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SELECTIONS FROM THE CURRENT LITERATURE
JOURNALSCAN
SELECTIONS FROM THE CURRENT LITERATURE
Compiled by Michael L. Barnett, DDS
ORAL SURGERY
Aspirin use and post-operative bleeding from dental extractions Brennan MT, Valerin MA, Noll JL, et al. J Dent Res 2008;87(8): 740-744.
he authors conducted a placebo-controlled clinical study to determine if healthy patients taking aspirin will have increased bleeding during and after the extraction of a single tooth. They enrolled 36 essentially healthy patients (19 of whom were male) with a mean (SD) age of 40.3 (± 10.4) years and an American Society of Anesthesiologists (ASA) physical status classification of P2 or less. They excluded patients taking warfarin, heparin, steroids or nonsteroidal antiinflammatory drugs; patients with systemic conditions predisposing them to bleeding such as liver or kidney disease and acquired or congenital bleeding disorders; and patients with prior or current ingestion of more than two alcoholcontaining drinks per day for more than two years. They used a computer-generated code to randomly assign patients to either a group receiving 325 milligrams of aspirin or a group receiving placebo for two days before and two days after the extraction. In addition to recording preoperative vital signs, the authors performed a cutaneous bleeding time test and conducted whole-blood aggregation tests.
T
1526
JADA, Vol. 139
http://jada.ada.org
The authors anesthetized patients with a single carpule of 2 percent lidocaine with 1:100,000 epinephrine and used 3 percent carbocaine without epinephrine for any additional anesthesia. They assessed intraoral bleeding time, the primary outcome variable, by observing the extraction site for two minutes and then placing gauze over the site to remove any blood extending beyond the socket. They observed whether any bleeding extended beyond the crest of the socket onto the adjacent gingivae during an observation period of one minute and repeated this procedure at five, eight, 11, 14 and 20 minutes. The time point at which bleeding no longer extended beyond the socket was considered the intraoral bleeding time. In addition, the authors assessed bleeding complications with follow-up telephone calls at three to seven hours and 40 to 55 hours after extraction. Comparing the two groups, the authors found no difference in mean extraction time, difficulty of extraction or location of extraction sites. They did find statistically significantly higher whole-blood aggregation results in the aspirin group but no statistically significant difference in cutaneous bleeding time in that group. In addition, they found no significant difference in intraoral bleeding time between groups, with the aspirin and placebo groups having respective mean (SD) bleeding times of 7.2 (± 5.9) and 5.8 (± 6.2) minutes (P = .51). After reviewing results of the two
November 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
J O U R N A L S C A N
follow-up telephone surveys, they found no significant difference between the two groups with respect to duration of bleeding after the extraction. The authors conclude that their findings suggest that there is no reason to discontinue aspirin use for patients needing a single-tooth extraction or similarly invasive dental procedure. They note, however, that the effect of aspirin on postoperative bleeding resulting from multiple extractions and the effect of other antiplatelet drugs on postoperative bleeding still need to be studied. Significance. Since a significant number of people at risk of experiencing a variety of cardiovascular diseases take aspirin prophylactically to inhibit platelet aggregation, this study can provide some guidance for deciding whether to discontinue aspirin therapy before a single-tooth extraction. In considering the results of this study, however, it is important to note that the study was conducted in a rather small and relatively healthy patient population and, therefore, the findings may not be applicable to patients with a higher ASA physical status classification. Moreover, on the basis of studies they cited showing that two doses will produce maximal platelet inhibition, the authors used an experimental model in which patients took only two daily doses of aspirin before the surgery. Therefore, although it may be reasonable to conclude that the results of this study will be applicable to patients receiving long-term aspirin therapy, further study is indicated to confirm that this is, in fact, the case. ORAL ONCOLOGY
Metastatic tumours to the oral cavity: pathogenesis and analysis of 673 cases Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Oral Oncol 2008;44(8):743-752.
