Osteonecrosis of the jaw associated with pembrolizumab

We report a case of osteonecrosis of the jaw (ONJ) with pembrolizumab, a rare yet possibly emerging complication. In this case, a temporal relationship between the development of ONJ and the patient's treatment regimen suggested an association between pembrolizumab/GVD therapy and the development of ONJ. Thrombocytosis and anatomic factors may also have played a role. The number of patients using pembrolizumab will likely continue to increase. We document this instance in order to better inform dental treatment around cancer patients undergoing pembrolizumab therapy.

Dental treatments, tooth extractions, and osteonecrosis of the jaw in Japanese patients with rheumatoid arthritis: results from the IORRA cohort study

This study aimed to evaluate dental treatments, tooth extractions, and osteonecrosis of the jaw (ONJ) in Japanese patients with rheumatoid arthritis (RA). Patients with RA enrolled in our cohort completed self-administered questionnaires, which included questions regarding their dental treatments, tooth extractions by dentists during the past 6 months, and past history of ONJ. The history of ONJ was validated with the patients' medical records. Logistic regression was used to determine the association of variables with dental treatments and tooth extractions during the past 6 months. Among 5695 Japanese patients with RA who responded to the questionnaires (mean age, 61.0 years; 85.6 % female), 2323 patients (40.8 %) and 378 patients (6.6 %) reported having had dental treatments and tooth extractions performed by a dentist within the past 6 months, respectively. In multivariate models, advanced age was significantly (P < 0.0001) associated with both dental treatments and tooth extractions during the prior 6-month period, and ever smoking was significantly (P = 0.023) correlated with tooth extractions during that time. Among patients who reported a history of ONJ, we confirmed five cases of ONJ with patient medical records. The prevalence of ONJ was 0.094 % among all RA patients and 0.26 % among female RA patients ≥65 years of age (n = 1888). Our data suggest that more than a few Japanese patients with RA have dental complications that require care by dentists, and that Japanese rheumatologists and dentists should cooperate to improve dental health in patients with RA.

[Pneumomediastinum Due to the Fracture of the Maxillary Antrum]

A 47-year-old man was admitted to the emergency room, half a day after having fallen down on his right cheek drunkenly onto a concrete block. Physical examination revealed that the contusion was limited to the right side of his face, only around the cheek, without trauma to the neck, chest or abdomen. But wide ranging tactile crepitus with severe swelling was present on his face and neck due to widely spread emphysema. Computed tomography (CT) scan revealed some fractures of maxillary antrum, facial and cervical emphysema spreading to the lower part of mediastinum. After a conservative treatment, he recovered without any severe systematic complication. It was found that the facial and cervical emphysema and pneumomediastimum completely disappeared on the follow-up CT scan, 18 days after the event.

Secondary jaw aneurysmal bone cyst (JABC)--a possible misnomer? A review of literature on secondary JABCs, their pathogenesis and oncogenesis

CONTEXT

Aneurysmal bone cysts are rare pseudocysts, commonly seen in long bones and vertebral column. Although a well described and reported lesion, many misconceptions still prevail regarding their etiopathogenesis. Many of the reported cases of jaw aneurysmal bone cysts (JABC) present with another bone pathology.

AIMS

The purpose of this review was to evaluate the incidence of neoplastic lesions occurring simultaneously with a JABC (in contrast to primary JABCs). Any pathogenetic and oncogenetic association between primary and secondary jaw ABCs has been reviewed and discussed.

SETTINGS AND DESIGN

A methodical narrative review of literature was performed, given the incidence of mostly case reports on this topic.

METHODS AND MATERIAL

A methodical electronic search of Pubmed, Pubmed Central, Medline and Cochrane databases was performed for reported cases of JABC. These articles were analysed and segregated into primary and secondary ABC and, if secondary, the lesion it concurrently occurred with. Another search was conducted to yield articles discussing the cytopathogenetic and oncogenetic origins of ABCs.

RESULTS AND CONCLUSIONS

About 15% of the ABCs reported were of secondary nature. Amongst the associated lesions, cement-ossifying fibroma and ossifying fibroma were the most common, followed by fibrous dysplasia and central giant cell granuloma. No ABCs were associated with metastatic changes. The search for histopathogenesis pointed to a specific cytogenetic abnormality as the origin of primary ABCs, with USP6 as its main oncogene and spindle cell as the neoplastic cell, unlike with secondary ABCs, suggesting that they are distinct pathological processes.

