Survey to assess dental practitioner's knowledge of infectious disease

The prerequisite to understanding the need for infection control practices in dentistry is a sound knowledge of infectious disease and the potential for its transmission in the dental setting. To assess the infectious disease knowledge-base of dental practitioners, a questionnaire was developed and distributed to dentists in British Columbia. The survey results showed that many of the mechanisms, routes and risks for the transmission of viral pathogens in the dental setting are not clearly understood by dentists. Continuing education is needed to ensure that compliance with current infection control recommendations, and the provision of appropriate patient care, continues to be based on a clear understanding by dentists of the mechanisms of infection. By identifying the current infectious disease knowledge-base of dentists, this survey may permit more specifically-directed continuing education programs to be offered.

Compliance to recommended infection control procedures: changes over six years among British Columbia dentists

Over the last decade, in response to the heightened awareness of HBV and HIV infections, world health authorities have produced specific infection control recommendations for dental practices. Surveys have been done in various countries to investigate the level of compliance to these recommendations. This paper reports on the changes in compliance over a six year period among British Columbia dentists, as indicated from four volunteer surveys conducted between 1987 and 1993. During that period, the percentage of dentists who reported taking a medical history for each new patient increased from 70 per cent to 99 per cent. The routine use of gloves increased from 61 per cent to 95 per cent, and of face masks from 49 per cent to 83 per cent. In 1993, most dentists (91 per cent) used a new pair of gloves with each patient, up from 62 per cent three years earlier. Dentists also reported on their sterilization and hygiene methods. Autoclavable handpieces were used by 66 per cent of respondents in 1990, and by 74 per cent in 1993. High-speed autoclavable handpieces were used by 83 per cent of dentists in 1993, but only 62 per cent sterilized these handpieces. Similarly, 65 per cent reported using low-speed autoclavable handpieces, but only 47 per cent sterilized them. It is apparent that disinfection of handpieces and intraoral instruments is still an important part of regular operatory hygiene. Biologic monitors were used by 61.6 per cent of respondents to test the efficiency of their office sterilizer in 1993.(ABSTRACT TRUNCATED AT 250 WORDS)

Exfoliative cytology and electron microscopy in the diagnosis of hairy leukoplakia

The diagnosis of lesions clinically suggestive of hairy leukoplakia was assessed by light and electron microscopic examination of cytologic smears. We found exfoliative cytology to be a simple and noninvasive technique that can confirm the clinical diagnosis of hairy leukoplakia. Our results suggest that electron microscopy may be more sensitive and reliable than light microscopy in confirming the clinical diagnosis of hairy leukoplakia.

Survey of knowledge of infectious disease and infection control practices of dental specialists

A questionnaire was developed to assess the knowledge of clinical specialists regarding infectious disease as well as their infection control practices. The questionnaire was mailed to 202 dental specialists in British Columbia. Seventy per cent returned completed surveys. Their responses indicate that the mechanisms, route and risk of transmission of the viral pathogens of importance in dental practice are not clearly understood. However, infection control practices closely follow the guidelines set forth by the Canadian Dental Association and the licensing bodies, including immunization for hepatitis B (82 per cent), glove use (in 89 per cent of non-surgical and 95 per cent of surgical procedures), and sterilization/disinfection of dental handpieces (94 per cent). Compliance with infection control guidelines was similar to that reported in the United States, where strict enforcement has been instituted. The majority of dental specialists (84-88 per cent) were either treating or willing to provide treatment to patients with infectious disease. Continuing education in the area of infectious disease is needed to improve dentists' understanding of the risk of transmission to dental providers and patients. This will ensure that compliance with infection control recommendations and appropriate patient care practices continue.

Assessing viral retention and elimination in rotary dental instruments

The authors of this article used a laboratory model of herpes simplex virus infection to assess the potential for contamination of dental handpieces by a human viral pathogen. They found that although all the handpieces in the study were fitted with anti-retraction valves, it was not until the units were flushed internally and disinfected externally that the pathogens were eliminated.

