at the age of 17 ± 0.6, of whom 7584 (2.5%) had color vision deficiency, as determined by the Farnsworth Panel D-15 color blindness test. Males with color vision deficiency had a 32% increased prevalence of migraine as compared with the control group (odds ratio 1.32, 95% confidence interval 1.18-1.48, P < .001), after adjusting for multiple variables.

CONCLUSIONS

The authors found an association between color vision deficiency and migraine in male adolescents. The study results lay the basis for further research into male migraine, as well as the visual aspects of migraine.

Levels of sirolimus in saliva and blood following mouthwash application

OBJECTIVES

Sirolimus (rapamycin) is a mammalian target of rapamycin (mTOR) inhibitor with antiproliferative activity. Its systemic administration is currently evaluated for the management of squamous cell carcinoma and various oral disorders. Topical oral application can enhance availability, efficacy and improve safety and compliance. Our objective was to evaluate the release profile and the safety of a sirolimus mouthwash.

SUBJECTS AND METHODS

A sirolimus mouthwash (0.05 mg ml(-1) ) was applied to ten healthy male volunteers. Saliva and blood samples were taken after rinsing. Mass spectrometry and chemiluminescent microparticle immunoassay were used to determine saliva and blood levels of sirolimus. A topical oral release profile measurement and safety evaluation were performed.

RESULTS

After rinsing with the mouthwash, a classic immediate release profile was noted in the oral cavity. Extremely high initial sirolimus levels rapidly declined over a 4-hour period. Systemic exposure was limited, with a maximum level significantly lower than therapeutic doses, and safety was confirmed.

CONCLUSIONS

A single rinse with sirolimus mouthwash leads to high transient levels of the drug in the saliva. Although levels were variable, a therapeutic concentration was achieved topically along with minimal systemic absorption. These results broaden the potential clinical use of oral topical rapalogs.

[Dental treatment and anti-thrombotic therapy. Part II: the era of new anti-thrombotic drugs]

Surgical intra-oral treatment for patients under antithrombotic therapy presents a challenge for the dental team. Within the last few years evidence based systematic reviews established new clinical guidelines for wide groups of patients which need to use antithrombotic treatment. The expected increase in use of antithrombotic treatment forced the pharmaceutical industry to provide new treatments. The former anticoagulant and anti-platelets aggregation groups of drugs were limited to small variety of medication. The search for the new treatments with ideal properties led to newly invented groups of drugs. In this article we will describe the new advancements in anti-thrombotic treatments. The article will summarize the limited knowledge of surgical management of patients under the new anti-thrombotic medications and the recommended approach for oral surgical procedures.

[Dental treatment and anti-thrombotic therapy. Part 1: clinical guideline]

The modern dental treatment plan opens a variety of new surgical rehabilitating treatments. Dental implants, socket preservation peri-apical endodontic surgery and alveolar bone augmentation were introduced to dentistry within the last three decades. The common characteristics of all these treatments are the surgical technique involving soft as well as heard tissue. Within the last decade various new anti-thrombotic indications for treatments of patients at risk for thrombotic events and a new armamentarium of anti-thrombotics techniques were introduced. Both medical improvements confront the dental health providers with the problem of surgical treatment with the threat of bleeding. The treatment approach is based on a tradeoff between major bleeding versus a catastrophic thrombotic event. The magnitude of bleeding risk is a summation of the antithrombotic treatment and the extant of surgical treatment. In this article we will summarize the clinical guidelines of dental treatment for patients under anti-thrombotic treatment.

Dental treatment of a patient with an implanted left ventricular assist device: expanding the frontiers

BACKGROUND

The left ventricular assist device (LVAD) is used as a bridge to heart transplantation. Currently, these devices are being used for longer periods of time than in previous years for the purpose of bridge to life, thus the need for dental assistance will emerge.

CASE DESCRIPTION

A female with severe acute congestive heart failure, owing to dilated cardiomyopathy, needed implantation of an LVAD as a bridge to heart transplantation. Six months after insertion of the device she suffered from spontaneous gingival bleeding and sought dental treatment. She presented with several dento-medical problems that required resolution before commencement of dental treatment.

CONCLUSIONS

Management of a patient with LVAD opens new frontiers for the dental team regarding treatment of the medically severely compromised patient who may present with multiple intervening medical aspects: profound antithrombotic therapy, high risk of device infection, possible magnetic interference with dental instruments, and even assessment of vital signs.

