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Intraoral lesions, abnormalities on the tongue or tissues in the mouth and throat, caused by infections have been associated with AIDS and HIV infection from the early stages of the epidemic. Increasingly, HIV disease is being defined by CD4+ and CD8+ T lymphocyte counts. This study examined if there is a relation between T lymphocyte counts and intraoral lesions. HIV-infected individuals, enrolled in a drug study, underwent oral examinations between January and December 1989. Up to four examinations were performed during the study period. T lymphocyte counts were averaged for a given time frame covering a period just prior to the first examination, and for later examinations, for a period between the prior and present examination. A total of 106 patients participated in the study and were examined at least once. Of the 106 participants, 88 percent participated in the second examination, 72 percent in the third, and 56 percent in the fourth. Oral lesions were seen in 38 patients (36 percent) at some point during the study. CD4+ and CD8+ counts did not differ significantly for patients who did not have lesions and those who did. At the first examination, oral lesions were seen in 25 percent of the patients. For subsequent examinations, the rates were 19, 15, and 20 percent. The most commonly seen lesions were ulcerative lesions and hairy leukoplakia. CD4+ counts were stable until after examination 4. CD8+ counts increased slightly by examination 4. When data on T lymphocyte counts performed before and after the examinations were compared with examination results, a relation was found between an elevated CD8+ count before the examination and the presence of an oral lesion at the examination. This relationship remained unchanged when smoking and alcohol use were considered. These results indicate that information on changes in CD8+ counts may be useful for preventing or managing HIV-related oral lesions. (Consumer Summary produced by Reliance Medical Information, Inc.)

Background:Peripheral arterial disease (PAD) is an important cardiovascular disorder of the peripheral arteries. Chronic infections, such as periodontitis, may play an important role in the etiology and pathophysiology of PAD and other cardiovascular conditions. Recently, Streptococcus mutanshas been found with high frequency in atheromatous plaques. The aim of this study is to evaluate the possible clinical and microbiologic association between PAD and periodontitis and dental caries. Methods:Thirty patients with PAD and 30 control individuals were selected. PAD and its severity were established by the use of the ankle‐branchial index (ABI). Clinical attachment loss (AL); probing depth; decayed, missing, and filled teeth (DMFT) index; and C‐reactive protein (CRP) levels were evaluated. The presence of bacterial DNA from Streptococcus mutans, Porphyromonas gingivalis, Tannerella forsythia, Prevotella intermedia, Treponema denticola, and Aggregatibacter actinomycetemcomitanswas identified by polymerase chain reaction in subgingival biofilm and serum. Results:Patients with ≥30% AL ≥ 4 mm had six‐fold increased risk of having PAD (odds ratio = 8.18; 95% confidence interval = 1.21 to 35.23; P= 0.031). There was statistical difference in the CRP (P= 0.0413) and DMFT index (P= 0.0002), with elevated number of missing teeth (P= 0.0459) in the PAD group compared with the control group. There were no significant differences in the frequency of bacteria in serum and subgingival plaque. Conclusion:There was a positive relationship between periodontitis based on AL and PAD determined by the ABI (odds ratio = 8.18).

In February 2009, the American Academy of Orthopaedic Surgeons (AAOS) published an information statement in which the organization “recommends that clinicians consider antibiotic prophylaxis [AP] for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.” The leadership of the American Academy of Oral Medicine (AAOM) thought that there was a need to respond to this new statement.

