Reduced auditory steady state responses in autism spectrum disorder

BACKGROUND

Auditory steady state responses (ASSRs) are elicited by clicktrains or amplitude-modulated tones, which entrain auditory cortex at their specific modulation rate. Previous research has reported reductions in ASSRs at 40 Hz for autism spectrum disorder (ASD) participants and first-degree relatives of people diagnosed with ASD (Mol Autism. 2011;2:11, Biol Psychiatry. 2007;62:192-197).

METHODS

Using a 1.5 s-long auditory clicktrain stimulus, designed to elicit an ASSR at 40 Hz, this study attempted to replicate and extend these findings. Magnetencephalography (MEG) data were collected from 18 adolescent ASD participants and 18 typically developing controls.

RESULTS

The ASSR localised to bilateral primary auditory regions. Regions of interest were thus defined in left and right primary auditory cortex (A1). While the transient gamma-band response (tGBR) from 0-0.1 s following presentation of the clicktrain stimulus was not different between groups, for either left or right A1, the ASD group had reduced oscillatory power at 40 Hz from 0.5 to 1.5 s post-stimulus onset, for both left and right A1. Additionally, the ASD group had reduced inter-trial coherence (phase consistency over trials) at 40 Hz from 0.64-0.82 s for right A1 and 1.04-1.22 s for left A1.

LIMITATIONS

In this study, we did not conduct a clinical autism assessment (e.g. the ADOS), and therefore, it remains unclear whether ASSR power and/or ITC are associated with the clinical symptoms of ASD.

CONCLUSION

Overall, our results support a specific reduction in ASSR oscillatory power and inter-trial coherence in ASD, rather than a generalised deficit in gamma-band responses. We argue that this could reflect a developmentally relevant reduction in non-linear neural processing.

Is gum disease killing your patient?

There is considerable epidemiological evidence to support the concept that poor oral health, especially the extent and severity of periodontal disease, may put patients at a significant risk for a variety of systemic conditions. This association raises the question that if patients or members of the dental profession ignore oral health, is there an increased risk of morbidity and mortality? In this presentation, the relationship between periodontal disease and many systemic conditions will be explored further. In addition, if periodontal disease does increase the risk of various systemic diseases, it raises the issue as to what the impact of treating periodontal disease is in reducing the magnitude of the risk. There is increasing evidence that reducing the inflammatory component in the periodontal tissues does have potential systemic effects. This has been shown to improve hyperglycaemic control in diabetics, reduce the prevalence of adverse pregnancy outcomes and improve surrogate markers that may be of benefit in patients suffering from coronary heart disease.

The efficacy of topical hyaluronic acid in the management of oral lichen planus

BACKGROUND

The aim of this study was to evaluate the efficacy of a topical hyaluronic acid (HA) gel preparation (0.2%) in the management of oral lichen planus (OLP).

METHODS

A total of 124 patients with erosive OLP participated in a randomized, placebo-controlled, double-blind trial to evaluate the efficacy of a topical HA preparation. Outcome measures included soreness relief following immediate application, oral function and size of erosive/ulcerative area. Patients were medicated for 28 days and completed a log diary recording oral function and soreness scores.

RESULTS

Application of topical HA produced a significant reduction (P < 0.05) in soreness scores when compared with placebo for up to 4 h post-application. There was no difference between treatment groups (P > 0.05) with respect to oral function. Patients treated with 0.2% HA showed a significant reduction (P < 0.05) in the size of the erosive/ulcerated area after 28 days of treatment when compared with baseline. There was no significant difference in changes in ulcerative areas between treatment groups.

CONCLUSIONS

Topical HA (0.2%) does appear to be of some benefit in the management of erosive lichen planus providing efficacy for up to 4 h after administration. Very frequent applications should be considered to obtain a more significant clinical benefit. Topical HA gel may be a useful addition to the treatment option for OLP.

Change in cardiovascular risk status after dental clearance

There is considerable debate over the relationship between periodontal and cardiovascular disease. It has been postulated that inflammatory mediators prevalent in periodontal disease may impact on atheroma formation and the thrombotic process. In cross-sectional, observational studies, periodontitis is associated with elevated C-reactive protein (CRP), hyperfibrinogenaemia and moderate leukocytosis. CRP levels have also been shown to decrease following periodontal therapy. CRP is a reliable marker of the acute phase reaction to infections and/or inflammation and is a powerful predictor of future coronary events.

An evidence-based update on nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), including both traditional nonselective NSAIDs and the selective cyclooxygenase (COX)-2 inhibitors, are widely used for their anti-inflammatory and analgesic effects. NSAIDs are a necessary choice in pain management because of the integrated role of the COX pathway in the generation of inflammation and in the biochemical recognition of pain. This group of drugs has recently come under scrutiny because of recent focus in the literature on the various adverse effects that can occur when applying NSAIDs. This review will provide an educational update on the current evidence of the efficacy and adverse effects of NSAIDs. It aims to answer the following questions: (1) are there clinically important differences in the efficacy and safety between the different NSAIDs, (2) if there are differences, which are the ones that are more effective and associated with fewer adverse effects, and (3) which are the effective therapeutic approaches that could reduce the adverse effects of NSAIDs. Finally, an algorithm is proposed which delineates a general decision-making tree to select the most appropriate analgesic for an individual patient based on the evidence reviewed.

The efficacy of topical hyaluronic acid in the management of recurrent aphthous ulceration

BACKGROUND

The aim of this study was to evaluate the efficacy of a topical hyaluronic acid (HA) preparation (0.2%) in the management of recurrent aphthous ulceration (RAU).

METHODS

One hundred and twenty patients with RAU participated in a randomized, placebo controlled, double-blind trial to evaluate the efficacy of the topical HA and preparation. Outcome measures include soreness relief on immediate application (recorded over 60 min). Thereafter, patients completed a log diary recording soreness from the ulcers, occurrence of new ulcers and ulcer duration.

RESULTS

Both topical HA and placebo resulted in a significant reduction in ulcer soreness following immediate application (P = 0.0004). Throughout the rest of the investigation period, there was no significant differences (P > 0.05) between the treatments for reducing soreness. Patients treated with topical HA recorded few ulcers on day 5 of the investigation than those treated with placebo (P < 0.001). Likewise, the occurrence of new ulcers was lower in the HA treated group on day 4 when compared with placebo (P = 0.047).

