Concept, diagnosis and classification of bisphosphonate-associated osteonecrosis of the jaws. A review of the literature

BACKGROUND: Bisphosphonates (BPs) and other antiresorptive agents such as denosumab are widely prescribed for the treatment of osteoporosis and are also used in patients with multiple myeloma and metastatic breast or prostate cancer for avoiding bone reabsorption and fractures that result in increased morbidity-mortality among such individuals. MATERIAL AND METHODS: We made a bibliographic search to analyze the concept, diagnosis and the different classifications for bisphosphonate-associated osteonecrosis of the jaws. RESULTS: Osteonecrosis of the jaws (ONJ) is an important complication of exposure to BPs or other antiresorptive agents, and although its prevalence is low, it can pose management problems. The definition, diagnosis and classification of osteonecrosis have evolved since Marx reported the first cases in 2003. CONCLUSIONS: The present study offers a literature review and update on the existing diagnostic methods and classification of the disorder, with a view to facilitating earlier and more effective treatment

Oxidative stress and recurrent aphthous stomatitis.

OBJECTIVES: This study analyzed the oxidative stress status in patients with recurrent aphthous stomatitis (RAS) in the presence and absence of active ulceration. MATERIAL AND METHODS: Oxidative stress was analyzed in peripheral mononuclear cells of 28 RAS patients with active ulceration and 29 controls. A further blood sample was collected from nine subjects randomly selected from the 28 RAS cases, during the period in which the patients did not have active oral ulceration. The reduced glutathione (GSH), malondialdehyde (MDA), and oxidized glutathione (GSSG) levels were measured in these samples. RESULTS: The mean MDA and GSSG levels were significantly higher in patients with active RAS than in the controls, while GSH was lower in the RAS group (p < 0.01). There was a nonsignificant tendency toward higher MDA and GSSG levels in patients with major RAS compared with minor RAS. On comparing the serum findings in the nine RAS patients in the presence and absence of lesions, the presence of ulceration was associated with even higher MDA and GSSG levels and lower GSH concentrations (p < 0.05) CONCLUSIONS: Oxidative stress was detected in our RAS patients.

Osteonecrosis of the jaws by intravenous bisphosphonates and osteoradionecrosis: a comparative study.

AIMS: We analyze the possible clinical differences between bone jaw exposed areas in ONJ (osteonecrosis of the jaws) and ORN (osteoradionecrosis). PATIENTS AND METHOD: Group 1 was composed with 53 ONJ cases and group 2 with 20 ORN cases. In both groups we analyzed, the major size of the exposed bone areas, the number of exposed areas, the location on the jaws and the presence of others associated and severe complications, such as skin fistulas and jaw fractures. We also investigated the possible local aetiology or trigger factor of the lesions. RESULTS: The major size of the bone exposed areas was 2.29+/-2.02(mean +/- std.dev) in group 1 and 2.7+/-2.9 (mean +/- std.dev) in group 2 (p>0.05). The number of exposed areas was 1.8+/-1.34 (mean +/- std.dev) in group 1 and 1.2+/-0.55 (mean +/- std.dev) in group 2 (p>0.05). There were more fractures in the second group (20%) (p<0.05), and skin fistulas (35%) (p<0.05). We found more patients in group 1 in which the dental extraction was the local aetiology of the bone necrosis (35 cases, 66.03%), while in group 2 there were 8 (40%) (p<0.05). CONCLUSIONS: In our study with ONJ there were not differences in the major size of the bone exposed areas, but there were more lesions per patient than in group with ORN. The severity of the complications, such as jaw fractures and skin fistulas were higher in ORN, and in this group it was more frequent the spontaneous lesions than in the ONJ where it is more frequent following dental extractions.

Lichen sclerosus of the oral mucosa: a case report.

Lichen sclerosus or lichen sclerosus et atrophicus is a chronic inflammatory disease predominantly affecting the genital mucosa and skin. Clinically, it is characterized by white atrophic plaques in the anogenital region. The lesions are generally asymptomatic, but may cause discomfort with itching and pain. Extragenital mucosal involvement is very unusual, and lesions limited to the oral mucosa are even less frequent. Knowledge of such lesions is important in order to establish a differential diagnosis with other white oral lesions, and histological confirmation is required. We present the case of a 31-year-old woman with a well delimited, pearly white lesion located in the upper gingival mucosa, lip mucosa and adjacent skin. The lesion had led to loss of periodontal attachment of the affected tooth, causing pain in response to tooth brushing. The biopsy confirmed lichen sclerosus, and treatment was provided in the form of intralesional corticoid injections, followed by improvement of the mucosal lesion, though without recovery of the periodontal loss.

