[show abstract][hide abstract] ABSTRACT: In 2003, the first reports describing osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates (BP) were published. These cases occurred in patients with cancer receiving high-dose intravenous BP; however, 5% of the cases were in patients with osteoporosis receiving low-dose bisphosphonate therapy. We present the results of a systematic review of the incidence, risk factors, diagnosis, prevention, and treatment of BP associated ONJ. We conducted a comprehensive literature search for relevant studies on BP associated ONJ in oncology and osteoporosis patients published before February 2008.All selected relevant articles were sorted by area of focus. Data for each area were abstracted by 2 independent reviewers. The results showed that the diagnosis is made clinically. Prospective data evaluating the incidence and etiologic factors are very limited. In oncology patients receiving high-dose intravenous BP, ONJ appears to be dependent on the dose and duration of therapy, with an estimated incidence of 1%-12% at 36 months of exposure. In osteoporosis patients, it is rare, with an estimated incidence < 1 case per 100,000 person-years of exposure. The incidence of ONJ in the general population is not known. Currently, there is insufficient evidence to confirm a causal link between low-dose BP use in the osteoporosis patient population and ONJ. We concluded BP associated ONJ is associated with high-dose BP therapy primarily in the oncology patient population. Prevention and treatment strategies are currently based on expert opinion and focus on maintaining good oral hygiene and conservative surgical intervention.
The Journal of Rheumatology 04/2009; 36(3):478-90. · 3.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: We have examined the effect of the peripheral application of glutamate and capsaicin to deep craniofacial tissues in influencing the activation and peripheral sensitization of deep craniofacial nociceptive afferents. The activity of single trigeminal nociceptive afferents with receptive fields in deep craniofacial tissues were recorded extracellularly in 55 halothane-anesthetized rats. The mechanical activation threshold (MAT) of each afferent was assessed before and after injection of 0.5 M glutamate (or vehicle) and 1% capsaicin (or vehicle) into the receptive field. A total of 68 afferents that could be activated by blunt noxious mechanical stimulation of the deep craniofacial tissues (23 masseter, 5 temporalis, 40 temporomandibular joint) were studied. When injected alone, glutamate and capsaicin activated and induced peripheral sensitization reflected as MAT reduction in many afferents. Following glutamate injection, capsaicin-evoked activity was greater than that evoked by capsaicin alone, whereas following capsaicin injection, glutamate-evoked responses were similar to glutamate alone. These findings indicate that peripheral application of glutamate or capsaicin may activate or induce peripheral sensitization in a subpopulation of trigeminal nociceptive afferents innervating deep craniofacial tissues, as reflected in changes in MAT and other afferent response properties. The data further suggest that peripheral glutamate and capsaicin receptor mechanisms may interact to modulate the activation and peripheral sensitization in some deep craniofacial nociceptive afferents.
Brain research 12/2008; 1251:130-9. · 2.46 Impact Factor
[show abstract][hide abstract] ABSTRACT: We examined the effect of the peripheral application of glutamate and capsaicin to the temporomandibular joint (TMJ) in influencing the activation and central sensitization of TMJ-responsive nociceptive neurons in the trigeminal subnucleus caudalis/upper cervical cord (Vc/UCC). The activity of single neurons activated by noxious mechanical stimulation of the TMJ was recorded in the Vc/UCC of 49 halothane-anesthetized male rats. Cutaneous mechanoreceptive field (RF), cutaneous mechanical activation threshold (MAT), and TMJ MAT of each neuron were assessed before and after injection of 0.5 M glutamate (or vehicle) and 1% capsaicin (or vehicle) into the TMJ. A total of 49 nociceptive neurons (37 nociceptive-specific, 12 wide-dynamic-range) that could be activated by blunt noxious mechanical stimulation of the TMJ were studied. When injected alone, glutamate and capsaicin activated and induced central sensitization (reflected in cutaneous RF expansion and cutaneous and/or TMJ MAT reduction) in most Vc/UCC neurons. Following glutamate injection, capsaicin evoked greater activity and less cutaneous/TMJ MAT reduction compared with capsaicin alone, whereas capsaicin abolished all subsequent glutamate-evoked activity and depressed cutaneous RF expansion in most neurons. Glutamate effects on deep afferents and Vc/UCC neurons were analogous since glutamate sensitized afferent and neuronal responses to capsaicin but the desensitizing effects of capsaicin on glutamate-evoked excitability of Vc/UCC neurons contrast with the lack of capsaicin-induced modulation of glutamate-evoked afferent excitability [Lam, D.K., Sessle, B.J., Hu, J.W., 2008a. Glutamate and capsaicin effects on trigeminal nociception I: activation and peripheral sensitization of deep craniofacial nociceptive afferents. Brain Res. doi:10.1016/j.brainres.2008.11.029], suggesting that peripheral and central sensitization may be differentially involved in the nociceptive effects of glutamate and capsaicin applied to deep craniofacial tissues.