CONCLUSION

Topical HA (0.2%) may be of benefit in the management of RAU. Immediate reduction of symptoms appears to be a barrier effect.

The management of drug-induced gingival overgrowth

OBJECTIVES

This review critically evaluates the different therapies that are available to manage drug-induced overgrowth (DIGO).

MATERIAL AND METHODS

This review is based on literature identified using the online databases MEDLINE and PUB MED. It is not a systematic review, but a conventional review of the relevant literature.

RESULTS

Patients benefit from a non-surgical approach if this can be delivered before commencement of medication although in many instances this may not be practicable. Systemic antibiotic usage has been evaluated in the management of ciclosporin-induced gingival overgrowth. Efficacy appears to be equivocal and long-term use is undesirable. Surgical excision remains the main treatment option especially for patients with severe overgrowth. Few studies have compared different techniques with respect to recurrence rate or post-operative sequelae.

CONCLUSION

DIGO is a common clinical problem that often requires intervention. Non-surgical techniques can limit the occurrence of this unwanted affect, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. Wherever possible this management strategy should be adopted first. Surgical treatment is often the most reliable option and scalpel gingivectomy remains the treatment of choice. Further investigations are required to develop appropriate management strategies to prevent recurrence of DIGO.

The efficacy of three different surgical techniques in the management of drug-induced gingival overgrowth

OBJECTIVES

The aim of the present study was to evaluate the efficacy of three different surgical techniques in both the management and effect upon rate of overgrowth recurrence of drug-induced gingival overgrowth (DIGO).

MATERIALS AND METHODS

Two cohorts of patients who required surgical correction of their DIGO participated in the study. After baseline periodontal measures (plaque index, gingival inflammation and probing pocket depths), the patients underwent surgery. A split-mouth, crossover design was used to compare conventional gingivectomy with flap surgery (n=27), and conventional gingivectomy with laser excision (n=23). The main outcome variable was the rate of recurrence of DIGO following surgery.

RESULTS

At 6 months, there was significantly less recurrence (p=0.05) in patients treated with laser excision, compared with those treated by conventional gingivectomy. The differences in rate of recurrence of DIGO were also reflected in changes in several periodontal parameters. Flap surgery offered no advantage over conventional gingivectomy with respect to the rate of recurrence.

CONCLUSIONS

DIGO can be managed by a variety of techniques. Laser excision results in a reduced rate of recurrence.

The efficacy of preoperative versus postoperative rofecoxib for preventing acute postoperative dental pain: a prospective randomized crossover study using bilateral symmetrical oral surgery

BACKGROUND

Previous data have demonstrated that rofecoxib has good analgesic efficacy for acute postoperative dental pain. However, up to half of these patients require rescue analgesics within the first 24 hours. As the timing of analgesic interventions may be an important factor in pain control, the present study tested the hypothesis that rofecoxib administered preoperatively would improve the analgesic efficacy and reduce rescue analgesic requirements within the first 24 hours compared with postoperative administration.

METHODS

This was a double-blind, randomized, crossover study where 45 patients had each of their identical impacted mandibular third molars removed under local anesthesia on 2 separate occasions. Patients acted as their own control; one side was pretreated with rofecoxib 50 mg, 2 hours before surgery, followed by placebo 15 minutes after surgery, and the contralateral side was pretreated with placebo 2 hours before surgery and posttreated with rofecoxib 50 mg 15 minutes after surgery. The difference in postoperative pain between 2 sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 hours, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment.

RESULTS

Patients reported significantly lower pain scores (P = 0.04), longer time to rescue analgesic (P = 0.02), lesser postoperative analgesic consumption (P = 0.008), and better global assessment (P = 0.01) in the pretreated compared with the posttreated sides. There were significantly more patients in the pretreated group who did not required rescue analgesic within the first 24 hours (80% vs. 58%, P = 0.01), and the pain scores were extremely low in both groups during the 12 hours postoperative period (9.8 +/- 5.0 mm vs. 14.3 +/- 7.4 mm).

CONCLUSION

Rofecoxib is an excellent analgesic for preventing postoperative dental pain and when given 2 hours preoperatively rendered most patients relatively pain free, requiring no rescue analgesics on the first postoperative day.

Analysis of changes in gingival contour from three-dimensional co-ordinate data in subjects with drug-induced gingival overgrowth

OBJECTIVES

This aim of this study was to develop and assess a technique that could be used to assess accurately the gingival volume changes seen in drug-induced gingival overgrowth by the analysis of data obtained from an entire gingival surface by means of three-dimensional imaging.

MATERIAL AND METHODS

Stone dental models of patients before and after gingivectomy procedures were digitized with a laser scanner and then regenerated as computer models constructed from the acquired three-dimensional co-ordinate data. A comparison of superposed "before" and "after" surfaces was undertaken to assess and accurately quantify changes in gingival contour.

RESULTS

The mean vertical tissue reduction varied from 1.58 to 2.56 mm in the four study subjects and individual differences are shown. The maximum thickness of removed buccal gingival overgrowth was found to range between 1.20 and 3.40 mm. The volume of tissue removed from each inter-dental papilla ranged from 4.2 to 46.1 mm3 and the mean volume of the papilla removed from each subject+/-SD values was 24.8+/-13.1 mm3.

CONCLUSION

This method will measure changes in gingival tissues to within 60 microm in one plane, making it ideal for the assessment of longitudinal changes in gingival contour as seen in the development of gingival overgrowth, its recurrence after surgery or the changes in volume brought about by surgery.

Lasers in periodontology

Since the development of the ruby laser by Maiman in 1960, lasers have been widely employed in medicine for a number of years. The purpose of this paper is to summarize potential applications for lasers in dentistry, with special regard to periodontology. This article briefly describes clinical applications of lasers and laser safety. Particularly, the use of a diode laser seems to be promising, especially in already compromised transplant patients, who need to be treated with a technique where the operative and post-operative blood loss, post-operative discomfort and the recurrence of drug-induced gingival overgrowth need to be kept to a minimum or eliminated. Therefore, the use of lasers in periodontology may lead to an alteration in present clinical practice and help to establish the best management strategy because, by maintaining periodontal health, the life quality of patients can be improved.

