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New evidence suggests that the extent and severity of periodontal disease may be a significant risk factor for erectile dysfunction, sperm motility and time to conception. This paper reviews the evidence and informs members of the dental team when dealing with this sensitive issue. As more research is forthcoming the topic of oral and sexual health is likely to be part of regular routine medical screening. Any issue concerning oral health as a risk factor for sexual health is likely to be a sensitive subject, rarely discussed in the dental setting. However, as new evidence emerges, this topic is likely to get into the public domain. All members of the dental team should be aware of such an association. Clinical Relevance: Furthermore, the information in this paper may provide further incentive for certain patients to improve their oral health.

Aggressive periodontitis is a relatively rare periodontal condition that can result in significant attachment loss over a short period of time. As the disease is difficult to manage, owing to its rapid progression and severity, a variety of adjuncts have been advocated in its management. The authors outline concepts of the aetiology and pathogenesis of aggressive periodontitis and how the different treatment regimens relate to the current understanding of the disease process. Clinical Relevance: There is a wide variety of treatment regimens advocated for the treatment of aggressive periodontitis. General dental practitioners and specialists should be aware of the relative advantages and disadvantages of these and how they relate to the disease process.

Full-mouth disinfection is a relatively new technique for the management of patients, especially those with moderate to severe chronic periodontitis. In this paper, the technique is reviewed and efficacy evaluated. The methodology and possible outcomes are illustrated with a case report.

Patients diagnosed or being treated for malignant disease can neglect their dental care and be reluctant to undertake dental treatment. This article considers the dental problems that may arise in such patients and how they can be managed. Chemotherapy and its sequelae are the main challenges to the delivery of routine dental care. For such patients, it is important to liaise with their oncologists to obtain an up-to-date haematological profile and time frame for any future treatments. For all such patients, dental care may be neglected, but it is important that dental and oral health is maintained.This article reviews the possible impact that malignant disease and its treatment can have on the delivery of dental care. Chemotherapy-induced bone marrow depression is likely to have the most profound effect on routine dental treatment.

Background There has been a trend over recent years for combining a nonsteroidal antiinflammatory drug (NSAID) with paracetamol (acetaminophen) for pain management. However, therapeutic superiority of the combination of paracetamol and an NSAID over either drug alone remains controversial. We evaluated the efficacy of the combination of paracetamol and an NSAID versus either drug alone in various acute pain models. Methods A systematic literature search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and PubMed covering the period from January 1988 to June 2009 was performed to identify randomized controlled trials in humans that specifically compared combinations of paracetamol with various NSAIDs versus at least 1 of these constituent drugs. Identified studies were stratified into 2 groups: paracetamol/NSAID combinations versus paracetamol or NSAIDs. We analyzed pain intensity scores and supplemental analgesic requirements as primary outcome measures. In addition, each study was graded for quality using a validated scale. Results Twenty-one human studies enrolling 1909 patients were analyzed. The NSAIDs used were ibuprofen (n = 6), diclofenac (n = 8), ketoprofen (n = 3), ketorolac (n = 1), aspirin (n = 1), tenoxicam (n = 1), and rofecoxib (n = 1). The combination of paracetamol and NSAID was more effective than paracetamol or NSAID alone in 85% and 64% of relevant studies, respectively. The pain intensity and analgesic supplementation was 35.0% +/- 10.9% and 38.8% +/- 13.1% lesser, respectively, in the positive studies for the combination versus paracetamol group, and 37.7% +/- 26.6% and 31.3% +/- 13.4% lesser, respectively, in the positive studies for the combination versus the NSAID group. No statistical difference in median quality scores was found between experimental groups. Conclusion Current evidence suggests that a combination of paracetamol and an NSAID may offer superior analgesia compared with either drug alone.

There has been an increase in the diagnosis and treatment options for malignant diseases. In this article we provide an overview of the impact of the treatments of malignant diseases on the oral structures. Whilst some of the complications, such as oral mucositis and oral infection, are of short duration and respond once chemotherapy has been completed, other treatments have a prolonged effect. Of particular concern is the effect of bisphosphonates on bone turnover and the risk of osteonecrosis on the jaw and hormones affecting the periodontal tissues. These unwanted effects all impact upon the quality of life of many patients diagnosed with malignant disease.Treatments of malignant diseases can have a profound effect on oral structures and functions. All members of the dental team need to be aware of adverse effects arising from such treatments and how they can affect oral function and quality of life.

Reports of an ageing population, increasing incidence of malignancy and improved treatments mean that dentists may have an increasing number of patients with, or who have recovered from, a malignancy. Dental professionals are expected to have an understanding of this important disease group so that appropriate dental care can be provided safely. In this first of three articles, we shall describe the important epidemiological and clinical features of the commonest malignancies in the United Kingdom.Dentists should understand the clinical implications of a patient with, or recovering from, a malignancy. This article gives a summary of the relevant features of the commonest malignancies.

The NICE Guidelines on Prophylaxis against Infective Endocarditis were published early this year. In this review, consideration is given to the evidence that the Working Party evaluated in arriving at their recommendations.The NICE Guidelines will have a very significant impact upon clinical practice. Antibiotic cover to prevent infective endocarditis prior to dental treatment has been a confusing and contentious issue. All members of the dental team should welcome these Guidelines which will impact upon the delivery of dental care to many categories of patient.