Brain research 12/2008; 1253:48-59. · 2.46 Impact Factor
[show abstract][hide abstract] ABSTRACT: Surgical trauma can affect spinal neuronal excitability, but there have been no studies of the effects of surgical cutaneous injury on central nociceptive processing of deep afferent inputs evoked by noxious stimuli such as capsaicin. Thus our aim was to test the effect of surgical cutaneous incision in influencing central sensitization induced by capsaicin injection into the temporomandibular joint (TMJ). The activity of single nociceptive neurons activated by noxious mechanical stimulation of the TMJ was recorded in the trigeminal subnucleus caudalis/upper cervical cord of halothane-anesthetized rats. The cutaneous mechanoreceptive field (RF), cutaneous mechanical activation threshold (MAT) and TMJ MAT of neurons before and after both surgical cutaneous incision alone and capsaicin injection were compared with results of incision and lidocaine pretreatment of the facial skin overlying the TMJ and capsaicin injection into the TMJ. Incision itself induced a barrage of neuronal spikes and excitability increases reflecting central sensitization (cutaneous RF expansion, cutaneous MAT reduction) in most neurons tested whereas lidocaine pretreatment significantly attenuated the barrage and central sensitization. Capsaicin injection into the TMJ induced cutaneous RF expansion, cutaneous MAT reduction and TMJ MAT reduction following lidocaine pretreatment of the cutaneous incision site whereas capsaicin injection following incision alone not only failed to induce further central sensitization but also decreased the existing incision-induced central sensitization (no cutaneous RF expansion, increased cutaneous MAT and TMJ MAT) in most neurons tested. These findings suggest that central sensitization induced by capsaicin alone or by cutaneous incision alone can readily occur in TMJ-responsive nociceptive neurons and that following incision-induced excitability increases, capsaicin may result in a temporary suppression of nociceptive neuronal changes reflecting central sensitization.
[show abstract][hide abstract] ABSTRACT: Following publication of the first reports of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates in 2003, a call for national multidisciplinary guidelines based upon a systematic review of the current evidence was made by the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) in association with national and international societies concerned with ONJ. The purpose of the guidelines is to provide recommendations regarding diagnosis, identification of at-risk patients, and prevention and management strategies, based on current evidence and consensus. These guidelines were developed for medical and dental practitioners as well as for oral pathologists and related specialists.
The multidisciplinary task force established by the CAOMS reviewed all relevant areas of research relating to ONJ associated with bisphosphonate use and completed a systematic review of current literature. These evidence-based guidelines were developed utilizing a structured development methodology. A modified Delphi consensus process enabled consensus among the multidisciplinary task force members. These guidelines have since been reviewed by external experts and endorsed by national and international medical, dental, oral surgery, and oral pathology societies.