Pain measurement in humans

Sound measurement, an essential component of any scientific discipline, remains a particular problem in pain research. The measurement of pain intensity, for example, is a difficult and often a subjective undertaking. This is of little surprise to clinicians and researchers, because it is well recognised that pain intensity, like other sensations and perceptions, is a private experience that displays considerable variability both across patients and within a patient across time. Nonetheless, pain measurement and discerning factors that may affect its measurement are important for diagnosis and to determine the effectiveness of treatment interventions. This article reviews the basic concepts, roles, instruments used, and factors affecting pain measurement. A variety of the most commonly used pain measurement instruments are evaluated for their advantages and disadvantages. The article aims to assist clinicians and researchers to select the pain measurement instruments that best serve their purposes.

A prospective randomized crossover study of the preemptive analgesic effect of nitrous oxide in oral surgery

OBJECTIVE

Preliminary animal data has shown that nitrous oxide has a preemptive analgesic effect on postoperative pain. Whether a similar effect occurs in humans is not established. In this prospective randomized crossover study, we investigated the effect of preincisional versus postincisional nitrous oxide on postoperative oral surgical pain.Study design The trial was a crossover study where 36 patients had each of their symmetrical impacted mandibular third molars randomly scheduled for removal in 2 sessions. Each of the 36 patients acted as his or her own control; one side of the jaw was allocated randomly to receive nitrous oxide preoperatively (pretreated side) and the other side postoperatively (posttreated side). The pretreated side received 50% nitrous oxide preoperatively for 20 minutes and 100% oxygen postoperatively for 20 minutes as placebo. The posttreated side received 100% oxygen preoperatively for 20 minutes and 50% nitrous oxide postoperatively for 20 minutes. The difference in postoperative pain between the pretreated and posttreated sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analog scale (VAS) hourly for 8 hours, time to first analgesic, total analgesic consumption during the first 48 hours, and a 5-point categorical patient global assessment scale (0=poor, 1=fair, 2=good, 3=very good, and 4=excellent).

RESULTS

The VAS scores did not differ between the 2 sides at any time (P=.50): neither did the time to first analgesic (P=.8), amount of total analgesic consumption (P=.77), and patient's global assessment differ (P=.63).

CONCLUSION

Our results do not support the preliminary animal data that nitrous oxide has a preemptive analgesic effect for postoperative pain. 50% nitrous oxide administered preoperatively for 20 minutes has no preemptive analgesic effect on postextraction pain.

Preoperative ketorolac has a preemptive effect for postoperative third molar surgical pain

There is uncertainty regarding the role of preemptive analgesia in preventing postoperative pain. Most previous studies were of parallel design completed under general anesthesia with many confounding inter-patient's variables. The present study evaluated the efficacy of preemptive ketorolac in a crossover design in patients undergoing bilateral mandibular third molar surgery. This was a double blind, randomized, placebo-controlled study where 34 patients had each of their identical impacted mandibular third molars removed under local anesthesia on two occasions. Each patients acted as their own control; one side was pretreated with intravenous ketorolac 30 mg before surgery followed by placebo injection after surgery, and for the other side, the patient was given placebo injection before surgery and post-treated with intravenous ketorolac 30 mg after surgery. The difference in postoperative pain between pretreated and post-treated side in each patient was assessed by four primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 h, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment. Throughout the 12-h investigation period, patients reported significantly lower pain intensity scores in the ketorolac pretreated sides when compared with the post-treated sides (P = 0.003). Patients also reported a significantly longer time to rescue analgesic (8.9 h versus 6.9 h, P = 0.005), lesser postoperative analgesic consumption (P = 0.007) and better global assessment for the ketorolac pretreated sides (P = 0.01). Pretreatment with intravenous ketorolac has a preemptive effect for postoperative third molar surgery and extended the analgesia by approximately 2 h.

Post-transplant lymphoproliferative disorders presenting as gingival overgrowth in patients immunosuppressed with ciclosporin. A report of two cases

BACKGROUND

Post-transplant lymphoproliferative disorder (PTLD) can occur in patients maintained on immunosuppressive therapy following transplantation. This paper describes two cases of PTLD occurring in gingival tissues, in patients receiving ciclosporin following cardiac transplantation.

TREATMENT

The lesions were localised to gingival tissues, mimicking ciclosporin-induced gingival overgrowth. They were removed surgically and the ciclosporin dose reduced to help prevent recurrence.

CONCLUSION

The importance of histopathological examination of all tissue removed during routine gingivectomy procedures for ciclosporin-induced gingival overgrowth is highlighted.

Salivary proteins and cytokines in drug-induced gingival overgrowth

Little is known about the involvement of saliva in gingival overgrowth (GO). It was hypothesized that, in this situation, the composition of saliva is altered. Thus, proteins, albumin, cytokines, and growth factors in whole and glandular saliva were investigated. Differences between glandular and gingival contributions to the composition of saliva were explored in patients medicated with cyclosporin who exhibited GO (responders), those without GO (non-responders), and non-medicated subjects (controls). In whole saliva, interleukin-1alpha (IL-1alpha), IL-6, IL-8, epidermal growth factor (EGF), nerve growth factor (NGF), and albumin were detected, but in glandular saliva only EGF and NGF were identified. Albumin and IL-6 differed significantly between responders and controls, although the overall profile of salivary proteins remained unchanged. Thus, inflammatory cytokines and albumin are confined to whole saliva and are associated with GO, whereas its content of EGF and NGF appears unaffected by cyclosporin.

Prevalence of gingival overgrowth in transplant patients immunosuppressed with tacrolimus

AIMS

The study aims to determine the prevalence and severity of gingival overgrowth in a group of adult organ transplant recipients immunosuppressed with tacrolimus in comparison with ciclosporin, and to examine various risk factors for the development of gingival overgrowth.

