Intranasal/intravenous sedation for the dental care of adults with severe disabilities: a multicentre prospective audit.

OBJECTIVE: This study was designed to provide an evaluation of the combined intranasal/intravenous midazolam sedation technique. It involved adults with severe disabilities which prevented them from being able to co-operate with dental treatment and intravenous cannulation for sedation. METHOD: Following a previous retrospective audit, additional treatment centres were enrolled and a standardised form used to collect prospective data about the effectiveness of the technique in facilitating cannulation, dental examination and treatment. Data was also collected on safety and patient acceptability. RESULTS: In a total of 316 sedation episodes in primary and secondary care settings, cannulation was achieved in 96.2% (304). Dental examination and treatment was able to be carried out without major interference from the patient in 78.8% (241) episodes. Adverse sedation events occurred in 6.0% (19), the most frequent being desaturation which was easily managed. There were no incidents with serious sequelae. Favourable acceptability ratings were given by carers regarding advantages of ease of administration and speed of onset of the intranasal dose, plus reduction in the stress associated with cannulation and treatment. CONCLUSIONS: This study provides further evidence to support the effectiveness, safety and acceptability of this technique. The authors suggest this provides sufficient basis to justify its use by suitably trained dental practitioners in primary care as part of the spectrum of anxiety and behaviour management for this group.

A practical skill one day medical emergencies course for dentists and DCPs.

This paper describes a practical skills one day course in the 'management of medical emergencies' which is aimed at fulfilling the requirements for training for dentists and DCPs as defined by the Resuscitation Council UK and prefaced by the GDC.

Natural rubber latex allergy: implications for the orthodontist.

Natural rubber latex (NRL) allergy can have potentially serious consequences, and reports of orthodontic patients reacting to NRL have increased significantly over recent years. It is therefore important for the orthodontist to know how to manage patients with an NRL allergy and how to deal with possible reactions to NRL. Safe and effective practice depends on recognizing patients who are at risk of NRL allergy, and an awareness of materials and equipment that contain NRL and the availability of suitable NRL-free alternatives.

Infective endocarditis and dentistry: the legal basis for an association.

OBJECTIVES: The objectives of this study were to determine on what evidence infective endocarditis (IE) could be legally linked to dental treatment. METHOD: The records of 319 legal cases involving dental treatment as the probable cause of IE were analysed. The medical history, type of dental operation, and whether antibiotic prophylaxis was provided were noted. The time taken for the onset of symptoms (incubation period) and hospitalisation was calculated. The identity of the infecting micro-organism was investigated and it was also noted whether litigation was successful for the patient. RESULTS: A total of 83 patients were successful in legally linking dental treatment to the onset of infective endocarditis. In all successful cases there was a short incubation period (circa nine days) and in 80 of the patients an oral Streptococcus was isolated. The dental operations included exodontia (28), scaling (29), endodontics (12) and minor oral surgery (11). CONCLUSIONS: Dental treatment was deemed to be the probable cause of IE in 26% of patients who sought litigation. In the majority of legal cases clinicians did not follow recognised guidelines or keep adequate clinical notes. The three main factors which link dental procedures legally were the dental operation, the isolation from the blood of an oral micro-organism and a short incubation period.

UK patients with primary Sjögren's syndrome are at increased risk from clinical depression.

OBJECTIVE: This study was undertaken to assess the presence and degree of anxiety and depression in a group of UK patients with primary Sjögren's syndrome (1 degrees SS). DESIGN: Cross-sectional. SETTING: Department of Oral Medicine, Liverpool University Dental Hospital. SUBJECTS: Eighty adult patients; 40 diagnosed with 1 degrees SS according to the revised European Criteria and 40 age/gender-matched controls with no history of chronic illness. INTERVENTION: Hospital Anxiety and Depression Scale (HADS), a self-administered questionnaire designed to evaluate the presence and degree of anxiety and depression in a clinical setting. MAIN OUTCOME MEASURES: Age, gender, Hospital Anxiety and Depression Scale (HADS). RESULTS: Forty patients with 1degrees SS and 40/age/gender-matched controls completed the HADS. Scores for anxiety in both the 1 degrees SS and control groups showed no statistically significant difference. Patients with 1 degrees SS had statistically significant higher, mean HADS scores for depression than the controls. There was an increased prevalence of 'definite' clinical depression in the 1 degrees SS group. CONCLUSION: Patients with 1 degrees SS appear to be at increased risk from clinical depression. Early recognition and appropriate intervention is therefore essential to reduce the negative impact of depression on the patient's quality of life and outcome of their disease.