AbstractBackground: The intrinsic musdes of the hand are of interest in spinal cord injury (SCI) and other myelopathies, because they are innervated by the most caudal cord segments innervating the upper limb. ln addition, abnormalities of the peripheral nervous system, such as peripheral nerve entrapments, often affect hand intrinsic musde strength of SCI patients. Therefore, measuring hand intrinsic strength may allow for early diagnosis of neurologic dedine.Methods: A method was developed for measuring strength of hand intrinsic musdes with a handheld myometer. With the use of a handheld myometer, this study examined the distribution of strength measurements for second-digit abductors, fifth-digit abductors, and thumb opposers in able-bodied participants and in individuals with weakness. The quantitative measurements were compared with manual musde test scores and interrater reliability is described for these hand intrinsic strength measurements. Thirty-one able-bodied individuals participated (17 men, 14 women; mean age = 37.7 years) . ln addition, 24, patients with SCI participated (23 men, 1 woman; mean age = 53.5 years; 9 with paraplegia and 14 with tetraplegia as a primary diagnosis). The Bland-Altman method was used to test for interrater reliability.Results: Mean strength of able-bodied participants was 5.0 kg for second-digit abduction, 3.1 kg for fifth-digit abduction, and 5.0 kg for thumb opposition, and the lower Iimits of normal were 3 .0, 1 .8, and 3.4 kg, respectively. The 95th percentile of interrater differences were 2 9.3% for second-digit abduction, 38.5% for fifth-digit abduction, and 43.7% for thumb opposition.Condusion: Abnormal hand intrinsic strength should be suspected if values are lower than the 5th percentile values listed above or if strength change exceeds the 95th percentile for interrater differences shown above. These quantitative hand strength measurements may allow for earlier diagnosis of secondary neurologic complications and may aid in monitaring neurologic recovery in persons with SCI.

AbstractBackground/Objective:Peripheral nerve disorders-whether due to peripheral nerve entrapment or to polyneuropathy—can alter the signs of myelopathy, masking both the sensory loss and distal hyperreflexia. Diagnosis of worsening myelopathy may be missed when there is a coexisting peripheral nerve disorder.Methods:This study is a case description and analysis of 3 consecutive cases identified over 2 years.Results:Three cases were identified in which the diagnosis of worsening myelopathy was missed and treatmentwas delayed because neurologic decline was attributed to a coexisting peripheral nerve disorder. This report describes 2 cases of posttraumatic syringomyelia masked by superimposed peripheral nerve entrapments and 1 case of cervical myelopathy due to cervical spinal stenosis from ossification of the posterior Iongitudinaiiigament masked by diabetic polyneuropathy.Conclusion:lt is important to continually question whether the working diagnosis of peripheral nerve disorder explains t he clinical findings, given neurologic decline; or whether a supe rimposed worsening myelopathy may coexist. Early diagnosis of worsening myelopathy is important, because prompt treatment of syringomyelia and myelopathy due to cervical spinal stenosis may yield better outcomes. Early diagnosis is aided by (a) considering alternative and multiple diagnoses, (b) assessing spinothalamic as weil as posterior column sensation and assessing these sensory modalities for proximal as weil as distal limbs, (c) assessing tendon hyperreflexia of proximal as weil as distallimb muscles, and ( d) utilizing electrodiagnostic tests that can identify myelopathy.

