Recent infective endocarditis research findings suggest dentists prescribe prophylactic antibiotics for patients having a bicuspid aortic valve or mitral valve prolapse.

BACKGROUND: The scientific validity of the European Society of Cardiology's (ESC) infective endocarditis (IE) guidelines limiting provision of prophylactic antibiotics (AP) only to patients having cardiac anomalies (e.g., prosthetic valves) believed to place them at "high risk" of adverse events when undergoing high risk dental procedures (HRDP) is unclear. MATERIAL AND METHODS: A systematic review of studies conducted between 2017 and 2022 and catalogued in the PubMed database was undertaken to ascertain if this edict was associated with changes in IE incidence, development of infection in unprotected cardiac anomalies, developing infection and resultant adverse clinical outcomes. RESULTS: Retrieved were 19 published manuscripts, however of these, 16 were excluded because they did not bare upon the issues of concern. Among the three studies eligible for review were those in the Netherlands, Spain, and England. The results of the Dutch study denoted a significant increase in the incidence of IE cases over the projected historical trend (rate ratio: 1327, 95% CI 1.205-1.462; p<0.001) after the introduction of the ESC guidelines. The findings from the Spanish study evidenced the uniquely high in-hospital IE associated fatality rates suffered by patients having bicuspid aortic valves (BAV); 5.6% or mitral valve prolapse (MVP); 10%. The British study provided evidence that the incidence of fatal IE infection was significantly greater among an "intermediate risk" cohort of patients, (a group likely including those with BAC and MVP for which the ESC guidelines don't recommend AP), than among "high risk" patients (P = 0.002). CONCLUSIONS: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the "high risk" category so that AP are recognized as being needed prior to provision of HRDP.

Detection of carotid artery calcification on the panoramic images of post-menopausal females is significantly associated with severe abdominal aortic calcification: a risk indicator of future adverse vascular events.

OBJECTIVES: Outcome studies among post-menopausal females with calcified carotid artery plaque (CCAP) on their panoramic images have not been previously undertaken. We sought to compare the extent of abdominal aortic calcification (AAC) on lateral lumbar spine radiographs (LLSRs), among groups of females with (CCAP+) and without (CCAP-) carotid lesions on their panoramic images. "Severe" levels of AAC have previously been validated as a risk indicator of future adverse cardiovascular events. METHODS: This cross-sectional case-control study included a "CCAP+ group" consisting of females more than 50 years of age having the carotid lesion diagnosed by their dentists and an atherogenic risk factor (age, body mass index, hypertension, diabetes and dyslipidaemia)-matched "CCAP- group". A physician radiologist, using the Framingham index, evaluated the LLSRs for the magnitude of AAC. Summary statistics for key variables were computed and conditional logistic regression techniques were considered. RESULTS: Members of the CCAP+ group were significantly (p=0.038) more likely to demonstrate "severe" levels of AAC on their LLSRs than members of the CCAP group. CONCLUSIONS: This is the first published study demonstrating that CCAP on panoramic images of post-menopausal females is significantly associated with "severe" levels of AACs on LLSRs independent of traditional risk factors. Given that these levels of AAC are a validated risk indicator of future myocardial infarction and stroke, dentists must evaluate the panoramic images of post-menopausal females for the presence of CCAP. Patients with carotid atheromas should be referred to their physicians for further evaluation given the systemic implications.

Prevalence of calcified carotid artery atheromas on panoramic images of individuals with primary hyperparathyroidism.

OBJECTIVES: Primary hyperparathyroidism (PHPT), affecting 1% of the population, is associated with increased cardiovascular morbidity and mortality. The presence of calcified carotid artery plaque (CCAP) on panoramic images is a validated risk indicator of future adverse cardiovascular events. We hypothesized that military veterans aged 50 years or older diagnosed with PHPT by increased parathyroid hormone and calcium levels would frequently have CCAP on their images. METHODS: We determined the prevalence rates of CCAP on the images of patients diagnosed with PHPT and evaluated their atherogenic risk profiles, including hypertension, dyslipidaemia, diabetes and obesity. Comparisons of atherogenic risk factors were made between subjects with and without observed CCAP on their panoramic images. RESULTS: Of the 60 patients (86.7% males and 13.3% females, mean age 73.2 ± 11.3 years) with PHPT, 40% had atheromas. There were no significant differences between CCAP+ and CCAP- groups in gender or race (p > 0.05). The atherogenic profile (age, body mass index, hypertension, diabetes, hyperlipidaemia) in the CCAP+ and CCAP- groups was not significantly different (p > 0.05). CONCLUSIONS: Calcified carotid artery atheromas are often seen on the panoramic images of patients with PHPT. Thus, dentists must be uniquely vigilant for these lesions when evaluating these studies.