Effects of head-up tilt-table test on the QT interval

BACKGROUND

The QT interval shortens in response to sympathetic stimulation and its response to epinephrine infusion (in healthy individuals and patients with long QT syndrome) has been thoroughly studied. Head-up tilt-table (HUT) testing is an easy way to achieve brisk sympathetic stimulation. Yet, little is known about the response of the QT interval to HUT.

METHODS

We reviewed the electrocardiograms of HUT tests performed at our institution and compare the heart rate, QT, and QTc obtained immediately after HUT with the rest values.

RESULTS

The study group consisted of 41 patients (27 females and 14 males) aged 23.9 +/- 8.4 years. Head-up tilting led to a significant shortening of the RR interval (from 825 +/- 128 msec at rest phase to 712 +/- 130 msec in the upward tilt phase, P < 0.001) but only to a moderate shortening of the QT interval (from 363.7 +/- 27.9 msec during rest to 355 +/- 30.3 msec during upward tilt, P = 0.001). Since the RR interval shortened more than the QT interval, the QTc actually increased (from 403 +/- 21.5 msec during rest phase to 423.2 +/- 27.4 msec during upward tilt, P < 0.001). The QTc value measured for the upward tilt position was longer than the resting QTc value in 33 of 41 patients. Of those, 4 male patients and 2 female patients developed upward-tilt QTc values above what would be considered abnormal at rest.

CONCLUSIONS

During HUT the QT shortens less than the RR interval. Consequently, the QTc increases during head-up tilt.

Flexible, removable partial denture for a patient with systemic sclerosis (scleroderma) and microstomia: a clinical report and a three-year follow-up

This article describes an optional mode of treatment for a partially edentulous patient with severe microstomia, severe changes to the intraoral soft tissues, and compromised hand function. The principles discussed in this article describe a patient with systemic sclerosis but are applicable to any patient who suffers from scarring in the oral and facial areas due to disease, trauma, or burning injuries. Since dental implants were contraindicated, it was determined that long-term comfort and function could be achieved only through the use of a removable partial denture (RPD). A Valplast flexible RPD was used because of its unique characteristics and a specially designed folded custom impression tray was used to obtain an accurate impression of hard and soft tissues. This article describes the complete process and management of the patient's needs, focusing on the decision-making process for the chosen treatment plan, the special impression technique, and the completion of the RPD.

[Antibiotic prophylaxis for the prevention of infective endocarditis--new guidelines of the American Heart Association]

Within the last twelve month both the working party of the British Society for Antimicrobial Chemotherapy and the American Heart Association have changed their attitude towards antibiotic prophylaxis for the prevention of infective endocarditis dramatically. The major change is the exclusion of the groups of patients formerly known as the "low and medium" risk groups from the new treatment group. A brief summary of the American as well as the British recommendations for adults and children is reported.

[Root canal treatments in a patient with florid cemento-osseous dysplasia]

This article follows the comprehensive dental treatment of a patient who presented with multi periapical radiolucencies on a complete set of periapical radiographs. All the affected teeth were treated and root canal fillings were performed. None of the periapical radiolucencies showed any evidence of a healing process. On a later stage, the lesions have been diagnosed as florid cemento-osseous dysplasia. (In this article the correct diagnosis and treatment will be discussed).

[Dental treatment for patients with myasthenis gravis]

Myasthenia gravis is an autoimmune disease, characterized by weakness of the skeletal muscles, which increases during action. The nature of the disease influences the mode of dental treatment. Careful treatment planning prevents over-activity of the muscles. The bulbar appearance of the disease, affects the chewing muscles, thus, it is important to avoid aspiration of foods or other particles from the mouth. Infections may exacerbate the symptoms of Myasthenia gravis, therefore the dentist must eliminate oral focal infections and avoid using medicines that might worsen the disease.

[Allergy-related emergencies]

Allergic reactions can develop to any of the drugs or materials commonly used in dentistry. They exhibit a broad range of clinical signs and symptoms ranging from mild, delayed reactions to immediate and life-threatening reactions developing within seconds. Allergies usually manifest themselves in reactions that are related to histamine release in one of three ways: skin reactions, respiratory problems and anaphylaxis. Anaphylaxis is the most critical allergic reaction in the dental environment. Measures such as airway management, oxygen supplementation, antihistamine, adrenaline and corticosteroid medication, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.