AbstractBackground/Objective: Vitamin B12 (or cobalamin) deficiency is well known in geriatric patients, but not in those with spinal cord injury (SCI) . This retrospective study describes vitamin B1 2 deficiency in SCI.Methods: This study utilized a retrospective chart review of patients with SCI who had received serum vitamin B1 2 testing over the last 1 0 years.Results: Probable vitamin B1 2 deficiency was noted in 1 6 patients with SCI. Twelve patients had subnormal serum vitamin B12 levels (< 220 pg/ml), whereas 4 patients had low-normal vitamin B12 levels (< 300 pg/ml) with neurologic and/or psychiatric symptoms that improved following vitamin B1 2 replacement. Classic findings of paresthesias and numbness often were not evident; such findings likely were masked by the pre-existing sensory impairment caused by SCI. Of the 1 6 SCI patients, 7 were ambulatory; 4 of the 7 presented with deterioration of gait. In addition, 3 of the 1 6 SCI patients presented with depression and fatigue, 2 had worsening pain , 2 had worsening upper limb weakness, and 2 had memory decline. Of the 1 2 patients with subnormal serum vitamin B12 levels, 6 were asymptomatic. Classic laboratory findings of low serum vitamin B1 2 , macrocytic red blood cell indices, and megaloblastic anemia were not always present. Anem ia was identified in 7 of the 1 6 patients and macrocytic red blood cells were found in 3 of the 1 6 patients. Only 1 of the 1 6 SCI patients had a clear pathophysiologic mechanism to explain the vitamin B12 deficiency (ie, partial gastrectomy); none of the patients were vegetarian. Twelve of the SCI patients appeared to experience clinical benefits from cyanocobalamin replacement (some patients experienced more than 1 benefit), including reversal of anemia (5 patients), improved gait (4 patients), improved mood (3 patients), improved memory (2 patients), reduced pain (2 patients) , strength gain (1 patient), and reduced numbness (1 patient).Conclusion: It is recommended that physicians consider vitamin B1 2 deficiency in their patients with SCI , particularly in those with neurologic and/ or psychiatric symptoms. These symptoms often are reversible iftreatment is initiated early.

AbstractObjective: The deep tendon reflex (DTR) is routinely used by clinicians to evaluate the nervous system. Depressed and hyperactive DTRs suggest peripheral and central nervous system compromise, respectively. Limitations of DTRs are: qualitative nature of the assessments based upon subjective grading, and limited inter-rater reliability. This preliminary study was undertaken to quantify the tendon tap used by clinicians to elicit DTRs and the reflex response elicited.Methods: Tendon taps were applied to a force transducer in hypo-, normo-, and hyperreflexic ranges by 2 clinicians, using 3 different tendon hammers (Babinski, Queen Square, and Taylor). Patellar DTRs, measured as joint angle excursion with an electrogoniometer, were compared in hyper- and normoreflexic individuals.Results: Median peak tap force was 12.8, 38.0, and 85.2 Newtons (Nt), respectively, for eliciting hyper-, normo-, and hyporeflexic DTRs. Peak tap force was similar in the hyper- and normoreflexic ranges for all 3 hammers; in the hyporeflexic range, peak tap forces with the Taylor hammer were lower. A good distinguishing feature between hyper- and normoreflexic patellar DTRs was briskness, measured as the quotient of knee excursion divided by peak tendon tap force. Knee excursion is a non-linear patellar DTR response, when measured sitting.Conclusions: Peak tap forces used by clinicians fall into 3 ranges: 0–20 Nt for hyperreflexia, 21–50 Nt for normoreflexia, and >50 Nt for hyporeflexia. The Taylor hammer, with small mass and short handle, has a ceiling effect in the hyporeflexic range. We propose a systematic method for DTR testing.

Thrombosis and the complicating emboli that can result are important causes of illness and death. Thrombosis is of greater overall clinical importance in terms of morbidity and mortality than all of the hemorrhagic disorders combined. Agents such as heparin, low-molecular weight heparin, warfarin, aspirin, ticlopidine, clopidogrel, and tirofiban are used to prevent venous or arterial thrombosis. Patients taking these antithrombotic agents may be at risk for excessive bleeding after invasive dental procedures. The current antithrombotic agents used in medicine are reviewed, and the dental management of patients taking these agents is discussed. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:544-51)

Dental patients with primary or secondary adrenal insufficiency, or AI, may be at risk of experiencing adrenal crisis during or after invasive procedures. Since the mid-1950s, supplemental steroids in rather large doses have been recommended for patients with AI to prevent adrenal crisis.