BACKGROUND: The aim of this study was to evaluate the efficacy of a topical hyaluronic acid (HA) preparation (0.2%) in the management of recurrent aphthous ulceration (RAU). METHODS: One hundred and twenty patients with RAU participated in a randomized, placebo controlled, doubleblind trial to evaluate the efficacy of the topical HA and preparation. Outcome measures include soreness relief on immediate application (recorded over 60 min). Thereafter, patients completed a log diary recording soreness from the ulcers, occurrence of new ulcers and ulcer duration. RESULTS: Both topical HA and placebo resulted in a significant reduction in ulcer soreness following immediate application (P = 0.0004). Throughout the rest of the investigation period, there was no significant differences (P > 0.05) between the treatments for reducing soreness. Patients treated with topical HA recorded few ulcers on day 5 of the investigation than those treated with placebo (P < 0.001). Likewise, the occurrence of new ulcers was lower in the HA treated group on day 4 when compared with placebo (P = 0.047). CONCLUSION: Topical HA (0.2%) may be of benefit in the management of RAU. Immediate reduction of symptoms appears to be a barrier effect. J Oral Pathol Med (2006) 35: 461–5

Objectives: This review critically evaluates the different therapies that are available to manage drug-induced overgrowth (DIGO). Material and Methods: This review is based on literature identified using the online databases MEDLINE and PUB MED. It is not a systematic review, but a conventional review of the relevant literature. Results: Patients benefit from a non-surgical approach if this can be delivered before commencement of medication although in many instances this may not be practicable. Systemic antibiotic usage has been evaluated in the management of ciclosporin-induced gingival overgrowth. Efficacy appears to be equivocal and long-term use is undesirable. Surgical excision remains the main treatment option especially for patients with severe overgrowth. Few studies have compared different techniques with respect to recurrence rate or post-operative sequelae. Conclusion: DIGO is a common clinical problem that often requires intervention. Non-surgical techniques can limit the occurrence of this unwanted affect, reduce the extent of plaque-induced gingival inflammation and reduce the rate of recurrence. Wherever possible this management strategy should be adopted first. Surgical treatment is often the most reliable option and scalpel gingivectomy remains the treatment of choice. Further investigations are required to develop appropriate management strategies to prevent recurrence of DIGO.

Objectives: This aim of this study was to develop and assess a technique that could be used to assess accurately the gingival volume changes seen in drug-induced gingival overgrowth by the analysis of data obtained from an entire gingival surface by means of three-dimensional imaging. Material and Methods: Stone dental models of patients before and after gingivectomy procedures were digitized with a laser scanner and then regenerated as computer models constructed from the acquired three-dimensional co-ordinate data. A comparison of superposed “before” and “after” surfaces was undertaken to assess and accurately quantify changes in gingival contour. Results: The mean vertical tissue reduction varied from 1.58 to 2.56 mm in the four study subjects and individual differences are shown. The maximum thickness of removed buccal gingival overgrowth was found to range between 1.20 and 3.40 mm. The volume of tissue removed from each inter-dental papilla ranged from 4.2 to 46.1 mm3 and the mean volume of the papilla removed from each subject±SD values was 24.8±13.1 mm3. Conclusion: This method will measure changes in gingival tissues to within 60 μm in one plane, making it ideal for the assessment of longitudinal changes in gingival contour as seen in the development of gingival overgrowth, its recurrence after surgery or the changes in volume brought about by surgery.

Objectives: This study investigates the effect of a range of potential risk factors on the severity of gingival overgrowth in transplant patients medicated with ciclosporin in the absence of any calcium channel blockers. Materials and Methods: One hundred dentate solid organ transplants medicated with ciclosporin (but not calcium channel blockers or phenytoin) were recruited for the study. Demographic, pharmacological and periodontal data were recorded and gingival overgrowth assessed from stone models. Results: Univariate analysis identified the duration of transplant, papilla bleeding index, creatinine serum concentration, azathioprine and prednisolone dosage as risk factors for overgrowth severity. Multivariate modelling, excluding the periodontal parameters, gave a predictive model that included dosages of ciclosporin, azathioprine, prednisolone and weight (p

Periodontal research over the last 40 years has been remarkably prolific. We now understand that severe periodontitis affects approximately 10–15% of the population (representing a large number of individuals in the UK) and gingivitis and mild periodontitis affect a majority of people. Microbiological research has identified some of the key pathogens that are implicated in periodontal disease. Plaque bacteria exist in biofilms, which have evolved to protect individual organisms within the subgingival bacterial community. For this reason, root surface instrumentation (RSI) remains the cornerstone of periodontal treatment, and is necessary to disrupt the subgingival biofilm mechanically and reduce the bacterial bioburden. Although bacteria are necessary for periodontal disease to occur, a susceptible host is also required. The immune-inflammatory response that develops in the gingival and periodontal tissues in response to the chronic presence of plaque bacteria results in destruction of structural components of the periodontium leading, ultimately, to the clinical signs of periodontitis. The nature of the host response is determined primarily by genetic factors and environmental and acquired factors such as smoking. The host response is essentially protective in nature, but both under-activity (hypo-responsiveness) and over-activity (hyper-responsiveness) of aspects of the host response can result in enhanced tissue destruction. The purpose of this paper is to review current thinking in periodontics with special reference to periodontal epidemiology, microbiology, and pathogenesis.