[Chest pains in the dental environment]

Chest pain does not necessarily indicate cardiac disease. The most common causes of acute chest pain encountered in dental situations include hyperventilation, pulmonary embolism, angina pectoris and myocardial infarction. Stress and fear often cause rapid breathing or hyperventilation. This usually occurs in young adults and although the hyperventilating patient often complains of chest pain, this is rarely a manifestation of cardiac disease. Pulmonary embolism usually indicates the occlusion of a pulmonary artery causing severe chest pain. The primary clinical manifestation of angina pectoris is chest pain. Although most instances of anginal pain are easily terminated, the dentist must always consider the possibility that the supposed anginal attack is actually a sign of acute myocardial infarction (AMI). AMI is a clinical syndrome caused by a deficient coronary arterial blood supply to a region of myocardium that results in cellular death. There is a high incidence of mortality among AMI with death often occurring within 2 hours of the onset of signs and symptoms. The initial clinical manifestations of all types of chest pain can be similar. Therefore the dentist must develop proficiency in constituting a differential diagnosis and an efficient management protocol. As in most medical situations prevention is the most powerful tool. However, if chest pains do occur, measures such as airway management, oxygen supplementation, coronary artery dilation, analgesis and in extreme cases, cardiopulmonary resuscitation and evacuation to the emergency room, may be necessary.

[Legal and ethical considerations of emergencies in the dental office]

The dentist has the ethical and legal responsibility to anticipate emergency situations in correlation with the patient's medical status. He has the obligation to do all in his power to prevent emergencies from happening and to be prepared to manage any emergency that might occur. This article also discusses the importance of monitoring and documentation.

[Emergencies evolving from local anesthesia]

Local anesthesia is without doubt the most frequently used drug in dentistry and in medicine. In spite of records of safety set by using these drugs, there is evidence to adverse reactions ranging from 2.5%-11%. Most of the reactions originate from the autonomic system. A recent, well-planned study indicates that adverse reactions are highly correlated to the medical status of the patient: the higher the medical risk, the greater the chance to experience an adverse reaction. This study also found that adverse reactions highly correlated to the concentration of adrenalin. Another recent study found a direct relationship between adverse reactions and the level of anxiety experienced by the patient and to the dental procedure. Most of the reactions in this study occurred either immediately at injection time and within 2 hours following the injection. Since the beginning of last century, vasoconstrictors have been added to local anesthesia solutions in order to reduce toxicity and prologue activity of the LA. However, today it is commonly agreed that this addition to local anesthesia should not be administered to cardiac patients especially those suffering from refractory dysrhythmias, angina pectoris, post myocardial infarction (6 months) and uncontrolled hypertension. Other contraindications to vasoconstrictors are endocrine disorders such as hyperthyroidism, hyperfunction of the medullary adrenal (pheochromocytoma) and uncontrolled diabetes mellitus. Cross reactivity of local anesthetic solutions can occur with MAO inhibitors, non specific beta adrenergic blockers, tricyclic antidepressants, phenothiazides and cocaine abusers. Noradrenaline added to local anesthetics as a vasoconstrictor has been described as a trigger to a great increase in blood pressure and therefore has been forbidden for use in many countries. This paper describes 4 cases of severe complications following the injections of local anesthesia of which three ended in fatality.

[Cardiac arrest in dental offices. Report of six cases]

The extreme medical emergency situation in the dental setting is cardiac arrest. The need to provide dental treatment to the medically compromised patients, suffering from very high risk heart diseases at special oral medicine hospital dentistry units, expose the dental and medical teams to the possibility of patients' death. Cardiac and cardiorespiratory arrest in these units faces the dentists with the need to perform basic and/or advanced cardiopulmonary resuscitation (CPR). Various etiologies are responsible for cardiac arrests. This article describes our experience and the outcome of six patients who have suffered cardiac arrests pre, during or post dental treatment in two special oral medicine centers. Two patients, suffering from severe congestive heart failure experienced fatal ventricular arrhythmia, both of them underwent CPR with early cardiac defibrillation, following which one patient completely recovered, and the other one expired. Two young and healthy patients experienced severe neurocardiogenic syncope with heart standstill for more than 40 seconds followed by spontaneous uneventful recovery. The fifth patient, who suffered from ventricular fibrillation as a result of an acute coronary ischemia, was resuscitated successfully. The last patient, a young woman, suffered from a severe status epilepticus causing bradycardia, which led to cardiac arrest, but recovered following CPR. All patients who did not recover spontaneously underwent methodical advanced CPR with early defibrillation. Only one patient out of the six died.

