Medication non-adherence: a role for the dental professional.

Medication non-adherence is a multifactorial and complex problem that poses an enormous health and economic burden. Medication non-adherence related to medication side effects, referred to as rational non-adherence, is increasingly seen in patients. This article discusses rational non-adherence with an exemplar of osteoporosis patients discontinuing their medication, mainly bisphosphonates, for fear of complications such as osteonecrosis of jaw. Also, the possible role of dental professionals in overcoming medication non-adherence in general is outlined.

Atypical odontalgia--an update.

Atypical odontalgia is a commonly misdiagnosed condition that frequently leads to unnecessary dental treatments such as extraction and endodontic therapy. These treatments often worsen the pain. Despite greater recognition and understanding of this condition, proper diagnosis and treatment remains a challenge. It is believed that atypical odontalgia is a neuropathic condition. This article updates the current understanding of the etiology and pathophysiology of atypical odontalgia, and provides appropriate diagnostic and management approaches for this condition.

Medication nonadherence: a role for the dental professional.

Medication nonadherence is a multifactorial and complex problem that poses an enormous health and economic burden. Medication nonadherence related to medication side effects, referred to as rational nonadherence is increasingly seen in patients. This article discusses rational nonadherence with an exemplar of osteoporosis patients discontinuing their medication, mainly bisphosphonates, for fear of complications such as osteonecrosis of jaw. Also, the possible role of dental professionals in overcoming medication nonadherence in general is outlined.

The role of microbial biofilms in osteonecrosis of the jaw associated with bisphosphonate therapy.

Microbial biofilms have been observed and described in bone specimens of patients with bisphosphonate (BP)-associated osteonecrosis of the jaw (BONJ) and investigators are more recently suggesting that this condition essentially represents an osteomyelitis of the jaw clinically, with greater susceptibility in some patients on BP therapy. This article explains the role of microbial biofilms in BONJ and also discusses associated factors in the disease pathogenesis, which include BP effects on bone remodeling, anti-angiogenesis, matrix necrosis, microcracks, soft tissue toxicity, and inflammation and wound healing. Recent findings suggest a key role for microbial biofilms in the pathogenesis of BONJ; this has important therapeutic implications because biofilm organisms represent a clinical target for prevention and treatment efforts aimed at reducing the significant morbidity and costs associated with this condition.

Prevalence and impact of sleep disorders and sleep habits in the United States.

PURPOSE: Epidemiologic studies on sleep disorders in the USA have mostly focused on specific disorders in specific groups of individuals. Most studies on sleep habits and sleep-related difficulties have focused on children and adolescents. The authors describe the prevalence of the three common physician-diagnosed sleep disorders (insomnia, sleep apnea, and restless legs syndrome (RLS)) by age, gender, and race in the US population. In addition, the authors describe the sleep habits and sleep-related difficulties in carrying routine daily activities. The authors also investigate the impact of the sleep disorders on performing routine daily activities. METHODS: Data from the 2005-2006 National Health and Nutrition Examination Survey for 6,139 individuals over the age of 16 was analyzed for sleep-related parameters. RESULTS: The prevalence was highest for sleep apnea (4.2%), followed by insomnia (1.2%) and RLS (0.4%). Hispanics and Whites reported longer sleep duration than Blacks by 24 to 30 min. The predominant sleep habits were snoring while sleeping (48%), feeling unrested during the day (26.5%), and not getting enough sleep (26%). Difficulty concentrating (25%) or remembering (18%) were the main sleep-related difficulties in our sample. Insomnia, sleep apnea, and RLS had the highest impact on concentration and memory. CONCLUSIONS: Our findings suggest that the prevalence of sleep disorders in the USA is much lower than previously reported in the literature suggesting under diagnosis of sleep disorders by primary care physicians.

Microbial biofilms in osteomyelitis of the jaw and osteonecrosis of the jaw secondary to bisphosphonate therapy.