AbstractBackground:Heterotopic ossification (HO) following spinal cord injury can lead tovarious complications, including venous thrombosis, autonomic dysreflexia, and pressure ulcers. We report refractory, complicated HO in a 19-year-old man with C8 incomplete tetraplegia. He first presented at 9 weeks postinjury with fever and swelling of his right leg. Ultrasound indicated a deep venous thrombosis (DVT) . Persistent symptoms prompted triple-phase bone scan and magnetic resonance imaging (MRI), which revealed HO compressing the right external iliac vein and no evidence of DVT. The HO was complicated by hypercoagulability.Clinical Course:The HO was refractory tooral indomethacin and etidronate; therefore, intravenous etidronate was instituted, resulting in only a transient decrease in alkaline phosphatase. Local irradiation of the right hip did not decrease the activity of HO. The patient was discharged on oral etidronate, indomethacin, and warfarin. This complicated case raises issues regarding early diagnosis and aggressive treatment of HO, as well as treatment of associated hypercoagulability.

Dentistry has played an important role in the detection of patients with hypertension. Patients found to have high blood pressure at or beyond defined levels should be referred for a medical diagnosis and indicated treatment. Once the hypertensive condition is under control, oral and dental evaluation and treatment can be initiated. Beginning in 1976, the percentage of the general population in the United States with undetected hypertension declined steadily. However, this decline reversed, beginning in 1994. In addition, fewer than 50% of the patients who are aware of their hypertension have it medically under control. Thus, a significant number of patients with undetected high blood pressure or uncontrolled hypertension today are seeking dental treatment. These patients are at high risk for significant complications such as stroke, heart disease, kidney disease, and retinal disease. Those with very high blood pressure are at great risk for acute medical problems when receiving dental treatment. For those reasons, dentistry must continue to place an emphasis on the detection and referral of patients with high blood pressure. In addition, increased numbers of medically compromised patients are seeking dental treatment who should have their blood pressure monitored during the more stressful dental procedures, such as oral surgery, periodontal surgery, and placement of dental implants. This article reviews the recent advances in the dental and medical management of hypertension. It is important for dentists to be aware of hypertension in relation to the practice of dentistry. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:591-9)

Significant changes were made in 1997 by The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus of the American Association of Diabetes regarding the diagnosis and classification of diabetes mellitus. The terms “insulin‐dependent diabetes mellitus” (IDDM) and “non‐insulin‐dependent diabetes mellitus” (NIDDM) were dropped. The new classification is, in general, based on etiology rather than on treatment and includes four groups: Type I (autoimmune), Type 2 (non‐autoimmune), Other specific types, and Gestational diabetes. The fasting blood glucose level for diagnosis was lowered from 140 mg/dL to 126 mg/dL A random blood glucose of 200 mg/dL or greater in a patient with symptoms of diabetes is diagnostic. Each of these diagnostic tests needs to be repeated on a separate day. The glucose tolerance test is no longer recommended for routine diagnostic use. Recommendations for the screening of diabetes mellitus in presumably healthy individuals are presented. New advances in insulin and its delivery to the diabetic patient are discussed. The impact of diabetes mellitus on the oral cavity is updated.

The spinal cord injury (SCI) physician oversees neurologic recovery in patients with traumatic SCI to achieve optimal functional outcomes. The SCI physician establishes a prognosis for neurologic recovery in muscles innervated from the zone of SCI and from below the SCI, and guides the patient and the interdisciplinary rehabilitation team in appropriate interventions to optimize that recovery. Active exercise, central nervous system stimulant medications, managing spinal hyperreflexia, optimizing nutrition, and preventing medical complications are interventions that can enhance recovery. SCI physicians must also monitor for neurologic decline and intervene early for reversible conditions.

