Antibiotic use and resistance: a nationwide questionnaire survey among French dentists

The aim of this survey was to describe the attitudes and self-reported practices of French dentists towards antibiotic use and resistance and to compare practices with national guidelines. A nationwide cross-sectional internet-based survey was conducted among the 41,800 French dentists. The online questionnaire was distributed through professional networks from April 2017 to April 2018. Seven-hundred seventy-five dentists participated but only 455 questionnaires were complete enough to be included in the analyses. Amoxicillin was the most frequently prescribed antibiotic (65.8%, 1783/2711), followed by spiramycin + metronidazole fixed-dose combination (11.6%, 312/2711) and amoxicillin-clavulanic acid (10.3%, 279/2711). The main indications for use were abscess (349/423, 82.5%), cervicofacial cellulitis (74.2%, 314/423), and pericoronitis (58.6%, 239/408). Most dentists (90.5%, 381/421) considered that antibiotic resistance is of concern but only half of them (56.3%, 238/423) felt adequately informed about antibiotic use. Many dentists did not comply with the national guidelines: the majority of them declared inappropriate antibiotic prescriptions for 11/17 clinical situations. They did not prescribe antibiotics for 5/6 clinical situations requiring prophylaxis. They reported that the publication of clinical guidelines is the main factor influencing their prescriptions (71.0%, 299/421). They wished to receive regular updates of national guidelines in the form of practical sheets (93.0%, 172/185). French dentists should urgently be targeted by antibiotic stewardship initiatives.

A non-syndromic case of maxillo-mandibular keratocysts

Introduction: Odontogenic keratocysts (OKCs) are frequent, aggressive lesions with a strong tendency to recur, particularly in their para-keratinized majority form. Although they are mainly non-syndromic, these lesions are found in a large majority of patients with Gorlin syndrome. Thus, multiple forms are almost always associated with this syndrome and require investigation to prevent the risk of various cancers. Non-syndromic multiple forms are exceptional. Observation: A 20-year-old patient presented with dual localization of maxillary and left mandibular OKC at consultation. Under general anesthesia, excision of the lesions and extraction of the impacted wisdom teeth 28 and 38 were performed. The patient showed no clinical sign of Gorlin syndrome. Discussion: The OKC or epidermoid cyst is derived from the dental lamina or its remnants and from the basal part of the oral epithelium and represents between 10 and 20% of all cystic lesions in the maxillae. Its peak of incidence is between the second and fourth decade (or earlier in case of association with basal cell necrosis). OKC occurs mainly in the mandible and preferentially at the Ramus, where its frequency can reach 70% depending on the series. Conclusion: The management of OKC by oral surgeons must be conducted in a multidisciplinary setting in close collaboration with dermatologists, geneticists, and anatomic pathologists. Due to the strong recidivating character of OKCs, patient monitoring is essential.

[Children's consultations for dental emergency. Retrospective study in Île-de-France]

BACKGROUND

In France, the children oral health status has improved but the use of care remains insufficient. The complexity of the acts, the access to care difficulties and the programs of prevention and care for children lack of knowledge contribute to late care and often, in emergency. This study aims to describe the young patients' characteristics consulting in dental emergency and analyse the modalities of recourse.

METHODS

A retrospective study was conducted on medical records. An extraction of data was carried out concerning all children under the age of 16, admitted to the Dental Emergency Functional Unit of the Pitié-Salpêtrière Hospital Group in 2015. Several variables of interest were analysed: socio-demographic characteristics, the time of the visit and the diagnostic category (tooth pathologies, facial trauma, infections, periodontal diseases and other emergencies). Descriptive and bivariate analyses were conducted.

RESULTS

On the 62,500 dental emergency consultations in 2015, 5359 were for patients under 16 years of age (8%). Data were available for 5044 children. Among these, children aged 6 to 11 accounted most of consultations (43.9%). There were more boys (57.2%). The most frequent emergency diagnoses were related to a tooth pathology (42.9%) and traumatic event (38.4%). Consultations were more held on the evening schedule on weekdays and the day on weekends. Patients aged 0 to 5 years consulted more at night (P<10^-3) and were, proportionally, the most affected by traumatic events (39.2%). Children aged 6 to 11 and 12 to 16 years consulted more often during the day (P<10^-3), for emergencies related to a carious event (43.9% and 43.6%). Patients residing in Seine-Saint-Denis accounted for 22.6% of total visits and those living in Paris accounted for 20.8%.

CONCLUSION

A large proportion of children presenting for dental emergencies, have most of the time, only the need for usual care. An offer of dental care, adapted to the territory needs, is necessary for the children dental health management. Preventive measures from an early age and early recourse would be favourable.

A questionnaire-based study evaluating differences between dental students in Paris (F) and Malmö (SE) regarding diagnosis and treatment decisions of patients with different severity levels of periodontal diseases

AIM

To evaluate differences between last-year dental students in Paris (F) and Malmö (SE) Dental Schools, in regard to their judgement and decision-making within periodontology.