oting that the oral tissues are not common sites for malignant tumor metastases and that when such metastases occur they usually are a sign of widespread disease, the authors conducted this survey of reports of metastases to the oral tissues published in the English-language literature between 1992 and 2006. They combined information from these patients with information from previously published surveys covering the period from 1916 to 1991. They included only reports that contained information about the primary origin of the tumor, the oral site of metas-
N
tasis and the histologic confirmation of metastasis. In all, the authors summarize data from 673 lesions. The authors found that most metastatic tumors to the oral region were seen in the fifth to seventh decade of life, with a mean age of 51.1 years for men and 47.1 years for women. Metastases to the mandible and maxilla were found twice as often as were metastases to the oral soft tissues, with the mandible the most common site. For the soft tissues, the attached gingiva was the most frequently affected site, followed by the tongue. In the case of metastases to bone, patients complained of rapidly progressing swelling, pain and paresthesia. Radiographs showed a lytic radiolucent lesion with poorly defined margins in most cases (86 percent) and occasionally osteoblastic lesions with either pure or mixed radiopacity. No radiographic changes were found in approximately 5 percent of lesions. The authors found that early gingival metastases resembled a hyperplastic or reactive lesion, such as a pyogenic granuloma, peripheral giant cell tumor or fibrous epulis, and that metastases to other oral soft-tissue locations manifested as submucosal masses. With more advanced softtissue lesions, patients complained of pain, bleeding, superinfection, dysphagia, interference with mastication and disfigurement. The authors note that in 56 patients the metastasis was discovered in an extraction site after tooth extraction and assume that in many of these cases the lesion was present before the extraction. They found that the most common primary sites for oral metastases in men were the lung, kidney, liver and prostate and in women were breast, genital organs and kidney. In approximately one-quarter of patients, the oral metastatic lesion is the first indication of a malignancy at a distant site and therefore presents a diagnostic challenge. In contrast, in the case of a patient with a known primary malignancy, the clinician would be likely to consider a metastatic lesion as a likely differential diagnosis. In either case, a biopsy is necessary to establish the definitive diagnosis. Significance. Although the exact prevalence of oral metastases cannot be determined from a survey of published reports, this article reminds us of the possibility that malignant tumors elsewhere in the body occasionally can metastasize to oral tissues. An awareness of the location and signs and symptoms of metastatic lesions can JADA, Vol. 139
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
November 2008
1527
J O U R N A L S C A N
help the clinician in establishing a differential diagnosis when confronted with such lesions during an oral examination. ORAL SURGERY
Iatrogenic injury to the inferior alveolar nerve: etiology, signs and symptoms, and observations on recovery Hillerup S. Int J Oral Maxillofac Surg 2008;37(8):704-709.
he author conducted a prospective descriptive study of patients with iatrogenic injury to the inferior alveolar nerve (IAN) to assess the severity of neurosensory impairment and its change across time. He studied 52 patients (40 women and 12 men with a median age of 41 years) with unilateral iatrogenic IAN injury who were available for multiple follow-up visits and whose injury was caused by a procedure other than major oral and maxillofacial surgery or a general neurological condition. The causes of the IAN injuries were third-molar surgery (36 patients), local anesthetic injection (five patients), implant surgery (five patients), endodontic treatment (four patients) or not determined (for example, attributable to more than one possible cause) (two patients). For each patient, the author conducted a neurosensory examination that included an interview and tests of pain perception, two-point discrimination thresholds and perception of seven tactile and thermal stimuli: feather-light touch, pin prick, discrimination between pointed and dull touch, warmth, cold, location of touch and brushstroke direction. Each patient’s unaffected IAN was used as the control. Neurosensory function was rated on a scale of 0 (no perception of stimulus) to 3 (normal perception of tactile and thermal stimuli). The patients’ first examinations occurred at zero to 24 months after the date of injury (median of three months), and they had follow-up examinations at three-month intervals, with a mean follow-up period of nine months (range of three to 27 months). At the initial examination, 14 patients experienced anesthesia, 36 patients experienced hypoesthesia, and two patients had no impairment. The author found that on the injured side in all patients, two-point discrimination thresholds were significantly higher and the perception of all tactile and thermal stimuli was significantly reduced. Four patients were treated with microsurgical procedures. Of the other 48 patients, 29