Topical bleomycin treatment of oral leukoplakia: a randomized double-blind clinical trial

BACKGROUND

Oral leukoplakia and oral erythroplakia may be associated with benign and dysplastic cellular changes, and are at risk of malignant transformation. Additional means of management of these lesions is needed. The results of nonblinded trials using topical bleomycin in oral leukoplakia indicated the need for phase III study.

METHODS

A prospective, double-blind, randomized trial of topical bleomycin versus placebo was conducted. Bleomycin 1% in dimethylsulphoxide (DMSO) or the carrier was applied for 5 minutes for 14 consecutive days. Clinical assessment and pre-application and post-treatment biopsies were conducted.

RESULTS

Twenty-two patients were randomized. Of the patients who received bleomycin, decrease in clinical size of the lesion was achieved (p = 0.001), and histological reduction in dysplasia was seen (p = 0.094).

CONCLUSIONS

The topical application of bleomycin in DMSO may represent an additional approach to management of oral leukoplakia. The treatment is well-tolerated, and may be considered when the location or extent of the lesion may make surgical excision difficult.

The role of malocclusion and orthodontics in temporomandibular disorders

The recent literature is reviewed to assess the role of the dental occlusion in the etiopathogenesis of temporomandibular disorders (TMD) and the role of orthodontic therapy in preventing and treating TMD. Little evidence was found to support occlusal factors in TMD other than lack of posterior occlusal support and anterior open bite, which may represent predisposing factors in TMD. Orthodontic therapy may not affect the risk of developing TMD and has little role in treatment.

Surgical periodontal treatment in the radiotherapy-treated head and neck cancer patient

A series of clinical cases is presented in which surgical periodontal therapy was conducted within the high-dose volume of prior radiation therapy. Close oral supervision is required in patients following head and neck radiation therapy. Non-surgical periodontal management is crucial in the care of these patients following radiation therapy. Careful selection of patients for possible surgical therapy and care in performing the procedure may allow successful periodontal management, as is demonstrated in the cases reviewed.

A clinical trial of bethanechol in patients with xerostomia after radiation therapy. A pilot study

The effects of bethanechol in the treatment of dry mouth were assessed in patients with xerostomia after radiation therapy to the head and neck. Bethanechol possesses muscarinic and nicotinic-cholinergic activity that likely accounts for its mode of action. Bethanechol (25 mg, three times daily) was not associated with significant side effects. Statistically significant increases in whole resting saliva (p = 0.003) and whole stimulated saliva (p = 0.001) were seen. In patients with pretreatment stimulated saliva volumes greater than resting saliva volumes, a positive response to subsequent use of the sialagogue was seen.

Hepatitis C: rapid progress in medicine and implications for dentistry

Recent developments in the recognition and diagnosis of the major infectious cause of posttransfusion hepatitis, hepatitis C virus (HCV), have led to an explosion in research. These developments are of relevance to dental providers. Patients may now present to the dentist with a diagnosis of hepatitis C infection and may be undergoing medical treatment for this disease. The risk for transmission of HCV in the dental setting is minimal. The dentist must understand the implications for the diagnosis of HCV for the patient and for the provision of dental care.

Topical application of capsaicin for treatment of oral neuropathic pain and trigeminal neuralgia

Neuropathic pain may be a major cause of pain in the head and neck. Trigeminal neuralgia may appear as intraoral pain. This article reviews a series of 24 consecutive cases of oral pain treated with topical capsaicin. Complete remission of neuropathic pain was seen in 31.6% of patients; partial remission was achieved in 31.6% of patients. Trigeminal neuralgia with an intraoral trigger was less responsive to topical therapy than neuropathic pain. Further study is needed to clarify the efficacy of topical capsaicin in neuropathic and neuralgic pain and the effect of differing dosages and frequency of application. On the basis of the findings in this open-label clinical trial, controlled clinical study of capsaicin in neuropathic oral pain states appears warranted.