Panoramic images of white and black post-menopausal females evidencing carotid calcifications are at high risk of comorbid osteopenia of the femoral neck.

OBJECTIVES: Femoral neck fractures in older females resulting from decreased bone mineral density (BMD; osteopenia) are associated with increased morbidity and mortality. Bone mineralization inhibition is probably controlled by proteins which also foster vascular calcification. Therefore, we evaluated the relationship between calcified carotid artery plaque (CCAP) on panoramic images and BMD on dual energy X-ray absorptiometry (DXA) bone scans. METHODS: Images and hospital records identified by dentists defined two study groups (20 white females and 24 black females) having CCAP and an incidentally obtained bone scan. Ethnically matched (age±7 years, body mass index ±3 units) control groups with panoramic images devoid of CCAP and accompanying DXA scan were likewise constituted. A physician determined the BMD on the DXA. RESULTS: Females with CCAP had significantly (p = 0.03) poorer BMD at the femoral neck than those without CCAP. Although mean femoral neck BMD was significantly lower (p = 0.009) for white than for black females, there was no significant interaction between race and CCAP (p = 0.80). CONCLUSION: We observed a significant inverse association between the CCAP on panoramic images and femoral neck BMD in post-menopausal white females.

Bilateral bifid mandibular condyles diagnosed with three-dimensional reconstruction.

Bifid mandibular condyles (BMCs) are rare anomalies. The overwhelming majority of prior reports described their predominantly unilateral occurrence diagnosed by panoramic radiography. We present an even rarer case of bilateral BMC initially identified by panoramic radiography and confirmed with colour-enhanced three-dimensional CT. These images substantiate the theory that the secondary condyles arise from the neck of the mandible (Lopez-Lopez et al. Bifid condyle: review of the literature of the last 10 years and report of two cases. Cianio 2010; 28: 136-140).

Carotid artery atheromas in postmenopausal women. Their prevalence on panoramic radiographs and their relationship to atherogenic risk factors.

BACKGROUND: More than 60 percent of the deaths in the United States attributed to stroke occur in postmenopausal women. As estrogen levels decline, atherosclerotic lesions (that is, atheromas) develop in the region of the carotid bifurcation and have been implicated as the precipitating cause in the majority of these strokes. Atheromas often are calcified and have been detected on the panoramic radiographs of neurologically asymptomatic male veterans; however, similar studies have not been conducted among female veterans. METHODS: The authors assessed panoramic radiographs and medical records of 52 neurologically asymptomatic female veterans (mean age, 70.4 years), with a history of amenorrhea of more than 12 months' duration, for atheromas and risk factors associated with atherosclerosis. RESULTS: The radiographs of 16 subjects (31 percent) exhibited atheromas located in the neck about 2.0 centimeters inferior and posterior to the angle of the mandible. These findings were confirmed in all instances by the presence of atheromas on anteroposterior cervical spine radiographs. The medical histories of these subjects were heavily laden with atherogenic risk factors (hypertension, 94 percent; body mass index of 27 to 29.9 [characterized as overweight], 25 percent; body mass index of 30 or higher [characterized as obese], 25 percent; smoking more than 15 pack-years, 38 percent; hyperlipidemia, 69 percent; type 2 diabetes mellitus, 21 percent). Hypertension was significantly associated with the presence of atheromas. CONCLUSIONS: Some neurologically asymptomatic women at high risk of developing stroke can be identified in the dental office via panoramic radiography. Women whose X-rays show calcified carotid artery atheromas are almost always hypertensive and have medical histories heavily laden with other atherogenic risk factors. CLINICAL IMPLICATIONS: Dentists should refer patients with such calcifications to an appropriate physician for further evaluation and treatment.

Major depressive disorder. Psychopathology, medical management and dental implications.