The 'anatomically difficult' denture case

Complete loss of teeth from one or both arches is a disabling condition which is usually managed by a conventional removable denture. Rehabilitation may be poorly tolerated by patients, particularly in the lower jaw, and is more difficult in situations when the anatomy of the denture-bearing area is less favourable. These situations may require specific prosthodontic or surgical techniques, or a combination of both. Prosthodontic solutions involve special impression techniques and the use of soft linings and it is vitally important to manage patient expectations in such cases. This article describes prosthodontic management options for dealing with the fibrous (flabby) anterior ridge and bony exostoses.

CLINICAL RELEVANCE

Although tooth loss in the UK is diminishing, it is nevertheless important that dental practitioners are able to demonstrate good prosthodontic skills for managing an ageing population. Surgical correction of anatomical defects may occasionally be employed.

Diagnosis and treatment of Sagliker syndrome: a case series from Iran

Sagliker syndrome was introduced in 2004 in patients with end-stage renal disease and severe secondary hyperparathyroidism. This syndrome describes maxillary and mandibular deformities, dental abnormalities, benign soft tissue tumors in mouth, and various kinds of skeletal changes including short stature and fingertip abnormalities. There are a few reports from different regions of the world. The aim of this study is to report 5 cases of the Sagliker syndrome from Iran.

[Complex approach to assessment of condition severity in patients with pyoinflammatory odontogenous diseases]

Dynamics of mean value indices and mean dispersion doesn't exclude the feedback (Mayanskiy D.N., 2008) in process of study the disease according to cooperative processes using system leukocyte-monocyte-lymphocyte (L+M+LM). The authors investigated a dynamic balance between these cell substratums and collagen formation. Acute inflammatory processes in tissues of maxillofacial area accompanied by leukemoid response of peripheral blood in the form of leukocytosis (10 x 10(9)-15 x 10(9)/l and more). The authors completely agree with the opinion of M.M. Solov'yov (2012) and N.K. Artyushenko (2008) that mechanism of this reaction is associated with both the leukocyte redistribution in the inflammation zone and with changes of hematopoietic rostock which aimed to balance the affected compensatory mechanisms of nonspecific resistance.

Risk factors of recurrence and life-threatening complications for patients hospitalized with chronic suppurative osteomyelitis of the jaw

BACKGROUND

Clinically, recurrence and life-threatening complications are challenging problems for chronic suppurative osteomyelitis of the jaw (CSOJ), but there is no quantitative analysis or report about the causes of or risk factors for the two problems to date. Doctors identify the causes or risk factors only through clinical experience. We performed a retrospective study of 322 patients with CSOJ to quantificationally analysed the risk factors for the abovementioned two problems by logistic regression analysis.

METHODS

A retrospective study of 322 patients hospitalized with CSOJ was performed. The socio-demographic and clinical characteristics were recorded. The risk factors for the above two problems were analyzed by logistic regression analysis. Frequency and percentage were used to indicate descriptive research factors. A univariate logistic regression analysis was performed to calculate the odds ratio (OR) and to identify independent risk factors. The independent risk factors were further identified by multivariate logistic regression analysis.

RESULTS

An age from 6-12 years or > 65 years, pre-admission antibiotic administration, a lesion at the mandibular ramus, concurrent maxillofacial space infection (MSI), and conservation of pathogenic teeth were found to be risk factors for recurrence. An age > 65 years, admission temperature > 39 degree Celsius, admission white blood cell (WBC) count >15×109/L, pre-admission antibiotic administration, concurrent MSI, pre-existing diabetes, and respiratory difficulty were found to be risk factors for life-threatening complications.

CONCLUSIONS

The results indicate that doctors should remain mindful of the risk factors listed above, and the management of CSOJ should be increasingly aggressive when the above risk factors are present, especially when the lesion is located at the mandibular ramus. In addition, pathogenic teeth must be extracted, and antibiotics should be administered properly.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT01670422).