BACKGROUND: The authors report their observations with respect to microbial biofilms in osteomyelitis of the jaw (OMJ), compare these findings with those for osteonecrosis of the jaw (ONJ) secondary to bisphosphonate therapy and discuss recent findings that the pathogenesis of ONJ may represent a biofilm-mediated infectious disease in the context of bisphosphonate therapy. METHODS: In 2004, a program was established at the University of Southern California, Los Angeles, to evaluate, treat and monitor patients who have OMJ and ONJ. Twenty people from this cohort of study patients who were scheduled to undergo surgical debridement or sequestrectomy and who met the authors' inclusion criteria gave informed consent for the study. The authors examined bone samples histopathologically and via scanning electron microscopy, a technique applicable to biofilm characterization. RESULTS: Specimens from all patients with OMJ and ONJ exhibited large surface areas of bone occluded with well-developed biofilms comprising microbial organisms embedded in an extracellular polymeric substance. Actinomyces predominated in OMJ cases, whereas ONJ cases represented more diverse bacterial organisms in addition to fungal organisms not seen in OMJ. The authors observed resorption pits, septic clots, putative nanowires and host inflammatory cells in all specimens. CONCLUSIONS: The findings of this study support a role for microbial biofilms in both disease processes. CLINICAL IMPLICATIONS: Microbial biofilms are a potential target for therapy that includes antibiofilm modalities in the treatment and prevention of OMJ and ONJ.

Xerostomia: prevalence, diagnosis, and management.

This article summarizes the common causes, clinical presentation, and complications of xerostomia and salivary gland hypofunction in the geriatric population and discusses the various management options.

Prevalence of hypertension in patients with trigeminal neuralgia.

It is unclear whether hypertension (HTN) is a predisposing factor for the development of trigeminal neuralgia (TN). The purpose of this study was to determine the prevalence of HTN in TN patients and controls at the USC Orofacial Pain and Oral Medicine Center. A retrospective chart review was conducted from a database of over 3,000 patient records from 2003 to 2007. We identified patients diagnosed with TN with or without HTN. A total of 84 patients (54 females; 30 males) between the ages of 33 and 93 years were diagnosed with TN; 37% had TN with HTN and 32% of controls had HTN. The increased prevalence of HTN in the TN patients was not statistically significant (P = 0.50). Since, both TN and HTN are seen in the elderly, it is likely that HTN is simply a co-existing condition in patients with TN and not a risk factor for its development.

Clinical characteristics and diagnosis of atypical odontalgia: implications for dentists.

BACKGROUND: Atypical odontalgia (AO) is a poorly understood and commonly misdiagnosed condition for which patients often undergo multiple unsuccessful dental or surgical procedures. The authors conducted a study to determine the prevalence and describe the characteristics of patients with AO seen at the University of Southern California Orofacial Pain and Oral Medicine Center (USC OFP-OM Center), Los Angeles. METHODS: The authors conducted a retrospective record review from a database of more than 3,000 patient records from June 2003 to August 2007 to identify patients diagnosed with AO. RESULTS: The authors identified 64 patients (44 women and 20 men) between the ages of 26 and 93 years as having a diagnosis of AO. Of those 64 patients, 71 percent initially consulted a dentist regarding their pain, and 79 percent had undergone dental treatment that failed to resolve the pain. The pain of 64 percent of the patients had no known cause. CONCLUSIONS: Dentists, who often are the first health care providers to see patients with AO, must be aware of this condition and must follow the appropriate steps to determine its diagnosis. CLINICAL IMPLICATIONS: Dentists and physicians should understand the implications and importance of early diagnosis of patients with AO and of referral to pain specialists for treatment.

Measuring salivary flow: challenges and opportunities.