Objective Preliminary animal data has shown that nitrous oxide has a preemptive analgesic effect on postoperative pain. Whether a similar effect occurs in humans is not established. In this prospective randomized crossover study, we investigated the effect of preincisional versus postincisional nitrous oxide on postoperative oral surgical pain. Study design The trial was a crossover study where 36 patients had each of their symmetrical impacted mandibular third molars randomly scheduled for removal in 2 sessions. Each of the 36 patients acted as his or her own control; one side of the jaw was allocated randomly to receive nitrous oxide preoperatively (pretreated side) and the other side postoperatively (posttreated side). The pretreated side received 50% nitrous oxide preoperatively for 20 minutes and 100% oxygen postoperatively for 20 minutes as placebo. The posttreated side received 100% oxygen preoperatively for 20 minutes and 50% nitrous oxide postoperatively for 20 minutes. The difference in postoperative pain between the pretreated and posttreated sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analog scale (VAS) hourly for 8 hours, time to first analgesic, total analgesic consumption during the first 48 hours, and a 5-point categorical patient global assessment scale (0 = poor, 1 = fair, 2 = good, 3 = very good, and 4 = excellent). Results The VAS scores did not differ between the 2 sides at any time ( P = .50): neither did the time to first analgesic ( P = .8), amount of total analgesic consumption ( P = .77), and patient's global assessment differ ( P = .63). Conclusion Our results do not support the preliminary animal data that nitrous oxide has a preemptive analgesic effect for postoperative pain. 50% nitrous oxide administered preoperatively for 20 minutes has no preemptive analgesic effect on postextraction pain.

Aims: The study aims to determine the prevalence and severity of gingival overgrowth in a group of adult organ transplant recipients immunosuppressed with tacrolimus in comparison with ciclosporin, and to examine various risk factors for the development of gingival overgrowth. Methods: Forty patients taking tacrolimus were compared with 197 ciclosporin patients. Demographic, pharmacological and periodontal data were recorded for all patients. Comparison between the groups was made using independent sample t-tests, χ2 statistic or Mann–Whitney test. The effects of risk variables on overgrowth severity were examined using forward and backward stepwise regression analysis. Results: Those taking tacrolimus had a significantly lower mean gingival overgrowth score (14.1%) compared with ciclosporin (22.4%). Fifteen percent of the tacrolimus group had clinically significant gingival overgrowth compared with 30% in the ciclosporin group (p=0.053). Conclusions: The prevalence and severity of gingival overgrowth is less in adult transplant patients taking tacrolimus compared with ciclosporin. Concomitant use of calcium channel blockers and previous medication with ciclosporin are significant risk factors for the presence and severity of gingival overgrowth. Patients who have alteration of their immunosuppressant from ciclosporin to tacrolimus may persist in demonstrating gingival overgrowth attributable to their ongoing therapy with calcium channel blockers.

Objectives: To provide a critical review of the current evidence that implicates dental-induced bacteraemia as a risk for joint infections in patients fitted with joint prostheses and appraise the need for antibiotic prophylaxis. Design: Retrospective analysis. Setting: Mainly hospital-based patients or subjects. Outcome measures: The relationship between joint infections and dental treatment is equivocal at the best and there is no evidence that antibiotic prophylaxis provides such patients with any protection. Results: Microbiological evidence linking dental treatment-induced bacteraemia to joint infections is weak and if an oral commensal is implicated, it is more likely to have arisen either from a spontaneous bacteraemia or from a dental infection. As a consequence of the latter, we recommended the institution of good dental health prior to joint replacement. There may be a case for providing prophylaxis to the immuno-compromised patient, but only if the immuno-suppression is associated with a neutropenia. In such circumstances, only emergency treatment should be considered until the neutropenia is resolved. Antibiotic regimens that are recommended by orthopaedic surgeons have not been evaluated in a randomised placebo-controlled study and many of the drugs are not licensed for this purpose. The evidence on cost-risk benefit seems to demonstrate that antibiotic prophylaxis with either amoxicillin or penicillin is not cost effective when compared with no prophylaxis. Conclusion: The case for providing antibiotic prophylaxis prior to dental treatment in patients fitted with a joint prosthesis is weak or virtually non-existent. Furthermore, the risk from providing prophylaxis is greater than the risk of a joint infection.

Background/Aims: Drug-induced gingival overgrowth remains a significant problem for the periodontologist. Many patients medicated with the drugs implicated in this unwanted effect experience significant, recurrent gingival problems that require repeated surgical excisions. In this review, we attempt to identify and quantify the various “risk factors” associated with both the development and expression of the drug-induced gingival changes. Method: The risk factors appraised include age, sex, drug variables, concomitant medication, periodontal variables and genetic factors. Elucidation of such factors may help to identify “at risk patients” and then develop appropriate treatment strategies. Results: Of the factors identified, the only one that can be affected by the periodontologist is the patents' periodontal condition. However, drug variables and concomitant medication do impact upon the expression of gingival overgrowth. Conclusion: The identificatioin of risk factors associated with both the prevalence and severity of drug-induced gingival overgrowth is important for all parties involved with this unwanted effect. Both periodontologist and patient have an important role to play in improving oral hygiene and gingival health. Likewise, there is always an opportinity to establish a close liaison between the patient's physician and the periodontologist to try and identify alternative drug regimens that can help reduce the impact of this unwanted effect.