Recommendations regarding diagnosis, prevention, and management of ONJ were made following analysis of all current data pertaining to this condition. ONJ has many etiologic factors including head and neck irradiation, trauma, periodontal disease, local malignancy, chemotherapy, and glucocorticoid therapy. High-dose intravenous bisphosphonates have been identified as a risk factor for ONJ in the oncology patient population. Low-dose bisphosphonate use in patients with osteoporosis or other metabolic bone disease has not been causally linked to the development of ONJ. Prevention, staging, and treatment recommendations are based upon collective expert opinion and current data, which has been limited to case reports, case series, surveys, retrospective studies, and 2 prospective observational studies. Recommendations: In all oncology patients, a thorough dental examination including radiographs should be completed prior to the initiation of intravenous bisphosphonate therapy. In this population, any invasive dental procedure is ideally completed prior to the initiation of high-dose bisphosphonate therapy. Non-urgent procedures are preferably delayed for 3 to 6 months following interruption of bisphosphonate therapy. Osteoporosis patients receiving oral or intravenous bisphosphonates do not require a dental examination prior to initiating therapy in the presence of appropriate dental care and good oral hygiene. Stopping smoking, limiting alcohol intake, and maintaining good oral hygiene should be emphasized for all patients receiving bisphosphonate therapy. Individuals with established ONJ are most appropriately managed with supportive care including pain control, treatment of secondary infection, removal of necrotic debris, and mobile sequestrate. Aggressive debridement is contraindicated.
Our multidisciplinary guidelines, which provide a rational evidence-based approach to the diagnosis, prevention, and management of bisphosphonate-associated ONJ in Canada, are based on the best available published data and the opinion of national and international experts involved in the prevention and management of ONJ.
The Journal of Rheumatology 08/2008; 35(7):1391-7. · 3.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: Infective endocarditis is a rare but life-threatening microbial infection of the heart valves or endocardium, most often related to congenital or acquired cardiac defects. The American Heart Association (AHA) recently updated its recommendations on prophylaxis during dental procedures. The revisions will have a profound impact on both the patient and the dental practitioner. The purpose of this paper is to review the pathogenesis and clinical presentation of infective endocarditis and discuss the 2007 AHA guidelines and their implications for dentists.
[show abstract][hide abstract] ABSTRACT: Systemic lupus erythematosus (SLE) is a chronic disease with far-reaching systemic implications. The hallmark feature in SLE is chronic inflammation. It can affect the skin, joints, kidneys, lungs, nervous system, serous membranes such as the pleura and pericardium, mucous membranes and other organs of the body. It is imperative that the dental practitioner be familiar with the broad range of systemic and oral implications, including the clinical and biochemical features of SLE. This review article offers an overview of the multiple organ systems affected by this complex heterogeneous disease process that are most relevant to both the general practitioner and the dental specialist. In particular, ways to recognize and manage the oral and dental manifestations of this systemic illness are presented.
[show abstract][hide abstract] ABSTRACT: Osteopetrosis is one cause of osteosclerosis and may result in such serious oral complications as osteomyelitis and exposed necrotic bone. Dentists should be aware of patients with the disease because of its effect on osteoclast function, which results in impaired wound healing. The purpose of this paper is to review the causes, pathogenesis and differential diagnosis of osteopetrosis and to provide guidance to dentists on the management of patients with osteopetrosis.
[show abstract][hide abstract] ABSTRACT: Scleroderma, or progressive systemic sclerosis (PSS), an autoimmune rheumatic condition affecting the connective tissues, has a profound impact on oral health. Common orofacial findings include xerostomia, gastroesophageal reflux disease and limited mouth opening. This review article describes scleroderma, or PSS, and its various manifestations. The features of CREST syndrome and morphea are reviewed. Concerns relevant to the prevention of dental disease and the safe delivery of dental care in this group of challenging patients are emphasized.