T
1528
JADA, Vol. 139
http://jada.ada.org
reported a subjective improvement in sensory function across time that was supported by improved neurosensory test scores, nine reported a worsening, and 10 reported no change. For the patients as a whole, scores improved for each of the seven tactile, thermal and location stimuli tested; however, the spontaneous recovery differed according to the cause of the injury. The author found that lesions related to third-molar surgery experienced significant recovery between initial and final examinations (P < .001), whereas there was no significant change in injuries resulting from injection, implant surgery or endodontic treatment. In patients who improved, the most rapid recovery typically occurred in the first six months after injury. In contrast to the sensory improvement documented by means of clinical testing, there was little change in neurogenic symptoms during the follow-up period; only five and eight patients had no neurogenic discomfort at the initial and final examinations, respectively, with the remainder experiencing a variety of symptoms, primarily paresthesia and dysesthesia. In the discussion, the author speculates that the lack of recovery associated with endodontic treatment and local anesthetic injection may be related to neurotoxicity as opposed to the mechanical injury that can accompany thirdmolar surgery. Significance. The author notes that, with the exception of major surgery, third-molar surgery is the most common cause of IAN injury. Results from this study showed that most patients experiencing IAN injury resulting from third-molar surgery can have significant spontaneous improvement of sensory function, with the rate of improvement most rapid during the first six months after the injury. ORAL MEDICINE
Desquamative gingivitis: retrospective analysis of disease associations of a large cohort Leao JC, Ingafou M, Khan A, Scully C, Porter S. Oral Dis 2008; 14(6):556-560.
esquamative gingivitis” is a term used to describe a clinical condition characterized by painful erosions or ulcerations of the attached and free gingivae. Although this condition at one time was considered to be related to hormonal changes associated with menopause, investigators have found that, in fact, it can be a manifestation
D
November 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
J O U R N A L S C A N
of a number of dermatologic disorders and reactions to chemicals or allergens. The authors conducted a retrospective study to determine the specific diseases manifested by desquamative gingivitis in a large cohort of patients. They studied 187 patients in the United Kingdom who were referred consecutively with clinical features of desquamative gingivitis. The patients, 126 of whom were female, had a median age of 51 years and an age range of 23 to 93 years. They obtained gingival biopsies from all patients for histologic examination and, when appropriate, direct immunofluorescent staining. They also obtained serum for indirect immunofluorescent examination. All patients complained of soreness or burning sensation of the gingivae, and 15 of the patients also complained of ocular symptoms. On the basis of history, clinical appearance, and histologic and immunological findings, the authors were able to assign the patients into four main groups: oral lichen planus (132 patients), mucous membrane pemphigoid (26 patients), pemphigus vulgaris (24 patients) and linear immunoglobulin A disease and other disorders
(five patients). The authors emphasize the need for a definitive diagnosis of desquamativeappearing gingival lesions because of the other manifestations of some of the underlying diseases—for example, conjunctival, pharyngeal and laryngeal involvement in mucous membrane pemphigoid; the possibility of pemphigus vulgaris’ progressing to more widespread cutaneous disease; and the possibility that oral lichen planus may be a precursor of oral malignancy. Significance. As the authors note, the findings in this large cohort suggest that oral lichen planus is the most common disease underlying desquamative gingivitis, in contrast to results of previous studies suggesting that mucous membrane pemphigoid is the most common. Since many of the underlying diseases can be associated with serious extraoral lesions, it is essential that a definitive diagnosis be obtained so that appropriate referrals and treatment can be accomplished in a timely fashion. Dr. Barnett is a clinical professor, Department of Periodontics/ Endodontics, School of Dental Medicine, University at Buffalo, The State University of New York.