Interspecies differences in phenytoin (PHT) metabolism to 5-(4-hydroxyphenyl)-5-phenylhydantoin (HPPH) were examined in human, cat and rat hepatic microsomes in vitro. Rat liver microsomes were 25 and 650 times more efficient at the conversion of PHT to HPPH than human and cat liver microsomes, respectively. Sulphaphenazole (83%) and tolbutamide (TOL) (64%) were the most potent inhibitors of HPPH formation in human liver microsomes, while ciprofloxacin (27%), enoxacin (27%) and TOL (26%) produced the greatest inhibition in cat liver microsomes. TOL was tested for its effect on HPPH formation and gingival overgrowth in cats in vivo. Eight cats received PHT sodium (4 mg/kg/d) and another 8 cats received PHT sodium together with TOL (20 mg/kg/d) for 10 wk. Six cats (75%) in the PHT group and 4 cats (50%) in the PHT & TOL group developed significant gingival overgrowth by the end of the study. However, the extent and incidence of the overgrowth were similar in the 2 groups. There were no significant differences in mean AUC 0-10 weeks for plasma PHT (552.90 +/- 29.6 micrograms.d/mL [PHT alone] vs. 582.41 +/- 24.49 micrograms.d/mL [PHT & TOL]) and unconjugated HPPH (1016.4 +/- 295.5 ng.d/mL [PHT alone] vs. 1174.5 +/- 397.2 ng.d/mL [PHT & TOL]) concentrations between the 2 groups of cats. Neither PHT nor HPPH were detectable in the plasma of 8 rats which received PHT (4 mg/kg/d) over a 10-wk period. The rats showed no sign of gingival inflammation (mean gingival index = 0) or gingival overgrowth (mean gingival overgrowth index = 0). Thirty-six adult epileptic patients on chronic PHT therapy were examined; 17 (47%) of the patients demonstrated clinically significant overgrowth. The mean steady-state plasma PHT concentration was comparable to, and the mean plasma unconjugated HPPH concentration 5-fold greater than, that observed in the cats. The results suggest that the rapid metabolism and elimination of PHT and HPPH in the rat may enable it to become more resistant towards developing gingival overgrowth, compared to the cat and man.

This review article considers the changes in antibiotic usage over the past 40 years. Perhaps the most significant advance is in the prophylactic use of these drugs to reduce the effect of dentally induced bacteraemia. A greater understanding of various dental infections and, in particular, the role of bacteria in the pathogenesis of periodontal disease, has led to further interest in the indications for these drugs as adjunctive measures. Whilst new indications for the use of antibiotics become more widespread, all members of the healthcare professions need to be aware that these drugs have significant adverse effects and their misuse can lead to life-threatening infection. Clinical Relevance: Antibiotics have revolutionized the control of infectious diseases and have a significant role in dental practice. Dentists should be fully appraised of the benefits of these drugs and when they should be prescribed. Antibiotics usage should not be a substitute for interventional procedures, such as drainage of pus or removal of sources of infection. Indications for the use of these drugs as prophylactic measures are now reducing.

The role of HLA phenotype as a risk factor for drug-induced gingival overgrowth was investigated in a cohort of 172 transplant recipients. Clinically significant overgrowth warranting surgical correction was observed in 72 patients (42%). Using stepwise regression modelling. 6 clinical parameters were identified as significant risk factors for the severity of gingival overgrowth. These were; age. sex. creatinine plasma level, duration of therapy, papilla bleeding index and concomitant medication with a calcium channel blocking drug. 3 HLA alleles were also identified as risk factors when adjusted for other clinically significant risk factors (HLA -DR2, A24, B37). However, when the p-values for the HLA variables were corrected to compensate for the use of multiple significance testing, only HLA-B37 remained statistically significant at the 5% level. Organ transplant patients are at risk of developing gingival overgrowth, with approximately 25% medicated with cyclosporin alone requiring corrective gingival surgery. This figure more than doubles in patients concomitantly medicated with a calcium blocking drug. The data at present available would suggest that the severity of gingival overgrowth is also significantly associated with the HLA-B37 phenotype.

The distribution of gingival overgrowth was investigated in a cohort of organ transplant patients, who were medicated with cyclosporin or the combination of cyclosporin and a calcium channel blocking drug. Gingival overgrowth scores were significantly higher at buccal sites than lingual-palatally (p0.0001). There was no significant difference between upper and lower overgrowth scores (p = 0.88). The most severe overgrowth was seen in the canine region. Overgrowth between the central incisors was significantly less than in the canine region (por = 0.044) and was similar to that in the molar and premolar region. Although raised overgrowth scores were associated with increased levels of plaque and gingival inflammation, the distribution could not be explained by this observation.