Atypical femoral fractures shortly after osteonecrosis of the jaw in a postmenopausal woman taking alendronate for osteoporosis

CONTEXT

Bisphosphonates effectively increase bone mineral density and reduce fracture risk in patients with osteoporosis, but there are concerns about osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) in the long-term users. So far both complications have not been reported as occurring simultaneously in an osteoporotic individual on oral alendronate.

OBJECTIVE

The aim of this study was to report a postmenopausal woman presenting with concomitant ONJ and AFF on oral alendronate treatment. SUBJECT, MEASURES, AND RESULT: The patient was a 63-year-old woman with a history of rheumatoid arthritis for 30 years and diabetes for 3 years. Spinal compression fractures at levels L3 and L4 were documented, and she took alendronate 70 mg weekly for 7 years. She is the first case whose dental periapical imaging and pelvic radiography documented her ONJ and AFF, which developed subsequently within 6 months.

CONCLUSIONS

This case report supports the association of both ONJ and AFF with long-term oral bisphosphonate therapy.

Rubber jaw in a Weimaraner dog due to juvenile nephropathy. A case without evidence for genetic involvement

The case of a 5-month-old male Weimaraner dog with severe osteodystrophia fibrosa (rubber jaw) and renal insufficiency is presented. Kidneys were smaller than normal with a granular cortical surface and a histopathological end-stage diagnosis consistent with juvenile nephropathy. Analysis of four described genetic mutations associated with Alport syndrome in dogs revealed no evidence for familiar inheritance in this dog.

[Cellular and tissue reactions of the mucous membrane of the maxillary sinus in the patients presenting with odontogenic aspergillous maxillary sinusitis]

The results of this morphological study of the mucous membrane of the maxillary sinuses in the patients presenting with the non-invasive fungal form of odontogenic sinusitis revealed the signs of granulematous inflammation. Epithelium underwent metaplasia into the single-row cubic or prismatic layer. The invasive form of fungal odontogenic sinusitis was characterized by allergic inflammation with intensive infiltration of maxillary sinus mucosa by antigen-representing and effector cells.

[Frequency and clinical outcome of odontogenic cervicofacial infection]

OBJECTIVE

To measure frequency, mortality, hospitals stay and the requirement of attention in the intensive care unit (ICU) of patients with cervical infections.

METHODS

A descriptive, observational and transversal study was carried out. We analyzed the database of patients admitted to Emergency Room of High Specialty Hospital, with cervical and facial infection with odontogenic origin, during a year period.

RESULTS

In three cases were ambulatory and 19 where hospitalized; only three required ICU attention. The average of hospital stay was 6.3 days and the mortality of 8.3%.

CONCLUSIONS

The mortality is significant in patients who require ICU and whose age is older than 60 years. Therefore this group of patients required a rapid multidisciplinary care to improve their expectations for survival expectancy.

Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw

Osteonecrosis of the jaw is an uncommon consequence of biphosphonate therapy. This has most commonly been a bone complication with little if any soft tissue involvement. An unusual case of necrotizing fasciitis with extensive soft tissue infection stemming from a prolonged case of osteonecrosis of the jaw presented. The management of this patient (aggressive surgical debridement and prolonged wound care) is reviewed as well as the review of the underlying processes.

Bisphosphonate-associated osteonecrosis of the jaw: a key role of inflammation?