JADA, Vol. 139
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
November 2008
1529
SELECTIONS FROM THE CURRENT LITERATURE
Compiled by Michael L. Barnett, DDS
ORAL SURGERY
Aspirin use and post-operative bleeding from dental extractions Brennan MT, Valerin MA, Noll JL, et al. J Dent Res 2008;87(8): 740-744.
he authors conducted a placebo-controlled clinical study to determine if healthy patients taking aspirin will have increased bleeding during and after the extraction of a single tooth. They enrolled 36 essentially healthy patients (19 of whom were male) with a mean (SD) age of 40.3 (± 10.4) years and an American Society of Anesthesiologists (ASA) physical status classification of P2 or less. They excluded patients taking warfarin, heparin, steroids or nonsteroidal antiinflammatory drugs; patients with systemic conditions predisposing them to bleeding such as liver or kidney disease and acquired or congenital bleeding disorders; and patients with prior or current ingestion of more than two alcoholcontaining drinks per day for more than two years. They used a computer-generated code to randomly assign patients to either a group receiving 325 milligrams of aspirin or a group receiving placebo for two days before and two days after the extraction. In addition to recording preoperative vital signs, the authors performed a cutaneous bleeding time test and conducted whole-blood aggregation tests.
T
1526
JADA, Vol. 139
http://jada.ada.org
The authors anesthetized patients with a single carpule of 2 percent lidocaine with 1:100,000 epinephrine and used 3 percent carbocaine without epinephrine for any additional anesthesia. They assessed intraoral bleeding time, the primary outcome variable, by observing the extraction site for two minutes and then placing gauze over the site to remove any blood extending beyond the socket. They observed whether any bleeding extended beyond the crest of the socket onto the adjacent gingivae during an observation period of one minute and repeated this procedure at five, eight, 11, 14 and 20 minutes. The time point at which bleeding no longer extended beyond the socket was considered the intraoral bleeding time. In addition, the authors assessed bleeding complications with follow-up telephone calls at three to seven hours and 40 to 55 hours after extraction. Comparing the two groups, the authors found no difference in mean extraction time, difficulty of extraction or location of extraction sites. They did find statistically significantly higher whole-blood aggregation results in the aspirin group but no statistically significant difference in cutaneous bleeding time in that group. In addition, they found no significant difference in intraoral bleeding time between groups, with the aspirin and placebo groups having respective mean (SD) bleeding times of 7.2 (± 5.9) and 5.8 (± 6.2) minutes (P = .51). After reviewing results of the two
November 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
J O U R N A L S C A N
follow-up telephone surveys, they found no significant difference between the two groups with respect to duration of bleeding after the extraction. The authors conclude that their findings suggest that there is no reason to discontinue aspirin use for patients needing a single-tooth extraction or similarly invasive dental procedure. They note, however, that the effect of aspirin on postoperative bleeding resulting from multiple extractions and the effect of other antiplatelet drugs on postoperative bleeding still need to be studied. Significance. Since a significant number of people at risk of experiencing a variety of cardiovascular diseases take aspirin prophylactically to inhibit platelet aggregation, this study can provide some guidance for deciding whether to discontinue aspirin therapy before a single-tooth extraction. In considering the results of this study, however, it is important to note that the study was conducted in a rather small and relatively healthy patient population and, therefore, the findings may not be applicable to patients with a higher ASA physical status classification. Moreover, on the basis of studies they cited showing that two doses will produce maximal platelet inhibition, the authors used an experimental model in which patients took only two daily doses of aspirin before the surgery. Therefore, although it may be reasonable to conclude that the results of this study will be applicable to patients receiving long-term aspirin therapy, further study is indicated to confirm that this is, in fact, the case. ORAL ONCOLOGY
Metastatic tumours to the oral cavity: pathogenesis and analysis of 673 cases Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Oral Oncol 2008;44(8):743-752.