[Syncope in the dental environment]

Syncope or Fainting is, by far, the most common emergency situation in the dental practice. Syncope is defined as an abrupt, transient, short term loss of consciousness and postural tone, followed by spontaneous and complete recovery. The pathophysiology of syncope consists of a sudden cessation or decrease in cerebral perfusion. Differential diagnosis of these medical conditions is of paramount importance in uncovering unrecognized systemic diseases. The dental team plays an important role in the process of establishing the correct diagnosis by its ability to recognize and document all the clinical symptoms and signs evident at the time of fainting. The dental surgeon is expected to be familiar with the various etiologies of syncope and should be able to differentiate between them. This article provides the essentials of the diagnostic procedure and an approach to the evaluation of the unconscious patient.

[Respiratory distress]

Dental treatment is usually conducted in the oral cavity and in very close proximity to the upper respiratory airway. The possibility of unintentionally compromising this airway is high in the dental environment. The accumulation of fluid (water or blood) near to the upper respiratory airway or the loosening of teeth fragmentations and fallen dental instruments can occur. Also, some of the drugs prescribed in the dental practice are central nervous system depressants and some are direct respiratory drive depressors. For this reason, awareness of the respiratory status of the dental patient is of paramount importance. This article focuses on several of the more common causes of respiratory distress, including airway obstruction, hyperventilation, asthma, bronchospasm, pulmonary edema, pulmonary embolism and cardiac insufficiency. The common denominator to all these conditions described here is that in most instances the patient is conscious. Therefore, on the one hand, valuable information can be retrieved from the patient making diagnosis easier than when the patient is unconscious. On the other hand, the conscious patient is under extreme apprehension and stress under such situations. Respiratory depression which occurs during conscious sedation or following narcotic analgesic medication will not be dealt with in this article. Advanced pain and anxiety control techniques such as conscious sedation and general anesthesia should be confined only to operators who undergo special extended training.

[The potential dangers of endocrinal disorders]

The symptoms of most endocrine system diseases are usually clearly recognizable and most of the times are accompanied by a rich medical history. Many general practitioners are reluctant to treat such cases and prefer to refer these patients to specialists who are trained in management of the medically compromised thus increasing the chances of dental treatment without complications. However, sometimes endocrinal diseases develop slowly and their clinical manifestations are hidden or subclinical in nature. In these cases, neither the patient nor the dentist are aware of the condition and there is the potential of life threatening, emergency situations in what at first seem as simple, straightforward dental procedures. Therefore, the dentist must be able to recognize the clinical problem, differentiate between the different symptoms and initiate the proper management protocol. The most unstable endocrinal disorders that should be treated with great care are diabetes mellitus, mainly hypoglycemia, hyperthyroidism and adrenal insufficiency. The general practitioner dentist can treat patients suffering from these disorders providing the disease is well controlled and balanced and that the dental treatment is not very traumatic.

The reliability and validity of the SF-36 health survey questionnaire for use with individuals with traumatic brain injury

In order to examine the reliability and validity of the SF-36 for use with individuals with TBI, the SF-36 and three measures of health-related problems in persons with TBI (BDI-II, TIRR Symptom Checklist, Health Problems List) were administered to 271 individuals without a disability, 98 individuals with mild TBI, and 228 individuals with moderate-severe TBI. Internal consistency (reliability) was demonstrated for all SF-36 scales. Significant correlations were found between the SF-36 scales and the other measures, with stronger correlations emerging in the TBI groups. The TBI groups obtained significantly lower SF-36 scores than the comparison group, and the mild TBI group scored lower than the moderate-severe group. For the most part, the differences between the TBI groups disappeared when BDI-II scores were controlled for. These findings suggest that the SF-36 is a reliable and valid measure for use with persons with TBI.

[The association between periodontal diseases and coronary artery diseases--a literature review]

The relation between periodontal disease and atherosclerotic cardiovascular disease was reported the first time at the end of the Eighties. Screening of the English written reported research papers revealed an increased risk of coronary artery disease and Cerebrovascular disease, in patients suffering from chronic periodontal infection. The same relation was found in patient who underwent multiple tooth extraction as a result of chronic advanced periodontal disease. These observations stress the importance of maintaining good oral hygiene and the prevention of chronic periodontal disease. The precise mode of influence, pathophysiology is still obscured, possible mechanisms were suggested. An indirect risk, by raising infection markers, such as fibrinogen and c-reactive protein. Other possibilities are by direct influence on Atherosclerotic plaque formation or another common cardiovascular risk factor such as smoking which influence both cardiovascular and periodontal diseases.