Osteonecrosis of the jaw (ONJ) can be associated with nitrogen-containing bisphosphonates (NBPs) therapy. Various mechanisms of NBP-associated ONJ have been proposed and there is currently no consensus of the underlying pathogenesis. The detailed medical and dental histories of 30 ONJ patients treated with NBPs for malignant diseases (24) or osteoporosis (6) were analyzed. The necrotic bone was resected and analyzed histologically after demineralization. In 10 patients the perinecrotic bone was also resected and processed without demineralization. Alveolar bone samples from 5 healthy patients were used as controls. In 14 ONJ patients, serial technetium-99m-methylene diphosphonate scintigraphic scans were also available and confronted to the other data. Strong radionuclide uptake was detected in some patients several months before clinical diagnosis of ONJ. The medullary spaces of the necrotic bone were filled with bacterial aggregates. In the perinecrotic bone, the bacteria-free bone marrow characteristically showed an inflammatory reaction. The number of medullary inflammatory cells taken as an index of inflammation allowed us to discriminate two inflammation grades in the ONJ samples. Low-grade inflammation, characterized by marrow fibrosis and low inflammatory cells infiltration, increased numbers of TRAP(+) mono- and multineacleated cells was seen in patients with bone exposure<2 cm(2). High-grade inflammation, associated with larger lesions, showed amounts of tartrate-resistant acid phosphatase(+)/calcitonin receptor(-) mono- and multinucleated cells, osteocyte apoptosis, hypervascularization and high inflammatory cell infiltration. The clinical extent of ONJ was statistically linked to the numbers of inflammatory cell. Taken together these data suggest that bone necrosis precedes clinical onset and is an inflammation-associated process. We hypothesize that from an initial focus, bone damage spreads centrifugally, both deeper into the jaw and towards the mucosa before the oral bone exposure and the clinical diagnosis of ONJ.

Florid osseous dysplasia: report of a case presenting acute cellulitis

In this review, we examined a 45-year-old Asian man who had been diagnosed with florid osseous dysplasia (FOD) of the mandible and acute perimandibular cellulitis. This presentation occurred after a history of off-and-on swellings of the jaw and multiple treatments received at another hospital. An aggressive resection of the jaw was planned; however, the patient denied the treatment and came to our clinic to seek a second opinion. The patient was successfully treated by conservative surgery and antibiotic treatment with preservation of the jaw integrity and the mandibular neurovascular canal. Intraoperatively, a piece of a calcified mass was removed and submitted for histopathological examination. The specimen showed woven bone and densely sclerotic mass of calcified materials exhibiting reversal lines and inflammatory cell infiltration of the connective tissue. The definitive diagnosis was FOD with a secondary infection. Treatments for FOD were discussed.

[Numb chin syndrome caused by biphosphonates-induced osteonecrosis of the jaw]

INTRODUCTION

Numb chin syndrome is caused by a mental or inferior alveolar nerve neuropathy. Traumatic and infectious injuries are the most frequent causes of the syndrome but, if an evident cause does not exist, a neoplastic etiology must be investigated. Other causes of the numb chin syndrome are rare.

CASE REPORT

A 73-year-old woman had had a diagnosis of metastatic breast cancer and was been treated with zoledronic acid. She attended because of hypoesthesia and dysesthesia of the chin congruent with mental nerve distribution. A computed tomography of the jaw showed an osteolytic lesion with central bone sequestration, so biphosphonate-induced osteonecrosis of the jaw was diagnosed. After zoledronic acid was withdrawn, clinical neuropathy and imaging findings remained stable.

CONCLUSIONS

Biphosphonates-induced osteonecrosis of the jaw is a recently described condition. It has been rarely reported as a cause for numb chin syndrome. In the future, osteonecrosis of the jaw must be considered in the differential diagnosis of this syndrome in cancer patients treated with biphosphonates.

Worsening of osteonecrosis of the jaw during treatment with sunitinib in a patient with metastatic renal cell carcinoma

We report on the potential association of suspected bisphosphonate-associated osteonecrosis of the jaw (BRONJ) recurrence with the use of the novel antiangiogenic drug sunitinib. A 59 year-old patient affected by metastatic renal cell carcinoma (RCC) and established BRONJ experienced consecutive episodes of painful jaw infection with cutaneous fistula and bone sequestration which occurred during active treatment with sunitinib, improved after discontinuation and antibiotic therapy, then rapidly worsened with resumption of sunitinib. We hypothesize that the potent antiangiogenic activity of sunitinib may amplify the inhibition of bone remodeling exerted by aminobisphosphonates entrapped within the osteonecrotic mineral matrix, antagonize mucosal healing and expose to infections during treatment. This supports the emerging role of soft-tissue damage in the pathogenesis of osteonecrosis of the jaw.

The entity of jaw tremor and dystonia

BACKGROUND

Jaw tremor in the context of dystonia is not well recognized.

METHOD

We describe 7 women (average onset age 70) with jaw tremor and dystonia.

RESULTS

All had features of primary dystonia. Applying MDS criteria for tremor, 3 had "dystonic jaw tremor"; 4 had "jaw tremor associated with dystonia". Drugs were unhelpful. Botulinum toxin injections proved effective in 1 case.