Gingival overgrowth is a well-documented unwanted effect, associated with phenytoin, cyclosporin, and the calcium channel blockers. The pathogenesis of drug-induced gingival overgrowth is uncertain, and there appears to be no unifying hypothesis that links together the 3 commonly implicated drugs. In this review, we consider a multifactorial model which expands on the interaction between drug and/or metabolite, with the gingival fibroblasts. Factors which impact upon this model include age, genetic predisposition, pharmacokinetic variables, plaque-induced inflammatory and immunological changes and activation of growth factors. Of these, genetic factors which give rise to fibroblast heterogeneity, gingival inflammation, and pharmacokinetic variables appear to be significant in the expression of gingival overgrowth. A more thorough understanding of the pathogenesis of this unwanted effect will hopefully elucidate appropriate mechanisms for its control.

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely researched in an attempt to control periodontal diseases. This double-blind parallel group study investigated the effect of a systemic flurbiprofen preparation (100 mg daily), when combined with toothbrushing on the resolution of experimental gingivitis in human volunteers. 47 volunteers abstained from tooth cleaning for 21 days. On day 21, 23 subjects were prescribed 100 mg of flurbiprofen daily whereas 24 subjects were prescribed placebo. In both groups, toothbrushing was re-introduced and all subjects used the Bass technique for 2 min each day. Both treatment regimens were continued for 7 days. Plaque indices, gingival indices and gingival crevicular fluid flow were assessed at baseline (day 0) and on days 21 and 27. There were no significant differences at p = 0.05 between the groups for plaque indices or gingival crevicular fluid flow. The flurbiprofen group, however, demonstrated greater resolution of gingival inflammation by day 27 when compared to the placebo controls (p = 0.04). The plasma levels of flurbiprofen in the test group showed mean concentrations of flurbiprofen of 4.7 (+/- 2.1) micrograms/ml at 1 h after dosing. After 6 h, this had fallen to 4.4 (+/- 1.6) micrograms/ml. It is concluded that these serum concentrations of flurbiprofen are sufficient to produce significant anti-inflammatory effects in the gingival tissues.

1. Recent evidence has hinted at a peripheral site of action of morphine analgesic efficacy. 2. Previous studies by the same authors have developed a model for testing local analgesic efficacy by placing drugs into tooth sockets after third molar surgery. 3. The present studies test the hypothesis of local morphine activity at two dosage concentrations, 100 ng ml-1 and 100 micrograms ml-1 after third molar surgery. 4. No significant analgesic efficacy was found at either dose when compared with placebo.

Human herpes simplex 1 virus (HSV-1) is a DNA virus that has the ability to lie latent and be subsequently re-activated at any point during a patient's life. In the immunocompetent patient, resolution of clinical signs and symptoms usually occurs spontaneously after 14 days. In the immunocompromised patient, healing is often delayed and the effects are much more debilitating. Indications for therapeutic regimes of systemic antiviral treatment are discussed. Clinical Relevance: Recurrent oral ulceration caused by HSV-1 may be seen by the general dental practitioner and can cause significant morbidity.

Solid organ transplant patients are at an increased risk of developing lip malignancies. The role of HLA mismatch as a risk factor for such changes has only been described in skin.Lip lesions were evaluated in 403 solid organ transplant patients (immunosuppressed for at least 3 months) and findings compared to age and sex matched, otherwise healthy patients who acted as controls. HLA typing was provided for the transplant patients. All patients provided details of smoking history, alcohol consumption, skin type, as assessed by ease of burning to sunlight, and exposure to sunlight or other forms of ultraviolet radiation.Lip lesions were identified in 36 transplant patients and 29 were biopsied. Fourteen of the biopsies confirmed dysplastic or malignant changes. For the control patients, one lesion was identified as dysplastic. The prevalence of dysplastic and malignant lip lesions was significantly higher (P = 0.006) in the transplant patients when compared to controls. Risk factors for dysplastic/malignant changes in the transplant group included age (P = 0.01), smoking (P = 0.033) and HLA-B mismatch (P = 0.001). Lip covering provided a significant reduction (P = 0.045) in the development of lip changes.All transplant patients should be regularly screened for lip malignancies and consulted on smoking and sunlight exposure. HLA-B mismatch does appear to make these patients more susceptible to dysplastic/malignant changes.

Non-steroidal anti-inflammatory drugs (NSAIDs) have been used as systemic and topical preparations to control chronic periodontal disease in both animal and clinical human trials. Equivocal findings have failed to confirm whether any one NSAID is particularly efficacious, although flurbiprofen appears to be one of the most promising. 49 patients were allocated at baseline to test (25) and control (24) groups in a 12-month, controlled clinical trial. The groups were of similar age and sex distributions. During the first 3 months, both groups were given oral hygiene instruction and received scaling and root planning. The test patients were prescribed a 1% w/w flurbiprofen toothpaste to use 2 x daily for the entire 12 months. Control subjects were prescribed a placebo dentifrice. Plaque scores, bleeding scores, crevicular fluid flow, probing pocket depths and attachment levels were assessed at baseline and at 3, 6, 9 and 12 months. Radiographs were taken at baseline and 12 months using a modified intraoral, repositionable film holder. Both the flurbiprofen and placebo showed significant improvements in the clinical parameters over 12 months and there were no significant differences between the groups. Flurbiprofen-treated patients however, demonstrated a significantly greater proportion of sites (8.0%) with bone gain when compared to the placebo group (3.3%). There were no significant differences between the groups in the number of sites showing bone loss or no change. It is concluded that the 1% w/w flurbiprofen toothpaste exerts a small, yet significant effect on bone metabolism in the absence of any apparent effects on clinical parameters.