The efficacy of sucralfate suspension in the prevention of oral mucositis due to radiation therapy

PURPOSE

The purpose of this study was to assess the value of sucralfate suspension in prevention of oral mucositis and for reduction of oral pain in patients who develop mucositis during radiation therapy.

METHODS AND MATERIALS

The study was a double-blind, placebo-controlled, randomized prospective trial of a sucralfate suspension in the prevention and management of oral mucositis during radiation therapy. Oral mucositis was assessed using a quantitative scale and symptoms were assessed using visual analogue scales. The statistical model was developed to detect a 40% reduction in mucositis.

RESULTS

No statistically significant reduction in mucositis was seen. Early during radiation therapy less oral pain was reported in the sucralfate group, but as treatment progressed all patients experienced pain. Patients in the sucralfate group were prescribed topical and systemic analgesics later in the course of radiation therapy.

CONCLUSION

Prophylactic oral rinsing with sucralfate did not prevent oral ulcerative mucositis. Sucralfate may reduce the experience of pain during radiation therapy.

Topical cyclosporin A for treatment of oral chronic graft-versus-host disease

Graft-versus-host disease (GVHD) following bone marrow transplant is an important cause of morbidity and mortality. Oral involvement in chronic GVHD occurs frequently and occasionally is the manifestation of greatest concern to the patient. Management with systemic immunosuppression is the principal approach to therapy although topical application of corticosteroids may also be beneficial. We evaluated the use of cyclosporin administered as an oral rinse in patients with oral GVHD which remained active despite the prior use of systemic immunosuppression plus topical dexamethasone. Signs and symptoms of ulcerative oral GVHD improved > or = 50% in 7 of 11 patients (64%) treated with the addition of topical cyclosporin A. The topical use of cyclosporin A may represent a useful adjunctive approach in the management of oral GVHD.

Rotary dental instruments and the potential risk of transmission of infection: herpes simplex virus

A laboratory model of herpes simplex virus infection was used to assess the potential contamination of dental handpieces. When contaminated instruments were treated with surface disinfection and internal chemical disinfection, viable virus was eliminated in all instruments.

Periodontal pocketing in HIV-associated periodontitis

Gingival and periodontal involvement has been described in individuals with Human Immunodeficiency Virus (HIV) infection. The manifestations often include erythematous gingivitis, necrotizing gingivitis, and periodontal involvement characterized by rampant loss of bone and soft tissue, resulting in recession without the formation of periodontal pockets. We present cases of HIV-associated periodontitis (HIV-P) in which advanced periodontal pocket formation was present. Periodontal disease may show a broad range of severity in patients with various T4 helper cell counts.

Management of orofacial pain in cancer patients

Pain in patients with cancer may arise due to the primary disease, or due to therapy of the malignant disease. Pain may be caused by oral infection, oral mucositis, and by alteration in musculoskeletal and neurological function. The management of orofacial and oropharyngeal pain in patients with cancer is reviewed in this paper.

Risk factors for oropharyngeal candidiasis in patients who receive radiation therapy for malignant conditions of the head and neck

Twenty-seven consecutive patients receiving radiation to the head and neck were followed to assess risk factors for the development of candidiasis. One-third of the patients developed oral candidiasis during radiation therapy. Xerostomia was shown to correlate with risk of oropharyngeal infection (p = 0.033). The presence and use of oral prostheses were shown to correlate with oral colonization of Candida albicans before radiation therapy (p = 0.011). Alcohol use and smoking represent risk factors for oral colonization by Candida during radiation therapy (p = 0.023 and p = 0.045 respectively). These factors must be assessed in future studies of oropharyngeal candidiasis in radiation therapy.