CONCLUSION

We propose the entity of "jaw tremor and dystonia". It is distinct from jaw tremor due to other causes including Parkinson's disease and essential tremor.

Orofacial pain – a presenting symptom of bisphosphonate associated osteonecrosis of the jaws

Osteonecrosis of the jaws (ONJ) associated with bisphosphonate therapy is being reported with increasing frequency all over the world. Pain may be the presenting symptom commonly associated with intra-oral bone exposure. The aetiology of this therapeutic complication is still not well understood. Three cases are presented and the management of the condition is discussed.

Hamartomatous proliferations of odontogenic epithelium within the jaws: a potential histogenetic source of intraosseous epithelial odontogenic tumors

BACKGROUND

The jawbone is replete with a vestige of odontogenesis. The overall consensus is that intraosseous remnants of the enamel organ and dental lamina are the only histogenetic option for central epithelial odontogenic tumors. Curiously, incipient tumors or possible precursor conditions of residual odontogenic epithelium have rarely been reported in the literature.

METHODS

We microscopically evaluated 39,660 biopsy samples to determine the presence of a tumor-like odontogenic epithelial nodule in the maxilla and mandible.

RESULTS

Seven intraosseous specimens that associated with a focal proliferation of odontogenic epithelium were retrieved. Six hamartomatous processes showed four different morphologic patterns comparable with the tumor nests comprising ameloblastoma (n = 1), squamous odontogenic tumor (n=1), calcifying epithelial odontogenic tumor (n=2) and calcifying cystic odontogenic tumor (n=2). Among six lesions, four were the intrafollicular development. The remaining case of interest was multiple hyperplastic clear rests of Malassez in association with an impacted tooth.

CONCLUSION

Although it is impossible to predict the fate of these microscopic structures of hamartomatous character, the present case series indicates that any of the dormant embryonic residues of odontogenic epithelium can return to an active state, capable of non-reactive, probably neoplastic proliferation of pathological significance.

Central giant cell granuloma associated with central ossifying fibroma of the jaws: a clinicopathologic study

OBJECTIVE

To investigate the prevalence of clinical, radiographic, and histopathologic characteristics of combined central giant cell granuloma (CGCG) and central ossifying fibroma (COF).

STUDY DESIGN

Retrospective clinical and histomorphometric analysis of all cases diagnosed as CGCG or COF between 1994 and 2002.

RESULTS

A total of 51 cases were included in the study: CGCG (n = 23), COF (n = 25), and combined COF-CGCG (n = 3). All 3 lesions presented expansile, well-defined unilocular radiolucencies, with radiopacities (66%), root resorption (66%) and tooth displacement (33%). Microscopically, areas of classical CGCG and COF were separated by a transition zone of nonvascularized densely packed spindle cells. Surgical procedure resulted in recurrence within 1 year in 1 of 2 patients, calcitonin nasal spray treatment resulted in growth arrest in 1 case.

CONCLUSIONS

Because of the small number of the combined cases, the biologic behavior of the lesions is uncertain. The CGCG component may drive the clinical behavior toward a more aggressive behavior than classical COF; therefore, close follow-up is recommended.

Clinically aggressive central giant cell granulomas in two patients with neurofibromatosis 1

BACKGROUND

Neurofibromatosis 1 (NF1) is an autosomal dominantly inherited disorder caused by a spectrum of mutations affecting the Nf1 gene. Affected patients develop benign and malignant tumors at an increased frequency. Clinical findings include multiple cutaneous café-au-lait pigmentations, neurofibromas, axillary freckling, optic gliomas, benign iris hamartomas (Lisch nodules), scoliosis, and poorly defined soft tissue lesions of the skeleton. Kerl first reported an association of NF1 with multiple central giant cell granulomas (CGCGs) of the jaws. There have since been 4 additional published cases of NF1 patients with CGCGs of the jaws.

CLINICAL CASES

We report on 2 patients who presented with NF1 and aggressive CGCGs of the jaws. In both cases, the clinical course was characterized by numerous recurrences despite mechanical curettage and surgical resection.