Dental management of the myasthenic patient.

Myasthenia gravis (MG) is an auto-immune disorder of neuromuscular transmission which results in weakness and fatigue of skeletal muscles. The defect in neuromuscular transmission is most commonly seen in the muscles of the eyes, face, neck and shoulders but, in some patients, the respiratory muscles are involved. Patients with this condition may present with problems that necessitate special consideration when managing their dental treatment. Patients who are only mildly affected by MG can be treated in general dental practice for routine care. There are no contra-indications to the use of local anaesthetic agents and the presence of a vasoconstrictor is desirable. More severely affected patients and those who are very anxious about dental treatment should be cared for within the hospital environment. In these patients, respiratory muscles may be affected and, as a result, a myasthenic crisis may arise which requires assisted ventilation and, in some cases, intubation. Those patients who are fearful of the dental environment are likely to be emotionally stressed during such times and this increases the risk of a myasthenic crisis; sedation techniques can be beneficial in this group of patients.

The etiology and management of gagging: a review of the literature.

Gagging in dental patients can be disruptive to dental treatment and may be a barrier to patient care, preventing the provision of treatment and the wearing of prostheses. This article reviews the literature on the gagging problem from English-language peer-reviewed articles from the years 1940 to 2002 found by conducting an electronic search of PubMed, coupled with additional references from citations within the articles. Dentally relevant articles have been cited wherever evidence exists, and a balanced view given in situations where there is controversy. The first section considers the normal gag reflex and factors that may be associated with the etiology of gagging, including anatomical and iatrogenic factors, systemic disorders, and psychological conditions. A review of the management of patients with an exaggerated gag reflex follows and includes strategies to assist clinicians.

Oral signs and symptoms as predictors of salivary gland hypofunction in general dental practice.

OBJECTIVE: To evaluate the signs and symptoms of oral dryness as predictors of salivary gland hypofunction (SGH) in general dental practice. DESIGN AND SETTING: Prospective study recruiting adult patients attending five general dental practices in Merseyside in 1999. MATERIALS AND METHOD: Patients were screened for subjective symptoms of oral dysfunction and clinical signs of oral dryness. Patients with oral symptoms or signs of SGH were invited to undergo sialometry. Results were analysed using multiple logistic regression. RESULTS: 1103 patients were screened for signs and symptoms of oral dryness, 115 reported continuous xerostomia, of these 65 were also clinically (subjectively) assessed as having a dry oral mucosa. One hundred and one patients attended for sialometry and 73% of these had objective evidence of SGH. Neither the patients' complaints of oral dryness or the assessment of dryness of the oral mucosa were significant predictors of SGH. CONCLUSIONS: Symptoms of oral dysfunction and clinical signs of oral dryness were not significant predictors of SGH in dental practice.

A comparison of salivary gland hypofunction in primary and secondary Sjögren's syndrome.

OBJECTIVE: A commonly held view by clinicians is that the salivary gland hypofunction associated with primary Sjögren's syndrome (SS-1) is more severe than that associated with secondary Sjögren's syndrome (SS-2). This study aimed to determine if this view could be substantiated, when applied to a large sample group. METHOD: Unstimulated and paraffin wax-stimulated whole salivary flow rates were retrospectively compared for age and gender matched, patients diagnosed with SS-1 or SS-2 according to the preliminary European criteria. The patients had attended the Xerostomia Clinic, in the Oral Medicine Department, at the Liverpool University Dental Hospital. RESULTS: Sixty-seven patients with SS-1 (average age 57.1 years) were matched with 67 patients with SS-2 (average age 57.6 years), according to gender and age, within 5 years. The mean unstimulated whole salivary flow rates (+/- s.d.) for patients with SS-1 and SS-2 were 0.11 (+/- 0.15) and 0.12 (+/- 0.18) mL min-1 respectively. The mean paraffin wax stimulated, whole salivary flow rates (+/- s.d.) for patients with SS-1 and SS-22 were 0.45 (+/- 0.02) and 0.47 (+/- 0.49) mL/min-1 respectively. No significant differences, in either stimulated (P = 0.54) or unstimulated (P = 0.60) whole salivary flow rates were found between individuals with SS-1 or SS-2. CONCLUSION: The severity of salivary gland hypofunction does not appear to be related to the clinical variant of Sjögren's syndrome.

Age and medication are significant risk factors for xerostomia in an English population, attending general dental practice.