Lichen sclerosus of the oral mucosa: A case report

Lichen sclerosus or lichen sclerosus et atrophicus is a chronic inflammatory disease predominantly affecting the genital mucosa and skin. Clinically, it is characterized by white atrophic plaques in the anogenital region. The lesions are generally asymptomatic, but may cause discomfort with itching and pain. Extragenital mucosal involvement is very unusual, and lesions limited to the oral mucosa are even less frequent. Knowledge of such lesions is important in order to establish a differential diagnosis with other white oral lesions, and histological confirmation is required.We present the case of a 31-year-old woman with a well delimited, pearly white lesion located in the upper gingival mucosa, lip mucosa and adjacent skin. The lesion had led to loss of periodontal attachment of the affected tooth (2.3), causing pain in response to tooth brushing. The biopsy confirmed lichen sclerosus, and treatment was provided in the form of intralesional corticoid injections, followed by improvement of the mucosal lesion, though without recovery of the periodontal loss

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Bacteremia originating in the oral cavity. A review.

In patients at risk because of heart disease, bacteremias induced by invasive dental treatments have been reported as a cause of bacterial endocarditis (BE) - a serious disorder that continues to involve a high mortality. As a result, different scientific societies have supported recommendations for the administration of antibiotics prior to invasive dental treatments, in order to neutralize bacteremia. In this context, the recommendations of the American Heart Association (AHA) are the most widely used in our setting. Advances in our knowledge of the etiopathogenesis of bacterial endocarditis have placed increasingly less importance on invasive dental treatments as a causal factor (the AHA again reduced the number of cases in which antibiotic prophylaxis is recommended, on occasion of its latest guidelines update in 2007) - with increasingly greater importance being placed on factors associated with hygiene and oral health. The present study offers a critical review of the relationship between dental treatment, bacteremia and bacterial endocarditis.

Bacteremia originating in the oral cavity. A review

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In patients at risk because of heart disease, bacteremias induced by invasive dental treatments have been reported as a cause of bacterial endocarditis (BE) -a serious disorder that continues to involve a high mortality. As a result, different scientific societies have supported recommendations for the administration of antibiotics prior to invasive dental treatments, in order to neutralize bacteremia. In this context, the recommendations of the American Heart Association (AHA) are the most widely used in our setting. Advances in our knowledge of the etiopathogenesis of bacterial endocarditis have placed increasingly less importance on invasive dental treatments as a causal factor (the AHA again reduced the number of cases in which antibiotic prophylaxis is recommended, on occasion of its latest guidelines update in 2007) - with increasingly greater importance being placed on factors associated with hygiene and oral health.The present study offers a critical review of the relationship between dental treatment, bacteremia and bacterial endocarditis

Pediatric dental care in a tertiary public hospital. Four years of experience in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain).

UNLABELLED: A study is made of the experience gained with the Child Oral Care Program (Plan de Atención Dental Infantil, PADI) in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain) after four years in operation (July 2003 - July 2007). STUDY DESIGN: The sample comprised 2626 children between 5-14 years of age, pertaining to department 9 of the Valencian public health system. A clinical history was compiled in each case, a radiological study was made, and a treatment plan was elaborated including fillings, extractions, and control visits. RESULTS: Of the 2626 designated children, 2369 visited our Service - mostly referred from the Preventive Dental Care Units. A total of 5784 fillings were carried out (93.3% with silver amalgam, 5.6% with composites and the rest as provisional fillings). The permanent first molars were the teeth with the largest number of fillings (70.2% of the total). These were followed in order of frequency by the second molars (19.1%). As regards composite resin fillings, most involved the upper central incisors, followed by the upper lateral incisors. A total of 644 extractions were performed, corresponding to 110 permanent teeth and 534 temporary teeth. In the case of the permanent dentition, the first molars were the most commonly removed teeth. In the temporary dentition, the most frequently removed teeth were the second molars. CONCLUSIONS: The response of the population to this program has been very good, and reinforces the preventive measures already in place, with the provision of restorative treatments to improve the oral and dental health of the pediatric population, and yielding good results in terms of the program quality indicators. The Service of Stomatology (Valencia University General Hospital) is able to address the demand and offers the public health network integrated and continuous patient care.