CONCLUSIONS

We review proposed mechanisms to explain the apparent association between NF1 and an increased incidence of CGCGs of the jaws. While the presence of CGCGs of the jaws in patients with NF1 could represent either a coincidental association or a true genetic linkage, we propose that this phenomenon is most likely related to NF1-mediated osseous dysplasia. Compared to normal bone, the Nf1-haploinsufficient bone in a patient with NF1 may be less able to remodel in response to as of yet unidentified stimuli (e.g. excessive mechanical stress and/or vascular fragility), and consequently may be more susceptible to developing CGCG-like lesions. Alternatively, the CGCG in NF1 patients could represent a true neoplasm, resulting from additional, as of yet unidentified, genetic alterations to Nf1-haploinsufficient bone.

Diagnostic imaging for chronic orofacial pain, maxillofacial osseous and soft tissue pathology and temporomandibular disorders

Since dentists can be faced by unusual cases during their professional life, this article reviews the common orofacial disorders that are of concern to a dentist trying to diagnose the source of pain or dysfunction symptoms, providing an overview of the essential knowledge and usage of nowadays available advanced diagnostic imaging modalities. In addition to symptom-driven diagnostic dilemmas, where such imaging is utilized, occasionally there are asymptomatic anomalies discovered by routine clinical care and/or on dental or panoramic images that need more discussion. The correct selection criteria of an image exam should be based on the individual characteristics of the patient, and the type of imaging technique should be selected depending on the specific clinical problem, the kind of tissue to be visualized, the information obtained from the imaging modality, radiation exposure, and the cost of the examination. The usage of more specialized imaging modalities such as magnetic resonance imaging, computed tomography, ultrasound, as well as single photon computed tomography, positron electron tomography, and their hybrid machines, SPECT/ CT and PET/CT, are discussed.

[Odontogenic mediastinitis]

Basing on the analysis of 143 cases of odontogenic mediastinitis it is shown that in the structure of acute odontogenic infectious diseases this severe complication accounts for 0.3% of cases. In 80% of the cases it develops on the background of chronic somatic diseases representing 51.7% of cases in the age group from 31 to 50 years. Outcome of mediastinitis depends on time of hospitalization, intensity and time of the treatment. Life span and quality of life of the patients depends first of all upon somatic disease compensation.

[Risk factors and incidence of dental diseases in children in a large industrial town]

A relationship has been studied between somatic diseases, functional changes, and dental mortality in children living in urban areas having different levels of ambient air pollution. Visceral diseases have been ascertained to contribute to the development or deteriorate the course of various pathological tooth and jaw processes. Systemic diseases change the conditions of formation and maturation of dentins, which makes them less resistant. The relationship between the changes in the somatic and dental statuses of children is more pronounced when the ecological situation is poor.

Clinical and radiological features of central giant-cell lesions of the jaw

OBJECTIVE

The purpose of this study was to evaluate the clinical and radiological features of central giant-cell lesions that were diagnosed in The Netherlands between January 1, 1990, and January 1, 1995.

STUDY DESIGN

A population-based retrospective study was carried out, examining all patients with a central giant-cell lesion from this period.

RESULTS

In 83 patients there was a central giant-cell granuloma (89 lesions). Aggressive signs and symptoms (pain, paresthesia, or root resorption) were found in 16 (19.3%) patients. Multiple lesions occurred in 3 (3.6%) patients. The overall recurrence rate was 26.3%, and there was a higher recurrence rate in patients who exhibited aggressive signs and symptoms than in patients without these features (RR 1.6). In 5 patients a clinical diagnosis of cherubism or concomitant neurofibromatosis type 1 was made (14 lesions).

CONCLUSION

In a general population, large and aggressive lesions are less common than suggested by the literature. Multiple lesions, however, occur more frequently than previously assumed. In patients with aggressive signs and symptoms, surgical curettage is not an effective therapy.

Sickle cell disease and trait: an increase in trabecular spacing, a case study

A case report of a patient with sickle cell disease trait and the radiographically evident trabecular bone changes is examined in this article. The purpose of this article is to raise awareness in the dental and dental hygiene professional community of the treatment and clinical management of patients with sickle cell disease (SCD) and sickle cell disease trait (SCD trait). Dentists and dental hygienists can provide optimum clinical care for this patient population by incorporating appropriate clinical management according to the most recent advances in the recognition and treatment of patients with SCD and SCD trait.