[show abstract][hide abstract] ABSTRACT: Bisphosphonate-associated osteonecrosis (BON) may result in serious oral complications, such as osteomyelitis and chronic exposure of necrotic bone. Dentists must be familiar with this disorder and pay special attention to all patients on bisphosphonate therapy due to their defective osteoclast function and reduced osseous tissue vascularity, leading to impaired wound healing. The purpose of this paper is to review the history and pathogenesis of BON, discuss its differential diagnosis, provide guidance to dentists on possible measures to prevent BON and review the management of patients with BON.
[show abstract][hide abstract] ABSTRACT: Patients with cleidocranial dysplasia often express concerns related to their perception of an undesirable esthetic appearance of their forehead and skull because of a combination of the persistence of metopic suture defects and frontal bossing. This case series reviews the use of a cranioplasty technique that has been developed to address such concerns.
A series of 7 adult patients with cleidocranial dysplasia were treated using a cranioplasty technique to correct visible metopic suture defects in the forehead region. The patients were 4 males and 3 females with a mean age of 29.0 years. All 7 patients underwent identical cranioplasty procedures.
The metopic suture cranial defects were found to range in size from 0.6 to 2.4 cm in diameter and were present as full-thickness osseous defects in 4 of the 7 patients. All postoperative complications resolved spontaneously. Inpatient admission times ranged from 1 to 3 days. Follow-up ranged from 9 to 48 months with satisfactory subjective esthetic outcomes. The patients were content in all cases.
This cranioplasty procedure successfully addresses the specific esthetic concerns of a rare and unique group of individuals. The procedure can be offered to cleidocranial dysplasia patients as part of their overall comprehensive craniomaxillofacial management.
[show abstract][hide abstract] ABSTRACT: We have previously documented that peripheral N-methyl-d-aspartate (NMDA) receptor mechanisms are involved in nociceptive reflex increases in jaw muscle activity to injection of mustard oil or glutamate into the rat temporomandibular joint (TMJ). The aim of the present study was to determine whether peripheral NMDA receptor mechanisms are also involved in the nociceptive reflex responses in the jaw muscles evoked by injection of the inflammatory irritant and algesic chemical capsaicin into the TMJ. The effects of peripheral injection of NMDA receptor antagonists, MK-801 and APV, on the increases in electromyographic (EMG) activities of digastric and masseter muscles reflexly evoked by capsaicin injection into the TMJ were tested in halothane-anesthetized male rats. The capsaicin injection following pre-injection of vehicle evoked significant increases in EMG activity in both digastric and masseter muscles whereas pre-injection of MK-801 or APV into the TMJ resulted in a significant concentration-related reduction in the magnitude of capsaicin-evoked digastric and masseter EMG activity (ANOVA-on-ranks, P < 0.05). This finding indicates that capsaicin-evoked digastric and masseter EMG activity can be attenuated by pre-injection into the TMJ of NMDA receptor antagonists, and that the activation of peripheral NMDA receptors may be important in the mechanisms whereby capsaicin evokes nociceptive trigeminal responses.
Brain Research 06/2005; 1046(1-2):68-76. · 2.88 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of the present review is to correlate recent knowledge of the role of peripheral ionotropic glutamate receptors in the temporomandibular joint and muscle pain from animal and human experimental pain models with findings in patients. Chronic pain is common, and many people suffer from chronic pain conditions involving deep craniofacial tissues such as temporomandibular disorders or fibromyalgia. Animal and human studies have indicated that the activation of peripheral ionotropic glutamate receptors in deep craniofacial tissues may contribute to muscle and temporomandibular joint pain and that sex differences in the activation of glutamate receptors may be involved in the female predominance in temporomandibular disorders and fibromyalgia. A peripheral mechanism involving autocrine and/or paracrine regulation of nociceptive neuronal excitability via injury or inflammation-induced release of glutamate into peripheral tissues that may contribute to the development of craniofacial pain is proposed.
Pain research & management: the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur 02/2005; 10(3):145-52. · 1.04 Impact Factor