Pediatric dental care in a tertiary public hospital. Four years of experience in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain)

A study is made of the experience gained with the Child Oral Care Program (Plan de Atención Dental Infantil,PADI) in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain) after four years in operation (July 2003 - July 2007).Study design: The sample comprised 2626 children between 5-14 years of age, pertaining to department 9 of theValencian public health system. A clinical history was compiled in each case, a radiological study was made, and a treatment plan was elaborated including fillings, extractions, and control visits.Results: Of the 2626 designated children, 2369 visited our Service - mostly referred from the Preventive Dental Care Units. A total of 5784 fillings were carried out (93.3% with silver amalgam, 5.6% with composites and the rest as provisional fillings). The permanent first molars were the teeth with the largest number of fillings (70.2% of the total). These were followed in order of frequency by the second molars (19.1%). As regards composite resin fillings, most involved the upper central incisors, followed by the upper lateral incisors. A total of 644 extractions were performed, corresponding to 110 permanent teeth and 534 temporary teeth. In the case of the permanent dentition, the first molars were the most commonly removed teeth. In the temporary dentition, the most frequently removed teeth were the second molars.Conclusions: The response of the population to this program has been very good, and reinforces the preventivemeasures already in place, with the provision of restorative treatments to improve the oral and dental health of the pediatric population, and yielding good results in terms of the program quality indicators. The Service of Stomatology (Valencia University General Hospital) is able to address the demand and offers the public health network integrated and continuous patient care (AU)

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Benign tumors of the oral mucosa: A study of 300 patients

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Objectives: To analyze the frequency and type of the most common benign tumors of the oral mucosa found at the Hospital Stomatology Service, and to study the clinical characteristics and possible etiological factors. Material and Methods: This is a retrospective study of 300 patients with histologically diagnosed benign tumors of the oral mucosa. Data was compiled for each case, documenting information relating to age, gender, medication, habits (smoking, oral hygiene), anamnesis (reason for consultation, symptomatology, evolution), and the characteristics of the lesion (site, color, size, surface, consistency, and base). Results: Of all the tumors studied, 53% were histologically diagnosed as fibroma. In the study of prevalence of benign tumors of the oral mucosa, no differences were found for age; however there were differences according to gender, finding a greater prevalence of fibromas, pyogenic granulomas, and giant cell granulomas in women, at a ratio of 2:1. The group of tumors studied showed a significantly asymptomatic behaviour, and self-limiting and slow growth. With respect to the possible etiologic agents, we found no statistically significant differences between them. Conclusions: Following the study of 300 patients histologically diagnosed with benign tumor of the oral mucosa, we can state that with regard to prevalence, we found significant differences with respect to gender, being more frequent in women. The fibroma is the most frequent benign tumor of the oral cavity

An update on the management of anticoagulated patients programmed for dental extractions and surgery

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Oral anticoagulants (OACs) antagonizing vitamin K - fundamentally sodium warfarin and acenocoumarol - are widely used for preventing arterial thromboembolism in patients with atrial fibrillation and/or heart valve prostheses, and for the treatment and prevention of deep venous thrombosis and pulmonary embolism.The handling of these drugs requires correct monitorization and dose adjustment to obtain the desired therapeutic effect while minimizing the adverse effects associated both with excessive anticoagulation (which leads to bleeding) and with insufficient antithrombotic action (which can produce thrombosis). This is particularly important when patients must be subjected to surgical procedures such as tooth extractions. In this context, a number of management recommendations are available.The present study offers an update on the recommendations for the management of anticoagulated patients programmed for tooth extractions. In recent years, most studies do not recommend reducing or interrupting anticoagulation, or replacing it with heparin, prior to tooth extraction - provided therapeutic international normalized ration (INR)levels are maintained, with emphasis on the application of local measures such as antifibrinolytic agents, for the control of hemostasia (AU)

Benign tumors of the oral mucosa: a study of 300 patients.