[Eales' disease with bilateral brain strokes and jaw-closing dystonia]

Eales' disease is an idiopathic occlusive vasculopathy of the retina, which is characterized by extensive peripheral non-perfusion, perivascular sheathing, and neovascularization. It is associated with recurrent vitreous hemorrhages. Both eyes are affected consecutively in 80% to 90% of the patients. In spite of the multiple theories that have been proposed, it continues to have unknown origin and its diagnosis relies on exclusion of other causes of retinal vasculopathy. In some occasions, these patients develop complications of the central nervous system, above all brain infarcts. We present the case of a 38 year old woman with Eales' disease who developed bilateral brain infarcts associated with occlusion or stenosis of the middle cerebral arteries. The cerebral angiography showed beading of the Silvian arteries, suggestive of an underlying inflammatory disorder. Early corticosteroid therapy could avoid contralateral retinal involvement and neurological complications. The patient also presented delayed jaw closing dystonia secondary to basal ganglia infarct which followed a benign course with spontaneous resolution in a few days.

Charlatans in dentistry: ethics of the NICO wars

The scientific and diagnostic status of neuralgia-inducing cavitational osteonecrosis, NICO, has not been definitively established. A case is presented in favor of this diagnosis based on published literature. It is argued that the case against NICO has been made largely based on personal experiences, by innuendo, and through personal attacks rather than in scientific debate.

The relative impact of local and endogenous patient-related factors on implant failure up to the abutment stage

The aim of the present study was to assess the influence of endogenous and local factors on the occurrence of implant failure up to the abutment stage. The study comprised a group of 399 consecutive patients, which represented the total of patients who had been treated from 1995 to 1997 (with a total of 1263 Brånemark Brån-system implants) at the Department of Periodontology of the University Hospital, Catholic University Leuven. For each patient, the medical history was carefully examined. Data collection and analysis were mainly focused on endogenous factors such as hypertension, osteoporosis, hypo- or hyperthyroid function, chemotherapy, diabetes type I or II, Crohn's disease, some local factors (e.g. bone quality, reason for tooth loss) and breach of sterility during surgery. The reason for tooth loss, smoking habits, radiotherapy and other local bone factors (bone quality and quantity) were also recorded. Implant failures were recorded up to the abutment connection. The present study indicated a success rate until this stage of 97.8%. General factors such as heavy smoking, chemotherapy plus poor bone quality increased implant failure rate. Radiotherapy, limited bone volume and claustrophobia, which led to breaching the strict preoperative rules of asepsis, appeared to be the most relevant local factors for early implant failures.

Oral osteoporosis: is there an association between periodontitis and osteoporosis?

Osteoporosis and periodontitis represent two highly prevalent diseases associated with advancing age. There is evidence that a patient with systemic osteoporosis is likely to have decreased oral bone density, which may affect treatment decisions. Further, a patient with decreased bone mineral density, indicative of osteoporosis, may be at a higher risk for periodontitis progression. Therefore, osteoporosis could be considered a risk factor for periodontitis. Ultimately, many of the medical, nutritional, and lifestyle interventions that are beneficial in the management of osteoporosis have the potential to be applied to oral health care and the management of oral bone loss.

Medullary and odontogenic disease in the painful jaw: clinicopathologic review of 500 consecutive lesions

Ischemic jawbone lesions were first discussed in the dental literature more than a century ago, but then seemingly forgotten. In recent years, there has been considerable resurgence in interest in this unique pathological condition. Controversy surrounds the subject. Some proclaim these lesions to be mere fabrications of the imaginations of non-traditional or alternative dental surgeons. Others attribute all human maladies to these maxillofacial lesions. Aside from these philosophical and metaphysical arguments, are there common diagnoses of jawbone pathologies that produce pain? This present investigation reviews the clinicopathologic features of 500 consecutive jawbone surgeries with pathological confirmation in patients with idiopathic facial pain. Four hundred seventy-six (476) of the 500 lesions (95.2%) were directly attributed to impaired blood flow in the jawbone, tooth, or both, according to histopathological analysis and confirming Cavitat (bone ultrasound) examination. Statistical data concerning the location, frequency, and pathological diagnoses of these bony lesions are presented, as are brief methods of diagnosis, and treatment is also discussed.