oting that the oral tissues are not common sites for malignant tumor metastases and that when such metastases occur they usually are a sign of widespread disease, the authors conducted this survey of reports of metastases to the oral tissues published in the English-language literature between 1992 and 2006. They combined information from these patients with information from previously published surveys covering the period from 1916 to 1991. They included only reports that contained information about the primary origin of the tumor, the oral site of metas-
N
tasis and the histologic confirmation of metastasis. In all, the authors summarize data from 673 lesions. The authors found that most metastatic tumors to the oral region were seen in the fifth to seventh decade of life, with a mean age of 51.1 years for men and 47.1 years for women. Metastases to the mandible and maxilla were found twice as often as were metastases to the oral soft tissues, with the mandible the most common site. For the soft tissues, the attached gingiva was the most frequently affected site, followed by the tongue. In the case of metastases to bone, patients complained of rapidly progressing swelling, pain and paresthesia. Radiographs showed a lytic radiolucent lesion with poorly defined margins in most cases (86 percent) and occasionally osteoblastic lesions with either pure or mixed radiopacity. No radiographic changes were found in approximately 5 percent of lesions. The authors found that early gingival metastases resembled a hyperplastic or reactive lesion, such as a pyogenic granuloma, peripheral giant cell tumor or fibrous epulis, and that metastases to other oral soft-tissue locations manifested as submucosal masses. With more advanced softtissue lesions, patients complained of pain, bleeding, superinfection, dysphagia, interference with mastication and disfigurement. The authors note that in 56 patients the metastasis was discovered in an extraction site after tooth extraction and assume that in many of these cases the lesion was present before the extraction. They found that the most common primary sites for oral metastases in men were the lung, kidney, liver and prostate and in women were breast, genital organs and kidney. In approximately one-quarter of patients, the oral metastatic lesion is the first indication of a malignancy at a distant site and therefore presents a diagnostic challenge. In contrast, in the case of a patient with a known primary malignancy, the clinician would be likely to consider a metastatic lesion as a likely differential diagnosis. In either case, a biopsy is necessary to establish the definitive diagnosis. Significance. Although the exact prevalence of oral metastases cannot be determined from a survey of published reports, this article reminds us of the possibility that malignant tumors elsewhere in the body occasionally can metastasize to oral tissues. An awareness of the location and signs and symptoms of metastatic lesions can JADA, Vol. 139
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
November 2008
1527
J O U R N A L S C A N
help the clinician in establishing a differential diagnosis when confronted with such lesions during an oral examination. ORAL SURGERY
Iatrogenic injury to the inferior alveolar nerve: etiology, signs and symptoms, and observations on recovery Hillerup S. Int J Oral Maxillofac Surg 2008;37(8):704-709.
he author conducted a prospective descriptive study of patients with iatrogenic injury to the inferior alveolar nerve (IAN) to assess the severity of neurosensory impairment and its change across time. He studied 52 patients (40 women and 12 men with a median age of 41 years) with unilateral iatrogenic IAN injury who were available for multiple follow-up visits and whose injury was caused by a procedure other than major oral and maxillofacial surgery or a general neurological condition. The causes of the IAN injuries were third-molar surgery (36 patients), local anesthetic injection (five patients), implant surgery (five patients), endodontic treatment (four patients) or not determined (for example, attributable to more than one possible cause) (two patients). For each patient, the author conducted a neurosensory examination that included an interview and tests of pain perception, two-point discrimination thresholds and perception of seven tactile and thermal stimuli: feather-light touch, pin prick, discrimination between pointed and dull touch, warmth, cold, location of touch and brushstroke direction. Each patient’s unaffected IAN was used as the control. Neurosensory function was rated on a scale of 0 (no perception of stimulus) to 3 (normal perception of tactile and thermal stimuli). The patients’ first examinations occurred at zero to 24 months after the date of injury (median of three months), and they had follow-up examinations at three-month intervals, with a mean follow-up period of nine months (range of three to 27 months). At the initial examination, 14 patients experienced anesthesia, 36 patients experienced hypoesthesia, and two patients had no impairment. The author found that on the injured side in all patients, two-point discrimination thresholds were significantly higher and the perception of all tactile and thermal stimuli was significantly reduced. Four patients were treated with microsurgical procedures. Of the other 48 patients, 29