METHODS

Forty patients taking tacrolimus were compared with 197 ciclosporin patients. Demographic, pharmacological and periodontal data were recorded for all patients. Comparison between the groups was made using independent sample t-tests, chi2 statistic or Mann-Whitney test. The effects of risk variables on overgrowth severity were examined using forward and backward stepwise regression analysis.

RESULTS

Those taking tacrolimus had a significantly lower mean gingival overgrowth score (14.1%) compared with ciclosporin (22.4%). Fifteen percent of the tacrolimus group had clinically significant gingival overgrowth compared with 30% in the ciclosporin group (p=0.053).

CONCLUSIONS

The prevalence and severity of gingival overgrowth is less in adult transplant patients taking tacrolimus compared with ciclosporin. Concomitant use of calcium channel blockers and previous medication with ciclosporin are significant risk factors for the presence and severity of gingival overgrowth. Patients who have alteration of their immunosuppressant from ciclosporin to tacrolimus may persist in demonstrating gingival overgrowth attributable to their ongoing therapy with calcium channel blockers.

Dentistry and the medically compromised patient

Certain medical conditions and their accompanying drug treatment do have an impact upon oral structures and the delivery of dental care. Recent evidence suggests that oral health could be a significant risk factor for coronary artery disease. Many medical conditions can affect dental care are often over-stated and lack an evidence base. Examples include the need for antibiotic cover in patients at risk from infective endocarditis and the necessity to provide supplementary corticosteroids for those patients on longterm steroid therapy. By contrast, certain systematic drug treatments can have a profound affect on the oral tissue. The most obvious is drug-induced gingival overgrowth. Drugs frequently implicated in this unwanted effect include phenytoin, ciclosporin and the calcium channel blockers. Several risk factors for drug-induced overgrowth have been identified and include age, sex, peridontal variables and a range of drug pharmacokinetic variables. The relationship between oral health and coronary artery disease opens up a potentially new vista for the delivery of oral care. Although the association is convincing, casualty has not been established. If casualty for this relationship can be confirmed then the delivery of dental care and the promotion of oral health will receive a significant impetus.

Antibiotic prophylaxis for patients with joint prostheses - still a dilemma for dental practitioners

OBJECTIVES

To provide a critical review of the current evidence that implicates dental-induced bacteraemia as a risk for joint infections in patients fitted with joint prostheses and appraise the need for antibiotic prophylaxis.

DESIGN

Retrospective analysis.

SETTING

Mainly hospital-based patients or subjects.

OUTCOME MEASURES

The relationship between joint infections and dental treatment is equivocal at the best and there is no evidence that antibiotic prophylaxis provides such patients with any protection.

RESULTS

Microbiological evidence linking dental treatment-induced bacteraemia to joint infections is weak and if an oral commensal is implicated, it is more likely to have arisen either from a spontaneous bacteraemia or from a dental infection. As a consequence of the latter, we recommended the institution of good dental health prior to joint replacement. There may be a case for providing prophylaxis to the immuno-compromised patient, but only if the immuno-suppression is associated with a neutropenia. In such circumstances, only emergency treatment should be considered until the neutropenia is resolved. Antibiotic regimens that are recommended by orthopaedic surgeons have not been evaluated in a randomised placebo-controlled study and many of the drugs are not licensed for this purpose. The evidence on cost-risk benefit seems to demonstrate that antibiotic prophylaxis with either amoxicillin or penicillin is not cost effective when compared with no prophylaxis.

CONCLUSION

The case for providing antibiotic prophylaxis prior to dental treatment in patients fitted with a joint prosthesis is weak or virtually non-existent. Furthermore, the risk from providing prophylaxis is greater than the risk of a joint infection.

Cardiovascular diseases and periodontology

BACKGROUND

Cardiovascular diseases represent a widespread heterogeneous group of conditions that have significant morbidity and mortality. The various diseases and their treatments can have an impact upon the periodontium and the delivery of periodontal care.

AIM

In this paper we consider three main topics and explore their relationship to the periodontist and the provision of periodontal treatment.

METHOD

The areas reviewed include the effect of cardiovascular drugs on the periodontium and management of patients with periodontal diseases; the risk of infective endocarditis arising from periodontal procedures; the inter-relationship between periodontal disease and coronary artery disease.

RESULTS AND CONCLUSIONS

Calcium-channel blockers and beta-adrenoceptor blockers cause gingival overgrowth and tooth demineralisation, respectively. Evidence suggests that stopping anticoagulant therapy prior to periodontal procedures is putting patients at a greater risk of thromboembolic disorders compared to the risk of prolonged bleeding. The relationship between dentistry and infective endocarditis remains a controversial issue. It would appear that spontaneous bacteraemia arising from a patient's oral hygiene practices is more likely to be the cause of endocarditis than one-off periodontal procedures. The efficacy of antibiotic prophylaxis is uncertain (and unlikely to be proven), and the risk of death from penicillin appears to be greater than the risk of death arising from infective endocarditis. Finally, the association between periodontal disease and coronary artery disease has been explored and there seem to be many issues with respect to data handling interpretation. Many putative mechanisms have been suggested; however, these only further highlight the need for intervention studies.

An investigation into the comparative efficacy of soluble aspirin and solid paracetamol in postoperative pain after third molar surgery

OBJECTIVE

To compare the efficacy of soluble aspirin 900 mg and paracetamol 1,000 mg in patients with postoperative pain after third molar surgery.

DESIGN

A randomised, placebo controlled, double-blind study.

SETTING

Day stay units of Oral and Maxillofacial Surgery at Cardiff Dental Hospital and Hexham General Hospital, Northumberland.

SUBJECTS AND METHODS

One hundred and sixty-seven (104 female) patients who required the removal of their impacted third molars under general anaesthesia.

INTERVENTION

In the early postoperative period, patients were medicated with either a single dose of soluble aspirin 900 mg, solid paracetamol 1,000 mg or placebo.

MAIN OUTCOME MEASURES

Pain intensity was measured on 100 mm visual analogue scales at 0, 5, 10, 15, 20, 30, 45, 60, 90, 120 and 240 minutes after dosing. Other efficacy variables evaluated included time to rescue medication and an overall assessment of the study medication efficacy by the patient on completion of the study.