What is the genetic factor in migraine?

Migraine is frequently assumed to have an hereditary origin, but what this hereditary factor is, no one really knows. Researchers are currently trying to find defects in genes which could either cause, or tend towards, the development of migraine. This approach is deemed mistaken for two reasons: firstly, pain, being only a signal of an essential monitoring system, cannot be an inheritable factor on its own without the accompanying physiological or pathological processes which give rise to it; and secondly, physicians, almost universally, fail to examine a large part of the head, viz., the mandible and maxillae and their appendages, before making their diagnoses or providing treatment, thereby contravening the fundamental principle of properly examining patients. It is hereby suggested, and evidence is offered showing that impacted teeth could be the long sought-after 'hereditary' factor causing migraine.

Pathologically significant pericoronal lesions in adults: Histopathologic evaluation

PURPOSE

Oral and maxillofacial surgeons devote a large portion of their practice to the removal of impacted teeth. Many of these teeth have associated soft tissue that is submitted along with or without the tooth for histopathologic examination. This study reports the histopathologic diagnoses of a large series of pericoronal lesions in adults submitted to an oral and maxillofacial pathology biopsy service.

MATERIALS AND METHODS

Two thousand six hundred forty-six pericoronal lesions received during a 6-year period were reviewed for location, age, and histopathologic diagnosis.

RESULTS

Retrospective evaluation showed that 67.1% of all submissions were nonpathologic follicular tissue. Pathologically significant lesions were diagnosed in 32.9% of cases. Among these lesions were 673 dentigerous cysts (28.4%), 79 dentigerous cysts with mucous cell prosoplasia, 71 odontogenic keratocysts (2.68%), 19 odontomas (0.7%), 13 ameloblastomas (0.5%), 6 carcinomas (0.23%), 6 calcifying odontogenic cysts (0.23%), 4 calcifying epithelial odontogenic tumors, and 1 odontogenic myxoma (0.04%). When stratified by age, the data showed pathologically significant lesions and age are related (chi(2), P <.0001).

CONCLUSIONS

Because of selection bias inherent in a study of this nature, population generalizations cannot be made. However, this study serves to show that the potential for the development of significant, even life-threatening, disease associated with impacted teeth is real and should be a factor in the decision-making process when oral surgeons and others are confronted with the dilemma of managing an impacted tooth.

Periodontal diseases and osteoporosis: association and mechanisms

There is increasing evidence that osteoporosis, and the underlying loss of bone mass characteristic of this disease, is associated with periodontal disease and tooth loss. Periodontitis has long been defined as an infection-mediated destruction of the alveolar bone and soft tissue attachment to the tooth, responsible for most tooth loss in adult populations. Current evidence including several prospective studies supports an association of osteoporosis with the onset and progression of periodontal disease in humans. The majority of studies have shown low bone mass to be independently associated with loss of alveolar crestal height and tooth loss. However studies that focus on the relation of clinical attachment loss and osteoporosis are less consistent. To date, the majority of studies on the relationship between periodontal disease and osteoporosis have been hindered by small sample sizes, limited control of other potential confounding factors, varying definitions of both periodontal disease and osteoporosis, and few prospective studies where the temporality of the association can be established. Potential mechanisms by which host factors may influence onset and progression of periodontal disease directly or indirectly include underlying low bone density in the oral cavity, bone loss as an inflammatory response to infection, genetic susceptibility, and shared exposure to risk factors. Systemic loss of bone density in osteoporosis, including that of the oral cavity, may provide a host system that is increasingly susceptible to infectious destruction of periodontal tissue. Studies have provided evidence that hormones, heredity, and other host factors influence periodontal disease incidence and severity. Both periodontal disease and osteoporosis are serious public-health concerns in the United States. Prevalence of both osteoporosis and tooth loss increase with advancing age in both women and men. Understanding the association between these common diseases and the mechanisms underlying those associations will aid health professionals to provide improved means to prevent, diagnose, and treat these very common diseases. This paper reviews the current evidence on the association between periodontal disease and osteoporosis.