OBJECTIVES: To analyze the frequency and type of the most common benign tumors of the oral mucosa found at the Hospital Stomatology Service, and to study the clinical characteristics and possible etiological factors. MATERIAL AND METHODS: This is a retrospective study of 300 patients with histologically diagnosed benign tumors of the oral mucosa. Data was compiled for each case, documenting information relating to age, gender, medication, habits (smoking, oral hygiene), anamnesis (reason for consultation, symptomatology, evolution), and the characteristics of the lesion (site, color, size, surface, consistency, and base). RESULTS: Of all the tumors studied, 53% were histologically diagnosed as fibroma. In the study of prevalence of benign tumors of the oral mucosa, no differences were found for age; however there were differences according to gender, finding a greater prevalence of fibromas, pyogenic granulomas, and giant cell granulomas in women, at a ratio of 2:1. The group of tumors studied showed a significantly asymptomatic behaviour, and self-limiting and slow growth. With respect to the possible etiologic agents, we found no statistically significant differences between them. CONCLUSIONS: Following the study of 300 patients histologically diagnosed with benign tumor of the oral mucosa, we can state that with regard to prevalence, we found significant differences with respect to gender, being more frequent in women. The fibroma is the most frequent benign tumor of the oral cavity.

An update on the management of anticoagulated patients programmed for dental extractions and surgery.

Oral anticoagulants (OACs) antagonizing vitamin K - fundamentally sodium warfarin and acenocoumarol - are widely used for preventing arterial thromboembolism in patients with atrial fibrillation and/or heart valve prostheses, and for the treatment and prevention of deep venous thrombosis and pulmonary embolism. The handling of these drugs requires correct monitorization and dose adjustment to obtain the desired therapeutic effect while minimizing the adverse effects associated both with excessive anticoagulation (which leads to bleeding) and with insufficient antithrombotic action (which can produce thrombosis). This is particularly important when patients must be subjected to surgical procedures such as tooth extractions. In this context, a number of management recommendations are available. The present study offers an update on the recommendations for the management of anticoagulated patients programmed for tooth extractions. In recent years, most studies do not recommend reducing or interrupting anticoagulation, or replacing it with heparin, prior to tooth extraction - provided therapeutic international normalized ration (INR) levels are maintained, with emphasis on the application of local measures such as antifibrinolytic agents, for the control of hemostasia.

Epstein-Barr virus in oral proliferative verrucous leukoplakia and squamous cell carcinoma: A preliminary study

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The aim of this study was to analyze proliferative verrucous leukoplakia (PVL) and oral squamous cell carcinoma (OSCC) for the possible presence of Epstein-Barr virus (EBV). We studied three groups: Sub-Group 1 was composed of 10 patients with PVL, (6 of whom had developed OSCC); Sub-Group 2 comprised 5 patients with OSCC but no preceding PVL; and Sub-Group 3 were 5 controls with clinically normal oral mucosa. Oral biopsies from all cases were examined for Epstein-Barr virus (EBV) by nested PCR. EBV was detected in 60% of Sub-Group 1 patients (PVL ) and in 40% of Sub-Group 2 (OSCC), but in 0% of Sub- Group 3 (controls) (AU)

Epstein-Barr virus in oral proliferative verrucous leukoplakia and squamous cell carcinoma: A preliminary study.

The aim of this study was to analyze proliferative verrucous leukoplakia (PVL) and oral squamous cell carcinoma (OSCC) for the possible presence of Epstein-Barr virus (EBV). We studied three groups: Sub-Group 1 was composed of 10 patients with PVL, (6 of whom had developed OSCC); Sub-Group 2 comprised 5 patients with OSCC but no preceding PVL; and Sub-Group 3 were 5 controls with clinically normal oral mucosa. Oral biopsies from all cases were examined for Epstein-Barr virus (EBV) by nested PCR. EBV was detected in 60% of Sub-Group 1 patients (PVL ) and in 40% of Sub-Group 2 (OSCC), but in 0% of Sub-Group 3 (controls).

Lack of association between proliferative verrucous leukoplakia and human papillomavirus infection.

PURPOSE: To analyze proliferative verrucous leukoplakia (PVL) for the presence of human papillomavirus (HPV) in different stages of the disease. MATERIALS AND METHODS: We studied 13 patients with PVL. In 10 patients (76.9%), a lesional biopsy was taken and frozen at -40 degrees C. Four patients were instructed to mouth rinse with sterile sera. The biopsy and rinse samples were analyzed for HPV by PCR. RESULTS: We did not detect HPV infection in the PVL tissue or in the oral rinse of any of the 13 patients in any stage of the disease analyzed, neither in oral squamous cell carcinoma nor in the simple hyperkeratosis. CONCLUSION: There was no association between PVL and HPV infection in our patients.