T
1528
JADA, Vol. 139
http://jada.ada.org
reported a subjective improvement in sensory function across time that was supported by improved neurosensory test scores, nine reported a worsening, and 10 reported no change. For the patients as a whole, scores improved for each of the seven tactile, thermal and location stimuli tested; however, the spontaneous recovery differed according to the cause of the injury. The author found that lesions related to third-molar surgery experienced significant recovery between initial and final examinations (P < .001), whereas there was no significant change in injuries resulting from injection, implant surgery or endodontic treatment. In patients who improved, the most rapid recovery typically occurred in the first six months after injury. In contrast to the sensory improvement documented by means of clinical testing, there was little change in neurogenic symptoms during the follow-up period; only five and eight patients had no neurogenic discomfort at the initial and final examinations, respectively, with the remainder experiencing a variety of symptoms, primarily paresthesia and dysesthesia. In the discussion, the author speculates that the lack of recovery associated with endodontic treatment and local anesthetic injection may be related to neurotoxicity as opposed to the mechanical injury that can accompany thirdmolar surgery. Significance. The author notes that, with the exception of major surgery, third-molar surgery is the most common cause of IAN injury. Results from this study showed that most patients experiencing IAN injury resulting from third-molar surgery can have significant spontaneous improvement of sensory function, with the rate of improvement most rapid during the first six months after the injury. ORAL MEDICINE
Desquamative gingivitis: retrospective analysis of disease associations of a large cohort Leao JC, Ingafou M, Khan A, Scully C, Porter S. Oral Dis 2008; 14(6):556-560.
esquamative gingivitis” is a term used to describe a clinical condition characterized by painful erosions or ulcerations of the attached and free gingivae. Although this condition at one time was considered to be related to hormonal changes associated with menopause, investigators have found that, in fact, it can be a manifestation
D
November 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
J O U R N A L S C A N
of a number of dermatologic disorders and reactions to chemicals or allergens. The authors conducted a retrospective study to determine the specific diseases manifested by desquamative gingivitis in a large cohort of patients. They studied 187 patients in the United Kingdom who were referred consecutively with clinical features of desquamative gingivitis. The patients, 126 of whom were female, had a median age of 51 years and an age range of 23 to 93 years. They obtained gingival biopsies from all patients for histologic examination and, when appropriate, direct immunofluorescent staining. They also obtained serum for indirect immunofluorescent examination. All patients complained of soreness or burning sensation of the gingivae, and 15 of the patients also complained of ocular symptoms. On the basis of history, clinical appearance, and histologic and immunological findings, the authors were able to assign the patients into four main groups: oral lichen planus (132 patients), mucous membrane pemphigoid (26 patients), pemphigus vulgaris (24 patients) and linear immunoglobulin A disease and other disorders
(five patients). The authors emphasize the need for a definitive diagnosis of desquamativeappearing gingival lesions because of the other manifestations of some of the underlying diseases—for example, conjunctival, pharyngeal and laryngeal involvement in mucous membrane pemphigoid; the possibility of pemphigus vulgaris’ progressing to more widespread cutaneous disease; and the possibility that oral lichen planus may be a precursor of oral malignancy. Significance. As the authors note, the findings in this large cohort suggest that oral lichen planus is the most common disease underlying desquamative gingivitis, in contrast to results of previous studies suggesting that mucous membrane pemphigoid is the most common. Since many of the underlying diseases can be associated with serious extraoral lesions, it is essential that a definitive diagnosis be obtained so that appropriate referrals and treatment can be accomplished in a timely fashion. Dr. Barnett is a clinical professor, Department of Periodontics/ Endodontics, School of Dental Medicine, University at Buffalo, The State University of New York.
JADA, Vol. 139
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission
November 2008
1529