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Craniofacial pain of cardiac origin
Oral-Systemic Linkages Craniofacial pain of cardiac origin Background.—Craniofacial pain, a common complaint in dental practice, may not originate from dental sources. Non-odontogenic craniofacial pain or heterotopic pain presents a significant diagnostic challenge. A cardiac source is possible, with craniofacial pain being the only symptom of cardiac ischemia experienced by about 6% of patients. The misdiagnosis of referred cardiac pain has potentially lethal implications for patients. Patients who never developed chest pain have a significantly higher cardiac mortality rate than those for whom chest pain was their chief complaint. The incidence and distribution patterns of craniofacial pain of cardiac origin were evaluated. Methods.—The 248 consecutive patients (age 26 to 88 years) had been hospitalized with confirmed cardiac
ischemic periods. Digital orthopantomogram (OPG) analysis was performed on all patients’ jaws and dentition, and all underwent clinical and radiographic examinations. Their symptoms were analyzed to determine the prevalence and distribution patterns of their craniofacial pain of cardiac origin. Results.—Craniofacial pain during a period of ischemia was reported by 34.2% of the patients, with a significantly higher incidence among women than men. Pain in the craniofacial region, chest, shoulders, and arms was also reported by 84.7% of patients. In 13 patients (15.3%) no other symptoms accompanied the craniofacial pain. The 85 patients who had craniofacial pain during ischemia reported the pain affected various regions, but the left mandible was the most often cited, found in 42.4% of patients. Two patients had bilateral toothache pain in the mandibular teeth. Fifty-two percent of patients had an acute myocardial infarction (AMI), and 62 of these 129 patients reported craniofacial pain in various distributions (Fig 2). Among those who experienced AMI, the right mandible was most often involved. For two men, craniofacial pain was the only symptom experienced. Nine percent of patients had no chest pain. Patients who had no chest pain were the most likely to experience craniofacial pain. Discussion.—Cardiac nociceptive input can stimulate nervous system neurons to produce referred pain in the craniofacial area. Various patterns of pain are experienced, with some patients having no chest pain and no symptoms other than the craniofacial pain. The mandible, TMJ, and ears are affected most often.
Fig 2.—Distribution of craniofacial structures affected by pain induced by myocardial infarction. (Courtesy of Danesh-Sani SH, Danesh-Sani SA, Zia R, et al: Incidence of craniofacial pain of cardiac origin: Results from a prospective multicenter study. Austral Dent J 57:355-358, 2012.)
Clinical Significance.—When patients do not experience chest pain associated with a cardiac event, craniofacial structures were the most commonly reported sites of pain associated with an ischemic episode. Dental practitioners should be aware of the possibility that craniofacial pain is referred from a cardiac source and manage patients accordingly. During history taking it is useful to ask whether the patient’s pain is associated with exertion and relieved by rest, which tends to indicate pain of cardiac origin. Early differential diagnosis
Volume 59
Issue 1
2014
29
of craniofacial pain of cardiac origin is an important task that dentists can perform for their patients.