BACKGROUND: Major depressive disorder, or MDD, is a psychiatric illness in which mood, thoughts and behavioral patterns are impaired for long periods. The illness distresses the person and impairs his or her social functioning and quality of life. MDD is characterized by marked sadness or a loss of interest or pleasure in daily activities, and is accompanied by weight change, sleep disturbance, fatigue, difficulty concentrating, physical impairment and a high suicide rate. In 2000, the World Health Organization, or WHO, identified MDD as the fourth ranked cause of disability and premature death in the world. WHO projected that by 2020, MDD would rise in disease burden to be second only to ischemic heart disease. The disorder is common in the United States, with a lifetime prevalence rate of 17 percent and a recurrence rate of more than 50 percent. CONCLUSIONS: MDD may be associated with extensive dental disease, and people may seek dental treatment before becoming aware of their psychiatric illness. MDD frequently is associated with a disinterest in performing appropriate oral hygiene techniques, a cariogenic diet, diminished salivary flow, rampant dental caries, advanced periodontal disease and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management requires a vigorous dental education program, the use of saliva substitutes and anticaries agents containing fluoride, and special precautions when prescribing or administering analgesics and local anesthetics. CLINICAL IMPLICATIONS: Dentists cognizant of these signs and symptoms have an opportunity to recognize patients with occult MDD. After confirmation of the diagnosis and institution of treatment by a mental health practitioner, dentists usually can provide a full range of services that may enhance patients' self-esteem and contribute to the psychotherapeutic aspect of management.

The effect of periodontal treatment on glycemic control in patients with type 2 diabetes mellitus.

BACKGROUND, AIMS: This study was designed to explore the effect of periodontal therapy on glycemic control in persons with type 2 diabetes mellitus (DM). METHODS: 36 patients with type 2 DM (treatment group) received therapy for adult periodontitis during an 18-month period. A 36-person control group was randomly selected from the same population of persons with type 2 DM who did not receive periodontal treatment. RESULTS: These groups were well matched for most of the parameters investigated. During the nine-month observation period, there was a 6.7% improvement in glycemic control in the control group when compared to a 17.1% improvement in the treatment group, a statistically significant difference. Several parameters that could confound or moderate this glycemic control were explored. These included the treatment of non-dental infections, weight and medication changes. No moderating effect was associated with any of these variables. However, there were too few subjects in the study to have the statistical power necessary to assess these possible moderators of glycemic control. CONCLUSIONS: We interpret the data in the study to suggest that periodontal therapy was associated with improved glycemic control in persons with type 2 DM.

The role of the dentist in detection of carotid atherosclerosis.

Cerebrovascular accidents (CVA), or stroke, afflict 731,000 Americans each year, with 165,000 of these individuals dying. Stroke is a major cause of death and disability throughout the world, including southern Africa. Atherosclerosis-related formation of thrombi and emboli at the bifurcation of the common carotid artery and proximal internal carotid artery represents a common cause of stroke. The detection of carotid atherosclerosis by dentists using panoramic radiographs recently has been presented to the public through television news stories and the press, but many dentists still do not know how to interpret panoramic radiographs for detection of this condition. This communication illustrates examples in which carotid atherosclerosis was detected using panoramic radiography. Differential diagnoses are presented. Since not every carotid plaque calcifies, panoramic radiography should never be used alone to exclude the possibility of carotid atherosclerosis. It should also be remembered that the mere presence of calcified carotid plaque is not necessarily a reflection on the degree of carotid stenosis. Definitive diagnosis and treatment requires referral of patients deemed to be at risk to an appropriate physician. A variety of advanced diagnostic methods, including gadolinium-enhanced MRI, Duplex Doppler sonography and angiography are used to confirm carotid stenosis.

Dentistry's role in the diagnosis and co-management of patients with sleep apnoea/hypopnoea syndrome.