BACKGROUND: Saliva is being studied extensively and is being used for risk assessment, diagnosis and monitoring high-risk behavior and disease progression. A variety of medical conditions and medications are associated with salivary gland hypofunction. The major disadvantage in the use of saliva for health-related purposes is the lack of standardization in saliva collection methods. METHODS: The authors provide a brief overview of different methods of saliva collection and the advantages and disadvantages associated with each method, as well as of how to assess the salivary flow rate. RESULTS: The authors present the complete set up and step-by-step guidelines for the collection of unstimulated and stimulated whole saliva. CONCLUSIONS: The life expectancy of people will continue to increase with advances in medicine and therapeutic modalities, and the prevalence of salivary gland hypofunction in the elderly population will increase owing to their longevity. The assessment of salivary gland hypo-function will need to be incorporated into everyday clinical practice. CLINICAL IMPLICATIONS: The saliva collection methods outlined in this article can be used by dentists to assess patients at risk of developing diseases and by scientists for scholarly activities.

Identification of microbial biofilms in osteonecrosis of the jaws secondary to bisphosphonate therapy.

PURPOSE: Biofilm theory has emerged to explain the etiology of the chronic infections that have come to constitute between 65% to 80% of the microbial diseases treated by physicians in the developed world. The purpose of this article is to report for the first time the observation of multispecies microbial biofilms on affected bone in patients with osteonecrosis of the jaws (ONJ) secondary to bisphosphonate therapy. PATIENTS AND METHODS: A program has been established at the University of Southern California to monitor and evaluate patients with ONJ as a multidisciplinary collaboration between the School of Dentistry, Center for Biofilms, Center for Craniofacial Molecular Biology and the Keck School of Medicine. From this cohort, 4 patients with active ONJ who were scheduled for necessary treatment in the form of sequestrectomy gave informed consent for this study. Bone samples were evaluated using conventional histopathologic techniques and scanning electron microscopy, a technique applicable to biofilm characterization. RESULTS: Bone specimens from affected sites in all patients showed large areas occluded with biofilms comprising mainly bacteria, and occasionally yeast, embedded in extracellular polymeric substance. The number of bacterial morphotypes in the biofilms ranged from 2 to 15, and they included species from the genus Fusobacterium, bacillus, actinomyces, staphylococcus, streptococcus, Selenomonas, and 3 different types of treponemes. The yeast identified was consistent with Candida species. Co-aggregation was observed between different species within the biofilms. CONCLUSION: These findings have important clinical and therapeutic implications and may suggest a role for microbial biofilms in the disease process of ONJ.

Oral mucosal melanoma with unusual clinicopathologic features.

Oral mucosal melanoma (OMM) is an extremely rare malignancy, accounting for < 0.5% of all melanomas and all oral malignancies. The rarity of OMM, the heterogeneity in clinical and histopathologic appearances, and the paucity of molecular and genetic studies to date have limited our knowledge of the etiopathogenesis of these cancers. A 39-year-old Hispanic male presented for evaluation of a large, pigmented, plaque-like and nodular growth of the maxillary gingival and palatal mucosa. On presentation, a presumptive clinical diagnosis of mucosal melanoma was made, which was confirmed by incisional biopsy with subsequent histopathologic evaluation. Macroscopically, the morphology and highly pigmented nature of the tumor was suggestive of a rarer subtype of melanoma known as animal-type melanoma, also referred to as pigmented epithelioid melanocytoma. However, microscopically, the tumor showed histopathologic features consistent with a high-grade acral (mucosal) lentiginous melanoma with overt cytomorphologic features of malignancy in addition to showing prominent pigment synthesis resembling animal-type melanoma. A detailed search of the literature did not identify a previous report of OMM with prominent pigment synthesis resembling animal-type melanoma. Identification of melanoma subtypes has specific implications for therapeutic approach, and thus their recognition is important to successful patient management.

Toxic epidermal necrolysis with a rare long-term oral complication requiring surgical intervention.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a rare and potentially fatal adverse dermatologic reaction, often secondary to drug intake. METHODS AND RESULTS: We report a case of an adult male who developed TEN that was complicated by a sepsis-induced coma lasting a period of 3 months. Although the patient eventually recovered, severe oral mucosal involvement during the course of disease resulted in frenum-like fibrotic bands that connected movable oral mucosa (tongue and lips) to attached oral mucosa (gingiva). This complication was painful and also affected his ability to speak and maintain adequate oral hygiene, requiring surgical intervention to restore structure and function. CONCLUSIONS: This oral manifestation in relation to TEN is rarely reported in the literature and represents a preventable complication.