The incidence of infection following joint replacement surgery is about 1 percent. The amount of illness caused by these infections is substantial, and when patients have developed infections caused by spread of bacteria via the blood stream from other locations in the body, the mortality rate has approached 18 percent. There have been some reports of joint replacement infection from bacteremia (bacterial infection in the blood) caused by dental work. A survey of orthopedic surgeons revealed that 57 percent did not believe that there was a strong relationship between the transient bacteremia caused by dental work and development of secondary infection of artificial joints. Surprisingly though, 93 percent of the responding orthopedists recommended preventive antibiotic administration prior to dental work in patients with a joint replacement. Despite the fact that penicillin is the antibiotic considered to be most effective against bacteria in the mouth, only 13 percent recommended its use (70 percent recommended cephalosporin). Transient bacteremias occur within minutes of the dental procedure and last up to 30 minutes; therefore prolonged antibiotic use is unnecessary. The authors believe the need for antibiotic prophylaxis before dental procedures to prevent infection in the area of an artificial joint has not been established. But until further research is performed, they recommend that joint arthroplasty patients be given penicillin V one hour before dental procedures and another dose six hours later. If the patient cannot take penicillin, erythromycin may be given. Other sources of bacteremia may be caused by different types of bacteria, and these will require the appropriate antibiotic. (Consumer Summary produced by Reliance Medical Information, Inc.)

A review of the literature on the possible link between late infections of major joint prostheses and dental bacteremias.

Careful attention to patients’ histories and their medical problems and consultation with their physicians should provide sound bases for selection of drugs. Antibiotic prophylaxis for patients with cardiovascular disorders is described by American Heart Association standards, but for other indications sound judgment based on the principles of antibiotic prophylaxis must be the rule. Patients with end-stage renal disease and severe liver impairment may be at risk with certain drugs. The most critical time for consideration of use of drugs during pregnancy is the first trimester. However, careful selection of drugs for use during the balance of the term can reduce the risk of harm to the mother and fetus.

Electrodiagnosis (EDX) compliments the clinical examination and imaging studies in managing patients with spinal cord injury (SCI). EDX elucidates the pathophysiology and delineates the recovery mechanisms. It allows early diagnosis of secondary neurologic complications of SCI such as paripheral nerve entrapment and post-traumatic syringomyelia. The full benefits of EDX in guiding motor recovery and minimizing complications will be realized with further refinement of methods and wider clinical use.

A 1986 survey o f all Minnesota dentists was repeated on a smaller scale in 1981 to monitor changes in infection control practices. The results showed the most dramatic change was an increase in use of all barrier techniques. Additional results concerning hepatitis B vaccination, willingness to treat patients with AIDS, and the age-compliance relationship are included.

Recovery of voluntary motor function after incomplete spinal cord injuries is attributed to a variety of physiological mechanisms, such as resolution of conduction block in injured axons, and neuroplasticity mechanisms in spared axons. To better understand these recovery mechanisms, we have examined motor recovery in one type of incomplete cord injury, the Brown-Sequard Syndrome. This syndrome is observed in patients with unilateral injury of the spinal cord and is manifested as asymmetric weakness and painjtemperature sensory loss contralateral to the weakest extremity. We have followed the course of motor recovery in two patients and reviewed the literature in an additional 59. Common features of this motor recovery include: 1) recovery of ipsilateralproximal extensor muscles before ipsilateral distal flexors, 2) recovery of any weakness in the extremity with pain / temperature sensory loss before the opposite extremity, and 3) recovery of voluntary motor strength and a functional gait by 1 to 6 months. We discuss these observations with respect to three hypotheses to explain motor recovery and suggest that neuroplasticity mechanisms functioning in spared descending axons may mediate much of the observed recovery after Brown-Sequard cord lesions.

A national survey of urologists was conducted regarding the need for prophylactic antibiotic coverage for patients with penile implants when undergoing invasive dental treatment. A total of 1,756 questionnaires was sent to urologists in the United States and 297 responses were received, for a participation rate of 17%. The low response rate might be partly related to a low level of concern by urologists due to the lack of reported cases of penile implant infections following invasive dental procedures and the lack of the literature calling attention to this possible association. This is supported by the fact that none of the responding urologists had noted any case of infection of the prosthesis following dental treatment. The majority of urologists who responded did not recommend antibiotic prophylaxis for penile implant patients undergoing invasive dental treatment. The majority of urologists who recommended prophylaxis selected a cephalosporin. None of the responding urologists indicated that they were aware of infection developing in any penile implant patients following invasive dental treatment. The dentist is advised to consult with the urologist of patients with penile implants on an individual basis to determine the need for antibiotic prophylaxis.