The sleep apnoea/hypopnoea syndrome (SAHS) is characterized by repeated upper airway narrowing or collapse during sleep. The obstruction is caused by the soft palate and/or base of tongue collapsing against the pharyngeal walls because of decreased muscle tone. These episodes are accompanied by hypoxaemia, surges in blood pressure, brief arousal from sleep and pronounced snoring. Individuals with occult disease are at heightened risk of motorway accidents because of excessive sleepiness, sustained hypertension, myocardial infarction, and stroke. The signs and symptoms of SAHS may be recognisable in the dental practice. Common findings in the medical history include daytime sleepiness, snoring, hypertension, and type 2 diabetes mellitus. Common clinical findings include male gender, obesity, increased neck circumference, excessive fat deposition in the palate, tongue (macroglossia) and pharynx, a long soft palate, a small recessive mandible and maxilla, and calcified carotid artery atheromas on panoramic and lateral cephalometric radiographs. Dentists who recognise these signs and symptoms have an opportunity to diagnose patients with occult SAHS. After confirmation of the diagnosis by a physician, dentists can participate in the management of the disorder by fabricating mandibular advancement appliances that enlarge the retroglossal space by anterior displacement of the tongue and performing corrective upper airway surgery that prevents recurrent airway obstruction.

Diagnosing and comanaging patients with obstructive sleep apnea syndrome.

BACKGROUND: Obstructive sleep apnea syndrome, or OSAS, is a common, but underdiagnosed, disorder that potentially is fatal. It is characterized by repetitive episodes of complete or partial upper airway obstruction leading to absent or diminished airflow into the lungs. These episodes usually last 10 to 30 seconds and result in loud snoring, a decrease in oxygen saturation, and chronic daytime sleepiness and fatigue. The obstruction is caused by the soft palate, base of the tongue or both collapsing against the pharyngeal walls because of decreased muscle tone during sleep. Potentially fatal systemic illnesses frequently associated with this disorder include hypertension, pulmonary hypertension, heart failure, nocturnal cardiac dysrhythmias, myocardial infarction and ischemic stroke. CLINICAL IMPLICATIONS: The classic signs and symptoms of OSAS may be recognizable by dental practitioners. Common findings in the medical history include daytime sleepiness, snoring, hypertension and type 2 diabetes mellitus. Common clinical findings include obesity; a thick neck; excessive fat deposition in the palate, tongue (enlarged) and pharynx; a long soft palate; a retrognathic mandible; and calcified carotid artery atheromas on panoramic and lateral cephalometric radiographs. CONCLUSIONS: Dentists cognizant of these signs and symptoms have an opportunity to diagnose patients with occult OSAS. After confirmation of the diagnosis by a physician, dentists can participate in management of the disorder by fabricating mandibular advancement appliances and performing surgical procedures that prevent recurrent airway obstruction.

The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus.

OBJECTIVE: Type 2 diabetes mellitus, which afflicts 15 million Americans, is associated with accelerated cervical carotid artery atherosclerosis and a heightened risk of stroke. This study attempted to determine the prevalence of calcified atherosclerotic lesions in a group of patients with type 2 diabetes mellitus. STUDY DESIGN: The panoramic radiographs of 49 men (age range, 55 to 81; mean age, 66.2 years) receiving routine dental treatment and insulin for diabetes at a Department of Affairs Veterans clinic were evaluated for calcified atheromas. Age-match controls, free of diabetes, were assessed in a like manner. Statistical comparison of the atheroma prevalence rates was by means of the Fisher exact test, and statistical comparison of atherogenic risk factors was by means of t test with Bonferroni adjustment and, where necessary, the Mann-Whitney U test. RESULTS: The radiographs of the diabetics (mean age, 66.9 years) revealed that 20.4% had atheromas whereas those of the controls (mean age, 68.1 years) demonstrated that 4% had atheromas (a statistically significant difference; P =.0275). Also statistically significant was the prevalence of atherogenic risk factors (plasma glucose, low-density lipoproteins, and serum triglycerides) identified in the diabetic group. The radiographic appearance of the atheromas manifested by both groups of individuals, however, was similar, with the lesions located 1.5-2.5 cm inferior-posterior to angle of the mandible. CONCLUSIONS: People with type 2 diabetes have a greater prevalence of calcified atheromas on their panoramic radiographs than do nondiabetics.

Detection of radiation-induced cervical atheromas by panoramic radiography.