Poor oral health has been associated with a variety of systemic diseases. More recent evidence suggests that the extent and severity of periodontal disease and tooth loss may be associated with an increased risk of malignant disease. An association between poor oral health, smoking, increased alcohol consumption as a risk for oral cancer is well established. Associations between oral health and tooth loss with gastric, lung and pancreatic cancers are explored. Some of the associations need further evaluation before patients are warned about their periodontal health increasing the risk of malignant changes elsewhere in the body. The smoking factor may have a commonality linking oral health with an increased risk for malignant disease.This paper reviews the association between oral health (especially the extent and severity of periodontal disease and tooth loss) as a risk for certain malignancies.

The association between periodontal disease and various systemic conditions raises the question of the impact of periodontal therapy on general health. There is increasing evidence that periodontal intervention can reduce the prevalence of an adverse pregnancy outcome, improve glycaemic control in diabetics, reduce systemic markers of inflammation, lower cholesterol levels and improve vascular endothelial function. The magnitude of the impact of periodontal therapy on these modalities needs further quantification/study. Despite such reservations, there are indications that any form of periodontal treatment may have outcomes that extend beyond improving life expectancy of the dentition.This article reviews the possible impact of periodontal therapy on a variety of systemic conditions and evaluates potential benefits.

This investigation examines the incidence of phenytoin-induced gingival overgrowth in a population of epileptic patients who attend General Medical Practices for treatment of their epilepsy and compares the gingival changes with an otherwise healthy group of patients. The plaque score, gingival index, and gingival overgrowth did not differ significantly between the two groups (P>0.05). A significant correlation was observed between plaque score and gingival overgrowth in the phenytoin-treated patient, but in this group there was no correlation between gingival overgrowth and salivary concentration of the drug. The overall incidence of clinically significant overgrowth (13%) is considerably less than in other studies.

This study evaluated the efficacy of and investigated the site of action of aspirin and acetaminophen placed directly into tooth sockets after bilateral third molar surgery under local anaesthesia. On completion of surgery, 12 patients received in random, blind order either a suspension of aspirin in a methyl cellulose gel (100 mg/ml) in their tooth sockets and an oral placebo or the methyl cellulose alone in their sockets and an oral dose of aspirin (50 mg). The remaining 12 patients were treated in the same fashion with use acetaminophen. Patients were asked to record their pain, at intervals, over an 8-hour period on a 10 cm visual analog scale. Significantly less pain (p less than 0.05) was recorded throughout the 8-hour investigation period after both locally placed drugs than after placebo. There was no adverse effect on healing. The peripheral activity of aspirin is confirmed, and our findings suggest that acetaminophen has a significant peripheral effect in mediating its analgesic properties in postoperative pain after third molar surgery.

The gingival health of 19 patients with cardiovascular problems who were medicated with nifedipine was compared with a similar cohort treated with atenolol and a control group of healthy patients. In the nifedipine and atenolol groups, patients had been taking their respective medication for a minimum period of 6 months. Plaque scores were similar for all three groups. However, patients medicated with nifedipine had a significantly higher gingival index (P less than 0.005), gingival overgrowth scores (P less than 0.02) and probing sites greater than 3 mm (P less than 0.005) when compared with the atenolol and control groups. 4 patients in the nifedipine group experienced clinically significant gingival overgrowth which required surgical excision. Gingival changes in the nifedipine patients were not related to drug dosage or plaque scores. It is concluded that nifedipine therapy results in significant gingival changes, an effect which may be mediated by the drug's action on calcium transport.

1. Single doses (500 and 1000 mg) of both buffered aspirin and aspirin tablets were compared with placebo in a randomised double-blind trial of parallel design in patients with postoperative pain after third molar surgery. 2. Only buffered aspirin 500 mg provided significant pain relief (P = 0.016) during the 5 h investigation period. 3. A significant correlation (P = 0.004) was observed between overall pain scores after the various aspirin treatments and aspirin esterase activity. 4. Buffered aspirin preparations afforded a slight advantage over aspirin tablets in the control of postoperative pain after third molar surgery. However, the duration of analgesia was short (approximately 2 h). 5. Aspirin esterase activity appears to be an important determinant of the drug's efficacy in postoperative dental pain.

Cyclosporin is a selective immunosuppressant that has a variety of applications in medical practice. Like phenytoin and the calcium channel blockers, the drug is associated with gingival overgrowth. This review considers the pharmacokinetics, pharmacodynamics, uses and unwanted effects of Cyclosporin, in particular the action of the drug on the gingival tissues. Clinical and cell culture studies suggest that the mechanism of gingival overgrowth is a result of an interaction between the drug and its metabolites with susceptible gingival fibro-blasts. Plaque-induced gingival inflammation appears to enhance this interaction.

An increasing number of our patients are on medication of various types. This increase in prescribed medicines also raises the significant issue of potential drug interactions between those drugs used in dental practice and those taken by the patient. This article addresses those interactions and, where appropriate, puts them into perspective and attempts to quantify the risk. Mechanisms of relevant drug interactions are also discussed. Certain categories of drugs are more likely to be involved in interactions and again these are highlighted. Drug interactions relevant to dentistry can for the most part be prevented. A careful drug history should be taken from each patient and updated on a regular basis.This article highlights drug interactions that can arise in dental practice and how they can be avoided and managed.