Oral squamous cell carcinoma incidence by subsite among diverse racial and ethnic populations in California.

OBJECTIVE: The aim of this report was to examine the oral cancer incidence by sex, race/ethnicity, and anatomical subsite. STUDY DESIGN: Data from the California Cancer Registry (CCR) were used to calculate the age-adjusted incidence rates of invasive oral squamous cell carcinoma (OSCC) by sex, race/ethnicity, and anatomical subsite among residents in California during 1988 to 2001. RESULTS: Although non-Hispanic (NH) black men have the highest overall incidence rate for OSCC, NH whites and NH blacks have similar incidence patterns by subsite, but the male-to-female (M:F) rate ratio is higher among NH blacks. The OSCC incidence rates for Hispanics are much lower than those for NH whites and NH blacks and similar to those of Asians. The Asian ethnic groups display dramatic variations in terms of the subsite-specific incidence rates and M:F rate ratios. CONCLUSION: The findings illustrate the heterogeneity and complexity of oral cancer by anatomical location and the importance of cultural habits and behavioral factors in the development of oral cancer.

Osteonecrosis of the jaws secondary to bisphosphonate therapy: a case series.

AIM: The objective of this report is to present the clinical experiences of several patients affected with osteonecrosis (ONJ) secondary to bisphosphonate (BP) therapy and to provide a discussion of the specific BPs implicated in this condition. BACKGROUND: ONJ secondary to BP therapy is becoming an increasingly reported complication following dental therapy. This is particularly true of surgical dental procedures such as extractions. BPs are a class of pharmaceuticals used in the treatment of numerous disorders affecting bone, including osteoporosis, cancer metastases to bone, hypercalcemia of malignancy, and multiple myeloma. Although ONJ is a more recently described phenomenon, it is an emerging problem that may be associated with significant morbidity such as oral dysfunction, impaired eating ability, pain, and compromised esthetics resulting in a poor quality of life in affected patients. CASE REPORT: This is a description of 13 patients affected with ONJ secondary to BP therapy managed at the Orofacial Pain & Oral Medicine Center, Special Patients Clinic, and Oral and Maxillofacial Surgery Clinic at the University of Southern California, School of Dentistry between October 2005 and April 2007, with a discussion of the specific BPs implicated in this condition, the clinical presentation, management, and follow-up. SUMMARY: Thorough reporting of every case of ONJ is important to help advance the understanding of this poorly understood condition. The authors' approach to care represents a more conservative mode to management than previously described by many investigators.

Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation.

Lichen planus, a chronic autoimmune, mucocutaneous disease affects the oral mucosa (oral lichen planus or OLP) besides the skin, genital mucosa, scalp and nails. An immune mediated pathogenesis is recognized in lichen planus although the exact etiology is unknown. The disease most commonly affects middle-aged females. Oral lichenoid reactions (OLR) which are considered variants of OLP, may be regarded as a disease by itself or as an exacerbation of an existing OLP, by the presence of medication (lichenoid drug reactions) or dental materials (contact hypersensitivity). OLP usually presents as white striations (Wickham's striae), white papules, white plaque, erythema, erosions or blisters. Diagnosis of OLP is established either by clinical examination only or by clinical examination with histopathologic confirmation. Direct immunofluorescence examination is only used as an adjunct to the above method of diagnosis and to rule out specific autoimmune diseases such as pemphigus and pemphigoid. Histopathologic features of OLP and OLR are similar with suggestions of certain discriminatory features by some authors. Topical corticosteroids are the treatment of choice for OLP although several other medications have been studied including retinoids, tacrolimus, cyclosporine and photodynamic therapy. Certain OLP undergo malignant transformation and the exact incidence and mechanisms are still controversial. In this paper, etiopathogenesis, diagnosis, management and malignant transformation of OLP and OLR have been reviewed.