RESULTS

One hundred and sixty-seven patients consented to take part in the study, but only 153 were medicated. Of the 14 patients not treated, 10 failed to develop sufficient pain to enter the study, two withdrew consent, one had an adverse reaction to the general anaesthetic and one was a protocol violator. Over the four hour investigation period, patients treated with soluble aspirin reported significantly less pain when compared with those treated with paracetamol (mean difference in AUC(0-240) = -2001, 95% CI -3893 to -109, p=0.038) and placebo (mean difference in AUC(0-240) = -3470, 95% CI -5719 to -1221, p=0.003). Similarly, at 20 and 30 minutes after dosing, patients in the soluble aspirin group were reporting significantly less pain than those in the paracetamol treatment group (mean difference in pain intensity: at 20 minutes -7.9, 95% CI -15.3 to -0.6, p=0.035; at 30 minutes -10.6, 95% CI -18.6 to -2.6, p=0.010). There were no significant differences between treatment groups with respect to the number of patients requiring rescue medication, however the time to dosing was significantly longer for those taking soluble aspirin when compared with placebo (hazard ratio 2.34, 95% CI 1.41 to 3.88, p<0.001).

CONCLUSION

The findings from this study showed that soluble aspirin 900 mg provides significant and more rapid analgesia than paracetamol 1,000 mg in the early postoperative period after third molar surgery.

Pathogenesis of postoperative oral surgical pain

Pain is a major postoperative symptom in many oral surgical procedures. It is a complex and variable phenomenon that can be influenced by many factors. Good management of oral surgical pain requires a detailed understanding of the pathogenesis of surgical pain. This article aims at reviewing postoperative pain from a broad perspective by looking into the nociception, neuroanatomy, neurophysiology, and neuropharmacology of pain. Therapeutic recommendations are made after reviewing the evidence from the literature for maximizing the efficacy of pain management techniques for oral surgical pain.

Maximizing the safety of nonsteroidal anti-inflammatory drug use for postoperative dental pain: an evidence-based approach

This article reviews the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative dental pain. An evidence-based approach is used to evaluate the clinical studies to date on the safe use of these drugs in dental patients. No drugs are without adverse effects or are perfectly safe, but their safe use in clinical practice would entail maximizing the therapeutic efficacy and minimizing the adverse effects. Therapeutic recommendations are made after reviewing the evidence for the safe use of NSAIDs in postoperative dental pain.

Oral myofibromatosis: an unusual cause of gingival overgrowth

BACKGROUND

This case report describes a rare benign tumour, which presented as discrete areas of gingival hyperplasia affecting both the mandible and the maxilla.

METHOD

Surgical excision of the lesions was carried out under local anaesthetic. Histopathological examination confirmed the diagnosis of oral myofibromatosis.

RESULTS

The condition responded to surgical excision and appears to have limited growth potential. It affects a wide spectrum of ages and can be alarming due to rapid enlargement and ulceration, so careful diagnosis is important to avoid unnecessary aggressive treatment.

Are dental infections a cause of brain abscess? Case report and review of the literature

Dental pathology and/or treatment have been linked to a small number of brain abscesses as possible sources of infection. A further case is presented, in which a dental site is implicated. A review of the evidence was undertaken. A wide range of dental procedures had been implicated. In some cases the brain isolate was not of dental origin. In many, the diagnosis was one of exclusion. In order to confirm the role of odontogenic infection in the pathogenesis of brain abscess, modern sampling techniques should be used to precisely identify the isolates. The causal organism should be identified in both oral and cranial sites.

Photographic scoring of gingival overgrowth

BACKGROUND

A wide range of methods have been employed to determine the severity of gingival overgrowth resulting in uncertainty regarding the prevalence of the side-effect. There is no simple, non-invasive, objective, blind method for assessing gingival overgrowth.

AIM

This article aims to describe a method which is suitable for use in large-scale population studies.

MATERIALS AND METHODS

Photographs were taken of the anterior, buccal gingivae and teeth of 925 patients medicated with calcium channel blockers. In addition, each patient was ascribed a clinical gingival overgrowth score. 100 patients had repeat photographs, and a further 10 patients had alginate impressions taken. The models were scored for severity of gingival overgrowth using a described technique. The slides were scored using a modification of this technique.

RESULTS

When photographic and study model scores were compared, photographic scores were consistently higher, and as a result, a photographic score of 38.6% was considered to represent a significant overgrowth. There was good agreement between clinically determined scores and photographic scores (kappa=0.71).

CONCLUSIONS

The results indicate that this method is suitable for large-scale population studies where it also has the advantage of providing a continuous scale of gingival changes for subsequent statistical analysis.

Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink?

OBJECTIVE

To provide a critical review of the current evidence that links dental treatment to infective endocarditis (IE) and appraise the risks of antibiotic chemoprophylaxis.

DESIGN

Retrospective analysis

SETTING

Mainly hospital based patients or subjects

OUTCOME MEASURES

The interrelationship between infective endocarditis and dental treatment is complex and in many instances uncertain. The risk from antibiotic chemoprophylaxis appear greater than the risk of contracting IE.

RESULTS

There is increasing evidence that spontaneous bacteraemia are more likely to cause IE in at risk patients than specific episodes of dental treatment. Antibiotic chemoprophylaxis may not necessarily reduce dental-induced bacteraemia and the protective effect if any from antibiotic cover may arise from an inhibitory action upon bacterial colonisation on the compromised cardiac valves.

CONCLUSION

There is increasing concern over the misuse of antibiotics in general and this has focused attention on chemoprophylaxis in dentistry to prevent IE. New evidence on dental-induced bacteraemia and the prevalence of IE in association with dental treatment raises further questions on the need to provide antibiotic cover in at risk patients. More prescriptive guidelines to define who is at risk from IE and what procedures require cover will help to reduce overprescribing of antibiotics and reduce the risks of their unwanted effects.

An investigation into the efficacy of intravenous diclofenac in post-operative dental pain

OBJECTIVE

To evaluate the efficacy of single doses of intravenous diclofenac sodium (25, 50 and 75 mg) in patients with post-operative pain after third-molar surgery in a randomised, placebo-controlled study.