Calcium channel blockers are widely used in medical practice for the management of cardiovascular disorders. Of concern to the dental practitioner is the effect of these drugs on the gingival tissues. All classes of calcium channel blockers have been implicated in causing gingival overgrowth. This review considers the prevalence, clinical features, histopathology, pathogenesis and management of this unwanted side-effect.

The aim of this study was to determine whether the non-steroidal anti-inflammatory drug, flurbiprofen, which has been shown to be an inhibitor of alveolar bone loss in human periodontal disease, is present in human crevicular fluid (CF) following oral dosing. A method is described whereby routine high-performance liquid chromatography is used to detect the drug in only 20 microliters of CF. 5 volunteers abstained from toothbrushing for 21 days to induce experimental gingivitis and increase the resting flow of CF. 100 mg of flurbiprofen was taken by each volunteer on d 21-28. On d 21 and 28, serum and CF samples were taken prior to dosing and afterwards at 1, 2, 4 and 6 hours. On d 21 the mean peak concentration of the drug in serum was about 11 micrograms/ml and was found between 1-2 h after dosing. The respective values for CF (d 21) were 0.32 micrograms/ml and 4 h. On d 28 flurbiprofen was detected in both fluids prior to dosing. The mean peak concentrations after dosing had increased to 13.13 micrograms/ml (serum) and 0.46 micrograms/ml (CF) although the levels of the drug in CF remained relatively constant throughout the observation period on d 28. The results indicate that flurbiprofen may be detected in human CF after oral administration and that the levels are in excess of the plasma level, which in beagles has been shown to inhibit alveolar bone loss in periodontal disease.

Background and Objective: Cyclosporin-induced gingival overgrowth arises from an alteration in collagen homeostasis and is enhanced by inflammatory changes in the gingival tissues. The aim of this study was to investigate the interaction among interleukin-1, oncostatin M, cyclosporin and nifedipine in promoting the up-regulation of matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase by gingival fibroblasts. Material and Methods: Fibroblast cultures (n = 5) were obtained from healthy controls and from patients with cyclosporin-induced gingival overgrowth, and cells were harvested between the fourth and ninth passages. Cells were stimulated with interleukin-1 and oncostatin M, alone or in combination, and with different concentrations of cyclosporin (0–2000 ng/mL) and nifedipine (0–200 ng/mL). MMP-1 and tissue inhibitor of metalloproteinase-1 production was determined using an enzyme-linked immunosorbent assay technique. A CyQuant cell proliferation assay was used to determine the DNA concentration in the sample. Results: Fibroblasts obtained from patients with cyclosporin-induced gingival overgrowth produced significantly lower levels of MMP-1 than control fibroblasts (p

The second edition of The first five years, published by the General Dental Council in 2002, identifies human diseases as a specific subject to be taught as part of the BDS curriculum. It states clearly the particular learning outcomes of such a course and then identifies a range of subjects (pathology, microbiology, medicine, surgery, pharmacology, therapeutics, accident and emergency services and medical emergencies) which should constitute the programme. Previously, many of these topics were taught and examined separately. In this article, we would like to share the Newcastle experience of developing a course in human diseases alongside the GDC guidelines.

Objectives: The aim of the present study was to evaluate the efficacy of three different surgical techniques in both the management and effect upon rate of overgrowth recurrence of drug-induced gingival overgrowth (DIGO). Materials and methods: Two cohorts of patients who required surgical correction of their DIGO participated in the study. After baseline periodontal measures (plaque index, gingival inflammation and probing pocket depths), the patients underwent surgery. A split-mouth, crossover design was used to compare conventional gingivectomy with flap surgery (n = 27), and conventional gingivectomy with laser excision (n = 23). The main outcome variable was the rate of recurrence of DIGO following surgery. Results: At 6 months, there was significantly less recurrence (p = 0.05) in patients treated with laser excision, compared with those treated by conventional gingivectomy. The differences in rate of recurrence of DIGO were also reflected in changes in several periodontal parameters. Flap surgery offered no advantage over conventional gingivectomy with respect to the rate of recurrence. Conclusions: DIGO can be managed by a variety of techniques. Laser excision results in a reduced rate of recurrence.

BACKGROUND Previous data have demonstrated that rofecoxib has good analgesic efficacy for acute postoperative dental pain. However, up to half of these patients require rescue analgesics within the first 24 hours. As the timing of analgesic interventions may be an important factor in pain control, the present study tested the hypothesis that rofecoxib administered preoperatively would improve the analgesic efficacy and reduce rescue analgesic requirements within the first 24 hours compared with postoperative administration. METHODS This was a double-blind, randomized, crossover study where 45 patients had each of their identical impacted mandibular third molars removed under local anesthesia on 2 separate occasions. Patients acted as their own control; one side was pretreated with rofecoxib 50 mg, 2 hours before surgery, followed by placebo 15 minutes after surgery, and the contralateral side was pretreated with placebo 2 hours before surgery and posttreated with rofecoxib 50 mg 15 minutes after surgery. The difference in postoperative pain between 2 sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 hours, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment. RESULTS Patients reported significantly lower pain scores (P = 0.04), longer time to rescue analgesic (P = 0.02), lesser postoperative analgesic consumption (P = 0.008), and better global assessment (P = 0.01) in the pretreated compared with the posttreated sides. There were significantly more patients in the pretreated group who did not required rescue analgesic within the first 24 hours (80% vs. 58%, P = 0.01), and the pain scores were extremely low in both groups during the 12 hours postoperative period (9.8 +/- 5.0 mm vs. 14.3 +/- 7.4 mm). CONCLUSION Rofecoxib is an excellent analgesic for preventing postoperative dental pain and when given 2 hours preoperatively rendered most patients relatively pain free, requiring no rescue analgesics on the first postoperative day.