MATERIALS AND METHODS

Ninety-six last-year dental students from Paris and 45 from Malmö participated in a questionnaire study based on four patient cases: (i) Patient case with generalised alveolar bone loss but no signs of inflammation (Well-maintained), (ii) Patient case with generalised alveolar bone loss and signs of inflammation (Periodontitis), (iii) Patient case with no alveolar bone loss and no signs of inflammation (Healthy) and (iv) Patient case with no alveolar bone loss but with signs of inflammation (Gingivitis). Through multiple-choice questions, the students judged each case as healthy or diseased proposed a diagnosis and treatment measures and estimated the treatment time for each patient. Furthermore, they assessed the prognosis of each patient in case of no treatment.

RESULTS

Based on a response rate of 83%, the majority in both groups judged all the patients as diseased. More Paris students diagnosed the healthy and the gingivitis case as having periodontitis (P < .05). Furthermore, a larger number of students from Paris recommended several treatment measures and estimated longer treatment times for all the cases (P < .05) and estimated a higher risk for disease progression for the healthy and the gingivitis case (P < .05).

CONCLUSIONS

Significant variation between students from Paris and Malmö Dental Schools in regard to judgement and decision-making was observed; this may in turn imply that there is still need of improving consistency amongst undergraduate educations in periodontology in Europe.

Neuropathic pain in the orofacial region: The role of pain history. A retrospective study

INTRODUCTION

Orofacial neuropathic pain is often difficult to treat, mostly because of still unclear underlying mechanisms. The occurrence of such neuropathic pain varies depending on different factors, of which preexisting preoperative pain seems to be of high importance. The aim of this study was thus to test the hypothesis that prior history of pain could indeed be considered a risk factor for the development of orofacial neuropathic pain in the same region.

METHODS

The study was performed in the dental department of the Groupe Hospitalier Pitié-Salpêtrière (GHPS) in Paris, France. We investigated the presence of prior inflammatory pain before development of orofacial neuropathic pain in 56 patients. For each patient file, the following items were collected: age, gender; medical history; diagnosis; description of the pain (at time of consultation); presence or absence of prior dental treatment; date and type of dental treatment received.

RESULTS

41 patients (73%) of orofacial neuropathic pain patients had a history of pain compatible with an inflammatory condition; 4% (n=2) did not report any prior pain and 23% (n=13) could not remember. Among the patients with documented history of pain prior to neuropathy, 88% (n=36) received surgical treatment; 61%, (n=25) endodontic treatment and 22%, (n=9) restorative treatment. All eventually received endodontic treatment or tooth extraction. These dental treatments are compatible with the hypothesis of prior inflammatory pain in these patients.

CONCLUSION

These results support the hypothesis that prior inflammatory pain could favor the development of orofacial neuropathic pain. Prevention and treatment of inflammatory trigeminal pain may therefore play a key role in preventing future neuropathic pain development.

[Pediatric keratocystic odontogenic tumor and nevoid basal cell carcinoma syndrome. Predictive factors for recurrence and aggressiveness]

INTRODUCTION

Keratocystic odontogenic tumors (KOT), as complications in Nevoid Basal Cell Carcinoma Syndrome (NBCCS), occur early (before 20 years of age) and are usually more aggressive. The aim of this retrospective study was to determine the clinical, histological, and genetic phenotype, of these lesions and to define predictive features of aggressiveness.

PATIENTS AND METHODS

We retrospectively studied five patients presenting with one or several KOT with NBCCS. We collected their clinical, radiological, and therapeutic data, rate of recurrence or new localization. Anatomopathological examinations were reviewed systematically. Somatic PTCH, SMO and SMAD 4 sequencing were completed.

RESULTS

The average age at diagnosis was 11.2 years. The average number of KOT was 3.2 most often located in the molar region. All the cysts were enucleated. Anatomopathological examination revealed the presence of satellite cysts and daughter cysts and epithelial expansion in more than 80% of cases. No somatic mutation was observed among KOT.

DISCUSSION

KOT develop in the first 10 years, in patients presenting with NBCCS, and recurrence is observed in the second and third decade. KOT are typically aggressive and have a tendency to recur, especially in patients with NBCCS. Anatomopathological examination may be predictive of the lesion's aggressiveness. Understanding the genetic and immunological mechanisms should open the way for new medical treatment.

Osteoclasts in the dental microenvironment: a delicate balance controls dental histogenesis

The impact of osteoclast activity on dental development has been previously analyzed but in the context of severe osteopetrosis. The present study sought to investigate the effects of osteoclast hypofunction,present in Msx2 gene knockin mutant mice (Msx2-/-), and hyperfunction, in transgenic mice driving RANK over-expression in osteoclast precursors (RANK(Tg)), on tooth development. In Msx2-/- mice, moderate osteopetrosis was observed, occurring exclusively in the periodontal region. Microradiographical and histological analyses revealed an abnormal dental epithelium histogenesis that gave rise to odontogenic tumor-like structures. This led to impaired tooth eruption, especially of the third mandibular molars. In RANK(Tg) mice, root histogenesis showed site-specific upregulation of dental cell proliferation and differentiation rates. This culminated in roots with a reduced diameter and pulp size albeit of normal length. These two reverse experimental systems will enable the investigation of distinctive dental cell and osteoclast communication in normal growth and tumorigenesis.