Presented for the dental practitioner are results of a survey of orthopedic surgeons. Information is included on joint replacement surgery, transient bacteremias of dental origin and prosthetic joint infections, and prophylactic antibiotics.

Most prosthetic joint infections (PJI) are due to wound contamination at the time of surgery. Some infections occur due to the hematogenous spread of bacteria from distant sites of infection. A review of the literature fails to associate PJI with transient bacteremias from invasive dental procedures. Several authors have described conditions which, they believe, render patients with prosthetic joints more at risk for infection. Prosthetic joint patients with these “high risk” conditions have the same types of infecting organisms as other patients with PJI. This indicates that the infecting bacteria are from wound contamination or distant sites of infection and not related to dental procedure bacteremias. Based on this review, antibiotic prophylaxis is not indicated for patients with prosthetic joints when receiving invasive dental procedures, since there is no proven benefit and there are known risks involved with the use of antibiotics. However, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS), in an advisory statement, suggest prophylaxis for “high risk” patients. The ADA and AAOS recommend a single dose of amoxicillin, cephradine, or clindamycin when prophylaxis is selected. The dentist is ultimately responsible for making treatment recommendations for his or her patients.

The role of oral diagnosis as an essential component of preventive dentistry is clear. The early identification of pathologic changes enables treatment to be rendered before severe or extensive tissue damages occur. In cases where severe tissue damage has occurred, an accurate and thorough examination is needed to establish a diagnosis upon which a comprehensive treatment plan can be based. This treatment plan should provide for the prevention, restoration, and maintenance of damaged tissue. The diagnostic procedure thus involves: examining the patient, interpreting the findings, establishing a diagnosis, planning the sequence of treatment, and educating the patient.

Oral lesions may be local in origin or they may be signs of systemic disorders. This chapter has presented an approach to the differentiation of several common types of lesions (ulcers, white lesions, hemorrhagic lesions) on the basis of their local or systemic etiology. No attempt was made to cover all the types of lesions that appear in the oral cavity, or to give an exhaustive list of all the possible origins of the three types of lesions discussed. The method of differentiation presented, however, can be used by the general practitioner in the diagnosis of many oral lesions and can be helpful to him in determining whether dental treatment can be rendered or whether medical referral is necessary.

AbstractBackground: Scheuermann’s kyphosis is an uncommon autosomal dominant disease that manifests as a progressive thoracic skeletal deformity. It can lead to severe restrictive lung disease or predispose to spinal cord injury (SCI). Neurologic sequelae are rarely reported in the literature.Method: Case PresentationSummary: A 47-year-old man sustained a cervical SCI requiring surgical anterior fusion and reoperation for fracture of the affected vertebra. One year after SCI, he presented with further kyphotic progression and cervical spine instability. Clinical presentation and family history led to a diagnosis of Scheuermann’s kyphosis. To prevent further progression, he underwent extensive multilevel anterior and posterior surgical stabilization.Conclusion: This case illustrates the importance of early diagnosis and treatment of progressive spinal deformities. With proper surgical correction, this patient made substantial gains in mobility, self-care, and respiratory status.J Spinal Cord Med. 2003;26:92-94

Representative adult patient populations seeking treatment at a dental school in 1976 and 1986 were analyzed for the prevalence and the characteristics of medical conditions. Patients’ records (N = 3,000) were randomly selected from the examination clinics and reviewed for the presence and types of compromising medical conditions. The results indicated a significant increase in the percentage of dental patients who had medical conditions in 1986 as compared with 1976 (P &spilt; .001), as well as significant changes in the types of medical conditions present. These data indicate an increase in the number of patients with medical problems in the general dental school patient population.