Hyperbaric oxygen and postradiation osteonecrosis of the mandible

The clinical and dental records of 26 patients with the clinical diagnosis of postradiation osteonecrosis (PRON) managed with hyperbaric oxygen (HBO) were reviewed to determine the efficacy of HBO. 19 patients were male and 7 were female; age at the first HBO session ranged from 28 to 80 years (median 57.5 years). All but 8 patients reviewed had some form of surgical management; 7 had mandibulectomy for PRON. As part of management, a total of 9-84 HBO sessions (median 35 sessions) was administered. 18 of the 26 patients ultimately achieved persistent mucosal and cutaneous coverage 1-84 months (median 24 months) after the first HBO session. 13 of the 26 patients met strict criteria for resolution of their disease; fully 21 of 26 patients had improved PRON status following HBO therapy. HBO treatment as part of a comprehensive management plan is safe and effective in the management of PRON.

Radiation therapy and pain in patients with head and neck cancer

Pain is commonly present at the time of diagnosis of head and neck cancer. Pain occurs in all patients treated for oropharyngeal cancer. This study examined the prevalence, severity and characteristics of pain in patients treated with radiation therapy for cancer involving the head and neck and oral cavity. Pain increases throughout the course of radiation and persists following treatment and in some patients continues for 6-12 months. Pain frequently requires systemic analgesics in addition to oral rinses.

Oral infections due to cytomegalovirus in immunocompromised patients

Herpes group virus infections in the immunocompromised host are associated with significant morbidity and mortality. Herpes simplex virus (HSV) and to a lesser extent varicella zoster virus (VZV) have long been recognized as causes of oral and peri-oral lesions in subjects undergoing bone marrow transplantation and in individuals infected with the Human Immunodeficiency Virus (HIV). A role for Cytomegalovirus (CMV) in such lesions is less clear and not well documented. This report describes two bone marrow transplant recipients and one individual infected with HIV in whom CMV was implicated as the cause of oral lesions. Diagnostic and management issues as well as clinical implications are discussed.

Hairy leukoplakia after bone marrow transplantation

Hairy leukoplakia in 10 patients after bone marrow transplantation was identified clinically and assessed histologically. In situ hybridization for Epstein-Barr virus and human papilloma virus confirmed Epstein-Barr virus in hairy leukoplakia in two cases, and human papillomavirus in three cases. All cases with clinical follow-up resolved without treatment. These findings suggest that severe immunosuppression after a bone marrow transplantation may result in the development of hairy leukoplakia, and that as the immunosuppression resolves after the transplant the lesions also resolve.

Oral manifestations of cytomegalovirus infection

Disease caused by cytomegalovirus is reported with increasing frequency. Cytomegalovirus is an important pathogen in immunocompromised and immunosuppressed patients. The most common manifestation of cytomegalovirus infection of the gastrointestinal tract including the oral mucosa is ulceration. The role of cytomegalovirus in xerostomia, Sjögren's syndrome, and Kaposi's sarcoma is continuing to be investigated. This article reviews the oral manifestations of cytomegalovirus, including recently reported oral manifestations.

Treatment of oral Kaposi sarcoma with intralesional vinblastine

BACKGROUND

Kaposi sarcoma (KS) is an acquired immune deficiency syndrome-defining condition in human immunodeficiency virus infection. Oral KS may produce local symptoms and require treatment. Palliation of oral lesions may be achieved with radiation therapy and chemotherapy. This review was conducted to assess the effect of intralesional vinblastine in the management of oral KS.

METHODS

Patients were referred because of oral KS. Intralesional injection of vinblastine (0.2 mg/ml) was conducted under local anesthesia, and patients were observed to determine the effect of treatment.

RESULTS

Forty-two patients with oral KS were treated with intralesional vinblastine. A greater than 50% reduction in the lesions was seen in 74% of patients. The mean duration of response was 3.52 months for all patients. For patients not lost to follow-up and observed until recurrence of the oral lesions, palliation was achieved for a mean of 4.25 months.

CONCLUSIONS

Effective local palliation of oral KS can be achieved with intralesional injection of vinblastine.