METHODS

Two hundred and sixty-nine patients (168 females) who required the removal of their impacted third molars participated in the study, which had received prior ethical approval. Surgery was completed under general anaesthesia and, during the early post-operative period, patients received either a single intravenous dose of diclofenac (25, 50 or 75 mg) or matched placebo in random, double-blind order. Pain intensity was assessed on 10-cm visual analogue scales at fixed time points throughout a 4-h investigation period. Other efficacy variables obtained included time until rescue medication and overall assessment at 4, 6, 12 and 24 h after dosing.

RESULTS

Throughout the 4-h investigation period, patients treated with diclofenac reported significantly less pain than those treated with placebo (P < 0.001). No differences were observed among the three doses of diclofenac (P = 0.22). Similar results were observed at 6, 12 and 24 h after dosing. Significant differences were also noted between the placebo group and all the diclofenac treatment groups with respect to time until rescue medication (P < 0.001) and the proportion of patients taking such medication.

CONCLUSION

Single doses of i.v. diclofenac (25, 50 and 75 mg) provide significant pain relief after third-molar surgery. The efficacy of this preparation does not appear to be dose related.

Risk factors for drug-induced gingival overgrowth

BACKGROUND/AIMS

Drug-induced gingival overgrowth remains a significant problem for the periodontologist. Many patients medicated with the drugs implicated in this unwanted effect experience significant, recurrent gingival problems that require repeated surgical excisions. In this review, we attempt to identify and quantify the various "risk factors" associated with both the development and expression of the drug-induced gingival changes.

METHOD

The risk factors appraised include age, sex, drug variables, concomitant medication, periodontal variables and genetic factors. Elucidation of such factors may help to identify "at risk patients" and then develop appropriate treatment strategies.

RESULTS

Of the factors identified, the only one that can be affected by the periodontologist is the patents' periodontal condition. However, drug variables and concomitant medication do impact upon the expression of gingival overgrowth.

CONCLUSION

The identification of risk factors associated with both the prevalence and severity of drug-induced gingival overgrowth is important for all parties involved with this unwanted effect. Both periodontologist and patient have an important rôle to play in improving oral hygiene and gingival health. Likewise, there is always an opportunity to establish a close liaison between the patient's physician and the periodontologist to try and identify alternative drug regimens that can help reduce the impact of this unwanted effect.

The efficacy of buffered ketoprofen in postoperative pain after third molar surgery

OBJECTIVE

To evaluate in a randomised, double-blind, placebo-controlled trial, the efficacy (time to onset of meaningful pain relief) of single doses of buffered ketoprofen (12.5 mg) and ibuprofen (200 mg) in 180 patients with postoperative pain after third molar surgery.

METHODS

180 adult patients who had undergone third molar surgery under general anaesthesia participated in this study. After dosing, patients recorded their time to meaningful pain relief, pain intensity on both visual analogue scales and verbal rating scales, pain relief and the need for additional analgesia. Pain recordings were made at fixed time points over a 6-h investigation period.

RESULT

Buffered ketoprofen (12.5 mg) provided quicker meaningful pain relief than placebo (P = 0.023). For secondary efficacy measures (SPIDS4, SPIDS6, TOTPAR4, TOTPAR6), the buffered ketoprofen was significantly superior to both placebo (P < 0.001) and ibuprofen (200 mg) (P < 0.05). Similarly, the amount of time before taking an escape analgesic was significantly less in the placebo group than both the ibuprofen and buffered ketoprofen groups (P < 0.03).

CONCLUSIONS

Buffered ketoprofen (12.5 mg) provides effective pain control in the early postoperative period after third molar surgery. This ketoprofen preparation was also superior to ibuprofen (200 mg) with respect to both reducing pain intensity and providing an earlier onset of pain relief.

The effect of multiple anticonvulsant therapy on the expression of phenytoin-induced gingival overgrowth

The potential effect of co-medication with phenobarbitone, primidone and carbamazepine on plasma and saliva concentrations of 5-(4-hydroxyphenyl)-5-phenylhydantoin (4-HPPH), the major metabolite of phenytoin in man and on the incidence of phenytoin-induced gingival overgrowth was investigated in a group of 36 adult epileptic patients. There were no significant differences in plasma or saliva concentrations of 4-HPPH or phenytoin in patients prescribed phenytoin alone, compared to those who received phenytoin with either phenobarbitone, primidone, or carbamazepine. In addition, the extent and the incidence of gingival overgrowth were similar in the 2 groups. The results suggest that chronic co-medication with other anti-convulsant drugs which induce phenytoin metabolism, does not affect the plasma or saliva 4-HPPB steady-state levels, nor the degree of gingival overgrowth in adult epileptic patients on therapy with phenytoin.

An investigation into the need for supplementary steroids in organ transplant patients undergoing gingival surgery. A double-blind, split-mouth, cross-over study

Organ transplant patients are frequently medicated with triple immunosuppressive therapy that includes both cyclosporin and the corticosteroid, prednisolone. Many of these patients experience gingival overgrowth that necessitates surgical intervention. Chronic dosing with corticosteroids can lead to suppression of the hypothalamic-pituitary axis, and subsequent adrenocortical suppression. To circumvent possible suppression, supplementary steroids are administered to such patients prior to so-called "stressful events". We have examined the need for supplementary steroids in 20 organ transplant patients undergoing gingival surgery under local anaesthesia to correct their drug-induced gingival overgrowth. All patients were operated upon in the first half of the morning. Prior to gingival surgery, resting blood pressure (BP) and serum ACTH concentrations were determined. Immediately before surgery patients received either intravenous hydrocortisone 100 mg or placebo in random, double-blind order. Each patient required 2 gingivectomies and thus acted as their own placebo control. BP was measured at various time points throughout surgery and upto 2 h postoperatively. On completion of surgery, a further blood sample was taken to determine ACTH concentration. There was no significant difference (p>0.05) between placebo and hydrocortisone treatments for BP and ACTH measurements. No patient experienced any symptoms that were suggestive of adrenocortical suppression. One patient did experience postural hypotension prior to gingival surgery, but this is attributed to his antidepressant medication. We can conclude from this study that immunosuppressed organ transplant patients taking the maintenance dose of prednisolone (5-10 mg/day) do not require corticosteroid cover prior to gingival surgery under local anaesthesia. We would however, advocate monitoring of their blood pressure throughout the procedure.