Whether preemptive analgesic interventions are more effective than conventional regimens in managing acute postoperative pain remains controversial. We systematically searched for randomized controlled trials that specifically compared preoperative analgesic interventions with similar postoperative analgesic interventions via the same route. The retrieved reports were stratified according to five types of analgesic interventions: epidural analgesia, local anesthetic wound infiltration, systemic N-methyl-d-aspartic acid (NMDA) receptor antagonists, systemic nonsteroidal antiinflammatory drugs (NSAIDs), and systemic opioids. The primary outcome measures analyzed were the pain intensity scores, supplemental analgesic consumption, and time to first analgesic consumption. Sixty-six studies with data from 3261 patients were analyzed. Data were combined by using a fixed-effect model, and the effect size index (ES) used was the standardized mean difference. When the data from all three outcome measures were combined, the ES was most pronounced for preemptive administration of epidural analgesia (ES, 0.38; 95% confidence interval [CI], 0.28-0.47), local anesthetic wound infiltration (ES, 0.29; 95% CI, 0.17-0.40), and NSAID administration (ES, 0.39; 95% CI, 0.27-0.48). Whereas preemptive epidural analgesia resulted in consistent improvements in all three outcome variables, preemptive local anesthetic wound infiltration and NSAID administration improved analgesic consumption and time to first rescue analgesic request, but not postoperative pain scores. The least proof of efficacy was found in the case of systemic NMDA antagonist (ES, 0.09; 95% CI, -0.03 to 0.22) and opioid (ES, -0.10; 95% CI, -0.26 to 0.07) administration, and the results remain equivocal.

Since the development of the ruby laser by Maiman in 1960, lasers have been widely employed in medicine for a number of years. The purpose of this paper is to summarize potential applications for lasers in dentistry, with special regard to periodontology. This article briefly describes clinical applications of lasers and laser safety. Particularly, the use of a diode laser seems to be promising, especially in already compromised transplant patients, who need to be treated with a technique where the operative and post-operative blood loss, post-operative discomfort and the recurrence of drug-induced gingival overgrowth need to be kept to a minimum or eliminated. Therefore, the use of lasers in periodontology may lead to an alteration in present clinical practice and help to establish the best management strategy because, by maintaining periodontal health, the life quality of patients can be improved.

Certain medical conditions and their accompanying drug treatment do have an impact upon oral structures and the delivery of dental care. Recent evidence suggests that oral health could be a significant risk factor for coronary artery disease. Many medical conditions can affect dental care are often over-stated and lack an evidence base. Examples include the need for antibiotic cover in patients at risk from infective endocarditis and the necessity to provide supplementary corticosteroids for those patients on long-term steroid therapy. By contrast, certain systematic drug treatments can have a profound affect on the oral tissue. The most obvious is drug-induced gingival overgrowth. Drugs frequently implicated in this unwanted effect include phenytoin, Ciclosporin and the calcium channel blockers. Several risk factors for drug-induced overgrowth have been identified and include age, sex, peridontal variables and a range of drug pharmacokinetic variables. The relationship between oral health and coronary artery disease opens up a potentially new vista for the delivery of oral care. Although the association is convincing, casualty has not been established. If casualty for this relationship can be confirmed then the delivery of dental care and the promotion of oral health will receive a significant impetus

Sound measurement, an essential component of any scientific discipline, remains a particular problem in pain research. The measurement of pain intensity, for example, is a difficult and often a subjective undertaking. This is of little surprise to clinicians and researchers, because it is well recognised that pain intensity, like other sensations and perceptions, is a private experience that displays considerable variability both across patients and within a patient across time. Nonetheless, pain measurement and discerning factors that may affect its measurement are important for diagnosis and to determine the effectiveness of treatment interventions. This article reviews the basic concepts, roles, instruments used, and factors affecting pain measurement. A variety of the most commonly used pain measurement instruments are evaluated for their advantages and disadvantages. The article aims to assist clinicians and researchers to select the pain measurement instruments that best serve their purposes.

Background: Post-transplant lymphoproliferative disorder (PTLD) can occur in patients maintained on immunosuppressive therapy following transplantation. This paper describes two cases of PTLD occurring in gingival tissues, in patients receiving ciclosporin following cardiac transplantation. Treatment: The lesions were localised to gingival tissues, mimicking ciclosporin-induced gingival overgrowth. They were removed surgically and the ciclosporin dose reduced to help prevent recurrence. Conclusion: The importance of histopathological examination of all tissue removed during routine gingivectomy procedures for ciclosporin-induced gingival overgrowth is highlighted.