Physiopathology of dental rickets in vitamin D receptor-ablated mice

1α25(OH)(2)vitaminD(3) and its nuclear receptor, VDR, are essential for normal tooth development. However, the relative contributions of the direct vs. indirect effects of vitamin D action on odontogenesis are unclear. The aim of this study was to discriminate among the specific roles of 1α25(OH)(2) vitaminD(3), calcemia/phosphatemia, and the maternal environment in mouse VDR null mutants. Microradiographic, histological, and molecular analyses were conducted on adult mice under hypocalcemic/hypophosphatemic vs. normocalcemic/normophosphatemic conditions, and pups of first- (VDR-/- born to VDR+/- dams) vs. second-generation (VDR-/- born to VDR-/- dams) mice. In VDR-/- mice, crown morphogenesis was affected exclusively in second-generation pups. In first-generation adult VDR-/- mice, both enamel and dentin were affected, and pathologic features of root resorption in both apical and cervical regions were observed. Nutritional calcium and phosphate normalization completely rescued the root resorption and partially rescued the dentin and enamel phenotypes (altered cell differentiation and matrix protein expression). Analysis of these data illustrates the co-existence of different pathways of vitamin D action in tooth differentiation and biomineralization. These targeted and cumulative effects would generate the diverse and wide spectrum of dental rickets phenotypes.

[Maxillary and mandibular carcinogenesis: research and prospects]

Development and growth of odontogenic tumours depend on impairment of numerous genes and molecules. In recent years, most of the genes involved in dental development were identified. This produced a new basis for the study of oral pathology and maxillofacial carcinogenesis. A better understanding of these molecular phenomena should allow to better determine the evolution of such lesions. Research breakthroughs should facilitate the development of new molecular and genetic therapeutic perspectives.

Reduced susceptibility to amoxicillin of oral streptococci following amoxicillin exposure

As antibiotic pressure often triggers bacterial resistance, the use of short-duration therapies is increasingly recommended. The objective of the present study was to evaluate both the clinical efficiency and the impact on oral streptococci of a 3 day versus a 7 day amoxicillin therapy for odontogenic infection requiring tooth extraction. On day 0, patients were randomly assigned to a 3 day or 7 day amoxicillin treatment. The tooth was extracted on day 2 and the post-operative follow-up was carried out on day 9. Oral flora was collected on days 0, 9 and 30, and the susceptibility of the streptococci to amoxicillin was determined. The results showed that treatment with amoxicillin for 3 or 7 days had a similar clinical efficiency, and also induced similar selection of oral streptococci with reduced susceptibility to amoxicillin, suggesting that the selection of strains with reduced susceptibility to amoxicillin is a rapid phenomenon, appearing even with short-duration therapies.

Does Vitamin D play a role on Msx1 homeoprotein expression involving an endogenous antisense mRNA?

Msx1 homeobox gene, a member of Msx family, has been implicated in numerous organs. Its participation was established in different events, such as morphogenetic field determinism and epithelio-mesenchymal interactions. Most of Msx1 target organs are also known for their sensitivity to Vitamin D: such as bone, tooth germ, and hair follicle. Whereas, the expression of Msx2, another member of Msx family, has been shown to be controlled by Vitamin D, no information is available for Msx1. This study aims to analyze the potential relationships between Vitamin D and Msx1 through: (1) comparative analysis of Vitamin D receptor (VDR) and Msx1 protein expression, (2) investigation of Msx1 expression in VDR null mutant mice, and (3) study of Msx1 overexpression impact on osteocalcin VDR expression in immortalized MO6-G3 odontoblasts. Results show the existence of cross-talks between Vitamin D and Msx1 regulation pathways. In odontoblastic cells, Msx1 overexpression decrease VDR expression, whereas in rickets Msx1 sense transcript expression is decreased. These cross-talks may open a new window in the analysis of rickets mineralized tissues physiopathology. In Vitamin D null mutants, the study of the natural Msx1 antisense transcript which has been recently described should be informative.

Cross-talk between Msx/Dlx homeobox genes and vitamin D during tooth mineralization

Rickets is associated with site-specific disorders of enamel and dentin formation, which may reflect the impact of vitamin D on a morphogenetic pathway. This study is devoted to potential cross-talk between vitamin D and Msx/Dlx transcription factors. We raised the question of a potential link between tooth defects seen in mice with rickets and Msx2 gene misexpression, using mutant mice lacking the nuclear vitamin D receptor as an animal model. Our data showed a modulation of Msx2 expression. In order to search for a functional impact of this Msx2 misexpression secondary to rickets, we focused our attention on osteocalcin as a target gene for both vitamin D and Msx2. Combining Msx2 overexpression and vitamin D addition in vitro, we showed an inhibitory effect on osteocalcin expression in immortalized MO6-G3 odontoblasts. Finally, in the same cells, such combinations appeared to modulate VDR expression outlining the existence of complex cross-regulations between vitamin D and Msx/Dix pathways.