The efficacy of a novel adenosine agonist (WAG 994) in postoperative dental pain

AIMS

To determine the comparative efficacy of a new novel adenosine agonist (WAG 994) in postoperative pain after third molar surgery.

METHODS

One hundred and twenty-two patients with postoperative pain after third molar surgery were randomised in a placebo double-blind trial with an active control group. In the early postoperative period patients received either a single dose of WAG 994 1 mg, ibuprofen 400 mg or matched placebos. Pain intensity score was recorded on serial visual analogue scales over a 6 h investigation period. Similarly, pain relief was completed on a 4 point categorical scale at each evaluation point. Patients had access to escape analgesic and if these were taken, the time and dosage were recorded. A sparse sampling technique was used to investigate the relationship between analgesic effects and plasma concentrations of WAG 994.

RESULTS

All three treatment groups were matched for various demographic variables. For all efficacy measures, WAG 994 was not significantly different from placebo (P >0.05), whereas ibuprofen 400 mg was significantly superior to placebo (P<0.001). No significant relationships (P<0.05) were found between WAG 994 pharmacokinetic variables and efficacy measures. Conclusion WAG 994, an adenosine agonist, did not show efficacy in the management of postoperative pain after third molar surgery. Although this pain responds well to nonsteroidal anti-inflammatory drugs, it appears to be resistant to compounds that interact with purinergic receptors.

Phenytoin metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) in man, cat and rat in vitro and in vivo, and susceptibility to phenytoin-induced gingival overgrowth

Interspecies differences in phenytoin (PHT) metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) were examined in human, cat and rat hepatic microsomes in vitro. Rat liver microsomes were 25 and 650 times more efficient at the conversion of PHT to HPPH than human and cat liver microsomes, respectively. Sulphaphenazole (83%) and tolbutamide (TOL) (64%) were the most potent inhibitors of HPPH formation in human liver microsomes, while ciprofloxacin (27%), enoxacin (27%) and TOL (26%) produced the greatest inhibition in cat liver microsomes. TOL was tested for its effect on HPPH formation and gingival overgrowth in cats in vivo. Eight cats received PHT sodium (4 mg/kg/d) and another 8 cats received PHT sodium together with TOL (20 mg/kg/d) for 10 wk. Six cats (75%) in the PHT group and 4 cats (50%) in the PHT & TOL group developed significant gingival overgrowth by the end of the study. However, the extent and incidence of the overgrowth were similar in the 2 groups. There were no significant differences in mean AUC 0-10 weeks for plasma PHT (552.90 +/- 29.6 micrograms.d/mL [PHT alone] vs. 582.41 +/- 24.49 micrograms.d/mL [PHT & TOL]) and unconjugated HPPH (1016.4 +/- 295.5 ng.d/mL [PHT alone] vs. 1174.5 +/- 397.2 ng.d/mL [PHT & TOL]) concentrations between the 2 groups of cats. Neither PHT nor HPPH were detectable in the plasma of 8 rats which received PHT (4 mg/kg/d) over a 10-wk period. The rats showed no sign of gingival inflammation (mean gingival index = 0) or gingival overgrowth (mean gingival overgrowth index = 0). Thirty-six adult epileptic patients on chronic PHT therapy were examined; 17 (47%) of the patients demonstrated clinically significant overgrowth. The mean steady-state plasma PHT concentration was comparable to, and the mean plasma unconjugated HPPH concentration 5-fold greater than, that observed in the cats. The results suggest that the rapid metabolism and elimination of PHT and HPPH in the rat may enable it to become more resistant towards developing gingival overgrowth, compared to the cat and man.

Prevalence of gingival overgrowth induced by calcium channel blockers: a community-based study

BACKGROUND

The prevalence of gingival overgrowth induced by chronic medication with calcium channel blockers is uncertain. Although there have been several studies examining this question, the results are conflicting, with previous estimates ranging from 20% to 83%. There have been only 2 studies examining the prevalence of overgrowth induced by diltiazem and amlodipine, with estimates of 74% and 3.3%, respectively.

METHODS

The current study aimed to address the problems associated with these studies by examining a sample of patients taking one of 3 calcium channel blockers, who were drawn from a community-based population in northeastern England. Nine hundred eleven (911) subjects were recruited from general medical practices in the area. Of these, 442 were taking nifedipine, 181 amlodipine, and 186 diltiazem. In addition, 102 control subjects were examined. Drug and demographic data for each subject were recorded. The periodontal condition of all subjects was assessed including plaque index, papillary bleeding index, and a photograph of the anterior gingivae for subsequent analysis of overgrowth severity.

RESULTS

More than six percent (6.3%) of subjects taking nifedipine were seen to have significant overgrowth. This overgrowth was statistically greater than the amount of overgrowth seen in either of the other 2 drug groups or the control population. The prevalence of gingival overgrowth induced by amlodipine or diltiazem was not statistically significant when compared to the control group. The severity of overgrowth within the nifedipine group was found to be related to the amount of gingival inflammation and also to the gender of the subject, with males being 3 times as likely to develop overgrowth than females.

CONCLUSIONS

The prevalence of clinically significant overgrowth related to chronic medication with calcium channel blockers is low, i.e., 6.3% for nifedipine. Males are 3 times as likely as females to develop clinically significant overgrowth. The presence of gingival inflammation is an important cofactor for the expression of this effect.