Bleeding tendency: a practical approach in dentistry

The dental profession faces the problems of exaggerated bleeding on a daily basis. The hemostatic, as well as the fibrinolytic processes are better understood today, and the dentist should be familiar with them. The activation of coagulation factors and their clinical expression in the circulation are both described. The most frequently used blood coagulation tests are explained. Antithrombotic medications are frequently used and their implications in dentistry are accentuated. Protocols of prevention and treatment of exaggerated bleeding following dental procedures are included. Among them, the transfusion of clotting factors and the administration of antifibrinolytic medications (tranexamic acid) are recommended for both congenital or acquired bleeding tendencies.

Systemic absorption of lidocaine after topical application for the treatment of oral mucositis in bone marrow transplantation patients

This paper evaluates lidocaine absorption via oral mucosa following its topical application for symptomatic treatment of bone marrow transplantation (BMT)-induced oral mucositis. Five patients with high-grade oral mucositis after allogeneic BMT were entered consecutively into the study. Five healthy individuals served as controls. All 10 participants rinsed their mouth with 5 ml of a 2% lidocaine solution for 1 min, after which they expectorated the liquid. Blood samples were drawn at 1, 5, 10, 20, 30 and 60 min after rinsing and centrifuged. Plasma lidocaine levels were measured by fluorescence polarization immunoassay. In the BMT patients, plasma lidocaine levels were lower than the therapeutic range of this drug (0.2 microg/ml vs 1.5-5.5 microg/ml), while in the controls no detectable lidocaine levels were noted. The data from this preliminary study indicate that lidocaine prescribed as an anesthetic mouthwash in BMT patients with oral mucositis results in minor systemic absorption of the drug.

Permanent neurologic deficit after inferior alveolar nerve block: a case report

Permanent neurologic damage after an inferior dental nerve block is reported. Clinical manifestations included hemisensory syndrome, facial nerve palsy, hearing impairment, and ataxia. Possible mechanisms and preventive measures are discussed.

Dental treatment in very high risk patients with active ischemic heart disease

A new method of predental treatment and management for patients with active ischemic heart disease is reported. Patients with unstable angina pectoris or who have just had a myocardial infarction underwent full treatment for pain-induced dental problems, with the use of an incremental three-level antiangina and antianxiety medication: before dental treatment; in the waiting room, and c) during dental treatment. The setting was a tertiary referral oral medical service and hospital dental clinic. Twenty-six patients were treated, 16 men, 10 women, ranging in age from 45 to 68 years. Ten patients with unstable angina pectoris and 16 patients less than 3 months after a myocardial infarction. All patients underwent comprehensive dental treatment. Good cardiovascular control was achieved, and all the procedures were uneventfully completed. This study indicates the need to reconsider the absolute versus relative contraindications for dental treatment in patients with active ischemic heart disease and recommends the use of a gradual three-level therapy.

Dental treatment in a patient with malignant pheochromocytoma and severe uncontrolled high blood pressure

A young female with severely uncontrolled hypertension suspected to result from malignant pheochromocytoma underwent combined medical and dental care for the treatment of acute dental pain. The dental treatment was performed with the patient under intravenous sedation and careful perioperative management with the use of high doses of alpha and beta receptor blocking agents. The procedure was completed without intraoperative problems and an uneventful posttreatment course.

Intrapericardial extralobar pulmonary sequestration in a neonate

A huge pericardial effusion was diagnosed during fetal ultrasound examination performed in the 42nd week of pregnancy on a healthy 25-year-old woman. Immediately after the birth, a two-dimensional echocardiogram confirmed this finding in the infant, and an intrapericardial kidney-shaped solid mass measuring 45 x 56 x 15 mm, completely surrounded by pericardial effusion, was visualized to the left part of the heart. The heart was normal. No signs of cardiac tamponade were seen. At the age of two days, the mass was surgically resected and the pericardial fluid evacuated. Microscopic examination revealed that the mass was formed totally of normal lung tissue surrounded by normal pleura. To the best of our knowledge, this is the first case of intrapericardial extralobar sequestration consisting of an accessory lung with completely normal lung tissue.

Dissecting aortic aneurysm in pregnant women without Marfan disease

Dissection of the young women without Marfan disease is related, in most instances, to pregnancy. The structural changes in the arterial wall that occur during pregnancy may predispose women to this complication of pregnancy. In this study, two young women, who had none of the characteristics of Marfan's syndrome, were operated upon for dissection of the ascending aorta. The first patient was in the 35th week of gestation and a cesarean section was performed prior to replacement of the ascending aorta. In the second patient, diagnosis of dissection and severe aortic regurgitation occurred in the postpartum period. Knowledge of this albeit relatively rare complication of pregnancy may assist the clinician in diagnosing and referring patients early for surgical treatment that, in most instances, may save the lives of both mother and fetus.