OBJECTIVE: To study the prevalence of xerostomia in an English population, attending general dental practice and relate it to age, medication and gender. DESIGN STUDY: Cross-sectional. SETTING: Five General Dental Practices in Merseyside, North of England. SUBJECTS: 1,103 adult patients attending for routine dental care. INTERVENTION: Questionnaire administered by dentists. MAIN OUTCOME MEASURES: Age, gender, systemic medication, reported oral dryness. RESULTS: 1,103 patients (654 females) were recruited, of whom 427 (39%) were aged 60 years or older. 26% of patients reported taking medication. The overall prevalence of xerostomia was 12.7% (males--10.3%, females 14.4%). Age, medication and female gender were found to be significant risk factors for xerostomia, using logistic regression analysis. CONCLUSIONS: The prevalence of xerostomia (12.7%) in an English population was lower than reported in previous North American and Swedish studies. Medication was a significant risk factor for xerostomia and a better predictor of risk status, than either age or gender.

Murmurs, infective endocarditis and dentistry.

Patients with cardiac murmurs may have a predisposition to infective endocarditis, and the dental practitioner must be aware of this potential problem. This article reviews cardiac murmurs and how they are investigated by physicians to assess their significance. Practical advice is offered concerning the need to refer patients with a suspected heart murmur. The emergency and elective dental management of patients with heart murmurs is included, together with recommended regimens for antibiotic prophylaxis.

Endodontics in the adult patient: the role of antibiotics.

OBJECTIVES: The aim of this study was to review the published work on the indications and efficacy for antibiotics in endodontic therapy. DATA SOURCES: Published works in the medical and dental literature. STUDY SELECTION: Evaluation of published clinical trials in endodontic and other pertinent literature. CONCLUSIONS: Antibiotics are not routinely indicated in the practice of endodontics. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequaelae.

The clinical assessment of oral dryness is a significant predictor of salivary gland hypofunction.

OBJECTIVES: To compare subjective complaints of xerostomia and salivary gland dysfunction and a clinical assessment of oral dryness with an objective measurement of salivary gland dysfunction, in a group of UK patients attending a Dry Mouth Clinic. The aim of the study was to identify signs and symptoms that may be of predictive value for salivary gland hypofunction (SGH) in clinical practice. METHODS: This prospective study investigated 214 patients who attended a Dry Mouth Clinic, held at Liverpool University Dental Hospital. Patients gave a history of xerostomia for a minimum of 6 months and were asked standardised questions to subjectively assess oral dysfunction. The oral mucosa was then clinically assessed for dryness and sialometry was performed. Unstimulated whole saliva flow rates (UFR) of < 0.2 ml min-1 were considered to be indicative of SGH. RESULTS: One or more symptoms of oral dysfunction were reported in 178 (83%) patients, in addition to xerostomia. The clinician diagnosed oral dryness in 105 patients. Objective evidence of SGH was found in 125 (58%) of patients. The clinicians' subjective assessment of oral dryness was indicative of a reduced UFR (P < 0.0001) and a significant predictor of an UFR < 0.2 ml min-1 using logistic regression analysis (odds ratio 9.6; 95% CI 4.8 and 19.3). The mean UFR of patients who reported symptoms of oral dysfunction was significantly lower than the mean UFR of patients who reported no oral dysfunction. Using logistic and multiple regression analyses, symptoms of oral dysfunction were not found to be significant predictors of either an UFR < 0.2 ml min-1 or a reduced UFR. CONCLUSIONS: The clinical assessment of oral dryness was a significant predictor of SGH, in this selected group of patients. Patients who complain of xerostomia may have additional symptoms of oral dysfunction indicative of a reduced UFR.

A practical guide to antibiotic prophylaxis in restorative dentistry.

The purpose of this paper is to review the principles and practicalities of antibiotic prophylaxis in medically compromised patients who require restorative dentistry. Guidelines for the management of patients who are susceptible to infection are given. The importance of oral health and the rational use of both local and systemic antimicrobial prophylaxis is described.

The dental management of patients with natural rubber latex allergy.

Reports of allergic reactions to natural rubber latex have increased during the past two decades with both dental personnel and patients being affected. A dental management protocol is outlined for patients who have latex allergy. This includes: the identification of patients at high risk for developing latex allergy; the creation of a controlled, 'latex free' environment in the dental surgery; and the provision of emergency drugs and equipment that are free from natural rubber latex and may be required for the management of an allergic reaction.