Danesh-Sani SH, Danesh-Sani SA, Zia R, et al: Incidence of craniofacial pain of cardiac origin: Results from a prospective multicenter study. Austral Dent J 57:355-358, 2012 Reprints available from SA Danesh-Sani, Dept of Dental Research, Mashhad Dental Faculty, Vakilabad Boulevarde, Mashhad 6517659114, Iran; e-mail: [email protected]
Peridontal Diseases Prevention Anticaries and remineralizing agents Background.—In January 2012, the second International Conference on Novel Anticaries and Remineralizing Agents (ICNARA) was held to update the science related to these agents. Its objectives were to explore further the state of knowledge on agents that were antibacterial or remineralizing for caries treatment, to provide a forum for discussing new and underused technologies and data, and to provide a shared multidisciplinary agenda for research over the coming decade. Recent studies on caries risk assessment and caries management by risk assessment were presented, along with important conclusions relevant to these topics. Caries Risk Assessment Techniques.—Many models for caries risk assessment have been developed over the years, and many attempts have been undertaken to validate these methods for use in practical dental settings. The concept of caries balance was introduced in 1999 and postulates that caries progression or reversal is determined by the balance between factors related to demineralization (pathologic factors) and factors that enhance remineralization or reduce the bacterial challenge (protective factors). If the pathologic factors outweigh the protective factors, patients are at high risk for future caries lesions. Based on this simple approach and research from around the world, a caries risk assessment procedure was developed (Table). A short list of risk factors, pathologic factors, and protective factors was compiled. Using the list of items and a method taught in pre-doctoral teaching clinics at the University of California San Francisco (USCF) School of Dentistry allowed the successful identification of 69% of patients at high risk and 88% of those at extreme risk of having new caries lesions at subsequent follow-up evaluations. Seventy-six percent of the patients identified as low risk did not develop caries. A cariogenic bacterial challenge was also evaluated using mutans streptococci (MS) and lactobacilli (LB) via the
30
Dental Abstracts
‘‘dipslide method.’’ High MS and high LB levels were linked to cavitation at 90% and 91%, respectively. These results indicate that the use of specific remineralization and antibacterial modalities may control caries and improve oral health for persons who are at high or extreme risk for this disease. Other procedures are also open to validation, and the method proposed may undergo improvements and modifications. Managing Caries by Risk Assessment Methods.— UCSF researchers tested the hypothesis that altering the caries balance changes caries risk and therefore caries outcome. A randomized parallel-group clinical trial evaluated whether combining antibacterial and fluoride agents improves the balance between caries pathologic and protective factors over the course of 2 years. Participants (age 18 years or older) had one to seven cavitated caries lesions at baseline and were randomly assigned to intervention or control groups. The intervention group received fluoride dentifrice, 0.12% chlorhexidine gluconate rinse based on bacterial challenge, and 0.05% sodium fluoride rinse based on salivary fluoride levels. The chlorhexidine rinse was used daily for 1 week each month. At baseline and every 6 months participants were assessed for levels of salivary MS, LB, and fluoride (F). Caries risk status was determined at baseline and every 6 months thereafter. All the cavitated lesions were restored after baseline determinations. The results indicated that mean MS levels were significantly lower in the intervention than the control group and remained lower throughout the 2-year period. Change in MS bacterial challenge showed significant differences between the two groups. Mean bacterial levels of MS and LB in controls showed no significant response. Persons who had cavities had higher levels of MS and LB. The mean caries increment (change in decayed-missing-filled surfaces [DMFS]) was significantly (24%) higher for the intervention group than the controls. The use of targeted antibacterial
ischemic periods. Digital orthopantomogram (OPG) analysis was performed on all patients’ jaws and dentition, and all underwent clinical and radiographic examinations. Their symptoms were analyzed to determine the prevalence and distribution patterns of their craniofacial pain of cardiac origin. Results.—Craniofacial pain during a period of ischemia was reported by 34.2% of the patients, with a significantly higher incidence among women than men. Pain in the craniofacial region, chest, shoulders, and arms was also reported by 84.7% of patients. In 13 patients (15.3%) no other symptoms accompanied the craniofacial pain. The 85 patients who had craniofacial pain during ischemia reported the pain affected various regions, but the left mandible was the most often cited, found in 42.4% of patients. Two patients had bilateral toothache pain in the mandibular teeth. Fifty-two percent of patients had an acute myocardial infarction (AMI), and 62 of these 129 patients reported craniofacial pain in various distributions (Fig 2). Among those who experienced AMI, the right mandible was most often involved. For two men, craniofacial pain was the only symptom experienced. Nine percent of patients had no chest pain. Patients who had no chest pain were the most likely to experience craniofacial pain. Discussion.—Cardiac nociceptive input can stimulate nervous system neurons to produce referred pain in the craniofacial area. Various patterns of pain are experienced, with some patients having no chest pain and no symptoms other than the craniofacial pain. The mandible, TMJ, and ears are affected most often.
Fig 2.—Distribution of craniofacial structures affected by pain induced by myocardial infarction. (Courtesy of Danesh-Sani SH, Danesh-Sani SA, Zia R, et al: Incidence of craniofacial pain of cardiac origin: Results from a prospective multicenter study. Austral Dent J 57:355-358, 2012.)