Therapeutic irradiation of the neck is frequently used to treat patients with head and neck carcinoma. The irradiation, however, has been implicated as the cause of cervical carotid artery atherosclerotic lesions and subsequent stroke. Panoramic radiography previously shown capable of demonstrating isolated lesions was used to assess their development over time. Individuals with a pre-irradiation radiograph free of atheromas were enrolled for study. The prevalence rate of atheroma formation on post-irradiation (bilateral portals at >/=45 Gy) radiographs obtained at an interval of >/=36 months was determined. A control group of non-irradiated patients having similar risk factors for head and neck carcinoma and atherosclerosis and having an initial radiograph free of atheroma formation were likewise enrolled for study. The prevalence rate of atheroma formation on a second radiograph obtained from these individuals at an interval of >/=36 months was determined. The study population consisted of 17 patients, with a mean age of 56.5 (range 21.5-77.8) years who received a mean therapeutic irradiation dose of 53.2 Gy (range 45-71) to each side of their neck. The prevalence rate of atheromas manifested on the post-irradiation radiographs was 53%. These radiographs were obtained, on average, 69.7 (range 37-133) months after completion of radiation therapy. The prevalence rate of atheromas manifested on the second radiograph of patients in the control group was 5.9%. These radiographs were obtained, on average, 53.5 (range 52-55) months after the first. The difference in prevalence rates was statistically significant (p=0.0003). Individuals who have received therapeutic irradiation to the neck are more likely to develop carotid artery atheromas after treatment than are risk-matched control patients who have not been irradiated. These lesions can be detected by panoramic radiography.

The prevalence of carotid atheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosis.

PURPOSE: Persons with obstructive sleep apnea syndrome (OSAS) suffer inordinately high rates of stroke, but the cause remains in doubt. Atherosclerosis (atheroma formation) of the extracranial carotid artery has been suggested as a possible cause. Because atheromas can be recognized on panoramic radiographs, this study compared their prevalence in subjects with OSAS and normal controls and analyzed their relation to atherogenic risk factors. PATIENTS AND METHODS: Panoramic radiographs and medical records of 54 male subjects (mean age, 60.4 years) with OSAS (apnea/hypopnea index [AHI] of 15 or greater and a history of snoring and excessive daytime sleepiness) were assessed for atheromas and risk factors. Age-matched controls were likewise assessed. RESULTS: Twelve individuals (22%) with OSAS showed atheromas on their radiographs. The radiographs of the controls showed that 3.7% had atheromas. This finding was statistically significant (P = .0079). The prevalence of type 2 diabetes mellitus among individuals with OSAS and atheroma formation (7 of 12 persons, 58%) was far greater than the prevalence of diabetes (10 of 42 persons, 24%) experienced by individuals with OSAS but free of atheroma formation. This finding was also statistically significant (P = .035). The lesions seen in both the subject and control populations were similar and were located in the neck, 1.5 to 2.5 cm inferior-posterior to the angle of the mandible. CONCLUSIONS: Persons with OSAS are more likely to manifest calcified atheromas on their panoramic radiographs than age-matched controls. Type 2 diabetes is significantly more prevalent in individuals with both OSAS and calcified atheromas.

The prevalence of calcified carotid artery atheromas in patients with obstructive sleep apnea syndrome.

PURPOSE: Persons with obstructive sleep apnea syndrome (OSAS) suffer cerebrovascular accidents at three to six times the rate of other Americans. Atherosclerosis of the cervical portion of the carotid artery has been suggested as a possible cause of these strokes. Lateral cephalometric radiographs used to determine the site of upper airway obstruction in sleep apnea patients can also image calcified cervical carotid artery atheromas. However, their prevalence in this group of patients has not been previously reported. PATIENTS AND METHODS: The radiographs of 47 male subjects (mean age 59.2 years, range 45 to 77 years) diagnosed as having OSAS (apnea/hypopnea index [AHI] of > or = 15 and a history of snoring and excessive daytime sleepiness) were assessed for calcified carotid atheromas. Healthy, age-matched (+/-18 months) controls were likewise assessed. RESULTS: The radiographs of the subjects with OSAS showed that 21.3% had calcified atheromas. The radiographs of the controls showed that only 2.5% had calcified atheromas. This finding was statistically significant (P = < .000001). The lesions seen in both populations were similar, and located within the soft tissues of the neck at the level of C3 and C4. The lesions were superimposed over these tissues, the prevertebral fascia, and the pharyngeal airspace. CONCLUSIONS: The results of this study seem to indicate that persons with OSAS have a greater prevalence of calcified carotid artery atheromas than healthy, age-matched persons. These lesions, a possible cause of future stroke, can be detected on lateral cephalometric radiographs.