The comparative efficacy of aceclofenac and ibuprofen in postoperative pain after third molar surgery

The aim of the present placebo-controlled, double-blind study was to evaluate the comparative efficacy of single doses of aceclofenac 150 mg and ibuprofen 400 mg in 217 patients with postoperative pain after third molar surgery. Outcome of primary efficacy was judged by overall assessment of the area under the curve (AUC) of graphs for pain intensity (AUC pain) pain relief (AUC relief), both measured from serial visual analogue scales over a 6 h investigation period. Other measures of efficacy included the rate of pain reduction in the first hour, the number of patients who took 'escape' analgesics and the time before they did, and an overall assessment of pain relief score on a five-point categorical scale. Ibuprofen 400 mg was significantly superior to placebo for pain relief (P < 0.01), degree of pain reduction in the first hour (P = 0.005), and the number of patients who required escape analgesia (P < 0.001), and the time before they did (P < 0.001). The outcome for patients treated with aceclofenac 150 mg was not significantly different from that of patients treated with placebo (P > 0.05). A single dose of ibuprofen 400 mg provided significant pain relief in the early postoperative period after third molar surgery, whereas a single dose of aceclofenac 150 mg was not effective in the management of postoperative pain after this operation.

Immunolocalization of collagenase (MMP-1) and stromelysin (MMP-3) in the gingival tissues of organ transplant patients medicated with cyclosporin

Cyclosporin-induced gingival overgrowth results from a disturbance in the homeostatic balance in the gingival tissues which is characterised by both an increase in the number of fibroblasts and in the volume of the extracellular matrix. Whilst the accumulation of the collagenous matrix is well recognised, little attention has been paid to the role of the degradative enzymes in the development of this condition in vivo. The matrix metalloproteinases MMP-1 (collagenase) and MMP-3 (stromelysin) were immunolocalized using specific polyclonal and monoclonal antisera in gingival specimens from 18 patients with drug-induced gingival overgrowth and 6 control subjects. A positive granular pattern of MMP-1 staining was seen in the vast majority of fibroblasts in specimens from drug-free controls throughout the connective tissue. This was in marked contrast to the findings in overgrown tissue, where positive cytoplasmic staining was shown by only a small number of fibroblasts. Where fibroblast staining occurred in overgrown tissue, the intracellular pattern was the same as in the drug free tissue. Positive staining was, however, largely confined to a small number of fibroblasts in the lamina propria of the outer gingival mucosa and even in this region there were areas that showed little or no fibroblast staining. This apparent cessation of collagenase production by many of the fibroblasts in gingival overgrowth supports the hypothesis that perturbation of collagenase activity is responsible for the disturbance in the homeostatic balance, which is pivotal to this condition.

Is there a link between periodontal disease and coronary heart disease?

OBJECTIVE

To provide a critical review of the studies completed to date that have investigated a link between coronary heart disease and dental health.

DESIGN

Retrospective analysis.

SETTING

Mainly hospital-based patients or subjects involved in longitudinal health care studies.

MAIN OUTCOME MEASURES

The incidence of coronary heart disease and its relationship to dental health and other recognised risk factors.

RESULTS

Evidence suggests that dental health, in particular periodontal disease, may be a significant risk factor for coronary heart disease and further coronary events. Possible biological mechanisms that link the two diseases are appraised.

CONCLUSIONS

There does appear to be increasing evidence that a relationship exists between dental health and coronary heart disease, especially in males aged 40-50 years. The presence of a hyperinflammatory monocyte phenotype may provide a common biological mechanism that links the two diseases.

Angiotensin converting enzyme (ACE) inhibitors and their implications for the dental surgeon

Angiotensin enzyme converting (ACE) inhibitors are a widely prescribed group of drugs used in the management of hypertension and heart failure. Several unwanted effects are associated with ACE inhibitors and this paper highlights those significant to the dental surgeon. Of particular concern is the problem of angioedema, which can be life threatening. Three case reports are presented that illustrate this problem and the management is discussed.

Oral lesions in organ transplant patients

Patients who have undergone organ transplantation can present with a variety of oral lesions that appear to be related either directly to their medication or arise as a consequence of drug-induced immunosuppression. Such lesions include hairy leukoplakia, an increased propensity to both fungal and viral infections and a high incidence of malignant change, especially lip cancer. Cyclosporin remains the immunosuppressant of choice in most transplant patients. Gingival overgrowth is the main unwanted oral effect associated with cyclosporin. Some 30% of dentate transplant experience this problem, which is further compounded by concomitant medication with a calcium channel blocker. This review appraises the various oral problems that can arise in this group of patients and emphasises the importance of regular oral screening and the establishment of links with the various transplant teams.

Are the pharmacokinetics of ibuprofen important determinants for the drug's efficacy in postoperative pain after third molar surgery?

The aim of the present placebo-controlled, crossover study was to evaluate the efficacy and pharmacokinetics of ibuprofen after a single oral dose of soluble ibuprofen 400 mg in 18 patients with postoperative pain after bilateral third molar surgery. Throughout a 5-hour investigation period, patients reported significantly less pain (P < 0.001) after treatment with soluble ibuprofen than after placebo. Peak plasma concentrations of ibuprofen occurred approximately 30 minutes after dosage. No significant correlations (P > 0.05) were observed between efficacy measures and the various pharmacokinetic parameters (AUC0-300, Cmax and Tmax) for ibuprofen after the soluble dose. It is concluded that a single dose of soluble ibuprofen 400 mg is an effective analgesic for the control of postoperative pain in the early period after third molar surgery. Efficacy of this preparation does not appear to be directly related to the drug's pharmacokinetic variables in plasma.

Nifedipine pharmacological variables as risk factors for gingival overgrowth in organ-transplant patients

The prevalence and severity of gingival overgrowth in organ-transplant patients medicated with cyclosporin are greater in patients concomitantly medicated with nifedipine; however, no relationship between the gingival overgrowth and any of the nifedipine pharmacological variables has been demonstrated. The study examined the effect of five nifedipine pharmacological variables (nifedipine dosage, plasma concentration and gingival crevicular fluid concentration, M1 metabolite plasma concentration and the nifedipine: M1 ratio). The effect of the nifedipine variables on the gingival overgrowth score were examined using univariate and multivariate regression analysis. Adjustment for the effect of other risk factors was made by adding the distribution of each of the nifedipine variables in turn to a stepwise regression model containing previously identified risk factors for this condition. Despite the high levels of nifedipine sequestered in the GCF, only the plasma concentration of nifedipine was identified as a risk factor for the severity of gingival overgrowth in these patients (P = 0.01) once adjusted for other known risk factors (R2 for the model = 55%).