Clinical Significance.—When patients do not experience chest pain associated with a cardiac event, craniofacial structures were the most commonly reported sites of pain associated with an ischemic episode. Dental practitioners should be aware of the possibility that craniofacial pain is referred from a cardiac source and manage patients accordingly. During history taking it is useful to ask whether the patient’s pain is associated with exertion and relieved by rest, which tends to indicate pain of cardiac origin. Early differential diagnosis
Volume 59
Issue 1
2014
29
of craniofacial pain of cardiac origin is an important task that dentists can perform for their patients.
Danesh-Sani SH, Danesh-Sani SA, Zia R, et al: Incidence of craniofacial pain of cardiac origin: Results from a prospective multicenter study. Austral Dent J 57:355-358, 2012 Reprints available from SA Danesh-Sani, Dept of Dental Research, Mashhad Dental Faculty, Vakilabad Boulevarde, Mashhad 6517659114, Iran; e-mail: [email protected]
Peridontal Diseases Prevention Anticaries and remineralizing agents Background.—In January 2012, the second International Conference on Novel Anticaries and Remineralizing Agents (ICNARA) was held to update the science related to these agents. Its objectives were to explore further the state of knowledge on agents that were antibacterial or remineralizing for caries treatment, to provide a forum for discussing new and underused technologies and data, and to provide a shared multidisciplinary agenda for research over the coming decade. Recent studies on caries risk assessment and caries management by risk assessment were presented, along with important conclusions relevant to these topics. Caries Risk Assessment Techniques.—Many models for caries risk assessment have been developed over the years, and many attempts have been undertaken to validate these methods for use in practical dental settings. The concept of caries balance was introduced in 1999 and postulates that caries progression or reversal is determined by the balance between factors related to demineralization (pathologic factors) and factors that enhance remineralization or reduce the bacterial challenge (protective factors). If the pathologic factors outweigh the protective factors, patients are at high risk for future caries lesions. Based on this simple approach and research from around the world, a caries risk assessment procedure was developed (Table). A short list of risk factors, pathologic factors, and protective factors was compiled. Using the list of items and a method taught in pre-doctoral teaching clinics at the University of California San Francisco (USCF) School of Dentistry allowed the successful identification of 69% of patients at high risk and 88% of those at extreme risk of having new caries lesions at subsequent follow-up evaluations. Seventy-six percent of the patients identified as low risk did not develop caries. A cariogenic bacterial challenge was also evaluated using mutans streptococci (MS) and lactobacilli (LB) via the
30
Dental Abstracts
‘‘dipslide method.’’ High MS and high LB levels were linked to cavitation at 90% and 91%, respectively. These results indicate that the use of specific remineralization and antibacterial modalities may control caries and improve oral health for persons who are at high or extreme risk for this disease. Other procedures are also open to validation, and the method proposed may undergo improvements and modifications. Managing Caries by Risk Assessment Methods.— UCSF researchers tested the hypothesis that altering the caries balance changes caries risk and therefore caries outcome. A randomized parallel-group clinical trial evaluated whether combining antibacterial and fluoride agents improves the balance between caries pathologic and protective factors over the course of 2 years. Participants (age 18 years or older) had one to seven cavitated caries lesions at baseline and were randomly assigned to intervention or control groups. The intervention group received fluoride dentifrice, 0.12% chlorhexidine gluconate rinse based on bacterial challenge, and 0.05% sodium fluoride rinse based on salivary fluoride levels. The chlorhexidine rinse was used daily for 1 week each month. At baseline and every 6 months participants were assessed for levels of salivary MS, LB, and fluoride (F). Caries risk status was determined at baseline and every 6 months thereafter. All the cavitated lesions were restored after baseline determinations. The results indicated that mean MS levels were significantly lower in the intervention than the control group and remained lower throughout the 2-year period. Change in MS bacterial challenge showed significant differences between the two groups. Mean bacterial levels of MS and LB in controls showed no significant response. Persons who had cavities had higher levels of MS and LB. The mean caries increment (change in decayed-missing-filled surfaces [DMFS]) was significantly (24%) higher for the intervention group than the controls. The use of targeted antibacterial