Esclerosis multiple como primera manifestacion en el territorio oral y facial: Presentación de cuatro casos / Multiple sclerosis as first manifestation in oral and facial area: Presentation of four cases

La esclerosis múltiple (EM) es una enfermedad inflamatoria crónica del sistema nervioso central de etiología no conocida caracterizada por la aparición de sintomatologia neurológica diversa en forma de brotes o de deterioro progresivo y de lesiones en cualquier localización de la sustancia blanca cerebral que pueden dejar como secuelas la desmielinización definitiva de la zona. Esta enfermedad afecta a gente joven siendo más frecuente su aparición entre los 20 y 40 años, en climas templados y fríos y con una relación hombre-mujer de 0,46 / 0,67. La importancia de esta enfermedad radica en que es la primera causa de invalidez permanente en adultos jóvenes. Presentamos 4 casos de EM cuyo síntoma de inicio de la enfermedad fue la aparición de parestesias en el territorio maxilo-facial afectando a una o más ramas del trigémino y de tiempo de evolución que oscilaba entre 15 días y un año. Todos los pacientes fueron diagnosticados clínicamente siendo confirmado el diagnostico, tanto con la resonancia magnética como con el estudio del liquido cefalorraquídeo (LC) y los potenciales evocados(PE). Las manifestaciones en el territorio oral y facial fueron la primera manifestación de la enfermedad en todos los casos

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, whose etiology is unknown, and which is characteristic by the appearance of a diverse neurological symptomatology consisting of outbreaks or gradual deterioration and lesions in any location of the brain’s white matter which may provoke the after-effect of a definitive demyelination of the area. The disease affects young people, with its appearance being most frequent between 20 and 40 years of age, in temperate and cold climates, and with a man-woman rate of 0.46 / 0.67. The magnitude of this disease lies in the fact that it is the primary cause for permanent disablement among young adults. We are presenting 4 cases of MS whose initial symptom of the disease was the appearance of paraesthesia in the maxillofacial area, affecting one or more ramifications of the trigeminal nerve, and a progression time varying from 15 days to one year. All the patients were clinically diagnosed, with their diagnostics being confirmed both with magnetic resonance imaging as well as through the study of their cerebrospinal fluid (CSF) and the Evoked potentials ( EPs). Manifestations in the oral and facial area were the first manifestation of the disease in all cases

Multiple sclerosis as first manifestation in oral and facial area: presentation of four cases.

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, whose etiology is unknown, and which is characteristic by the appearance of a diverse neurological symptomatology consisting of outbreaks or gradual deterioration and lesions in any location of the brain s white matter which may provoke the after-effect of a definitive demyelination of the area. The disease affects young people, with its appearance being most frequent between 20 and 40 years of age, in temperate and cold climates, and with a man-woman rate of 0.46/0.67. The magnitude of this disease lies in the fact that it is the primary cause for permanent disablement among young adults. We are presenting 4 cases of MS whose initial symptom of the disease was the appearance of paraesthesia in the maxillofacial area, affecting one or more ramifications of the trigeminal nerve, and a progression time varying from 15 days to one year. All the patients were clinically diagnosed, with their diagnostics being confirmed both with magnetic resonance imaging as well as through the study of their cerebrospinal fluid (CSF) and the evoked potentials (EPs). Manifestations in the oral and facial area were the first manifestation of the disease in all cases.

Proliferative verrucous leukoplakia: unusual locations of oral squamous cell carcinomas, and field cancerization as shown by the appearance of multiple OSCCs.

Proliferative verrucous leukoplakia (PVL) is an uncommon entity with a high tendency to develop oral squamous cell carcinomas (OSCCs). The objective of this study was to analyse the presence of various OSCCs in the same patient with PVL. We studied 19 patients with PVL who had developed at least one OSCC. We analysed how many of these developed more than one OSCC over a period between 24 and a maximum of 130 months, indicating the location of their OSCC, clinical type and the time lapse between the appearance of each of the different OSCCs in the same patient. Of the 19 patients, 10 presented more than one of these cancers, one of whom even went on to develop five different cancers. The most frequent location of OSCC was the gingiva and the palate; the least common was the tongue/floor of mouth. Ninety percent were women and 20% were smokers. The average time elapsed between the detection of the first tumour and the appearance of the second was 19.20 months (SD 13.41). Our patients with PVL developed a high frequency of OSCCs, on many occasions manifesting several cancers at different oral locations, thus demonstrating the field cancerization of this entity. The OSCC in PVL patients were at sites quite uncommonly affected in patients who develop OSCC in the absence of PVL.