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Warfarin is commonly used for prevention of embolic events. Bleeding is the main side effect of warfarin. Lingual and sublingual haematoma are rare. In the literature, nine cases have so far been reported. We report the case of a 70-year-old Caucasian woman who developed spontaneous lingual and sublingual haematomas while on warfarin therapy. Spontaneous lingual and sublingual haematoma are rare, but can be potentially life-threatening complications as they cause airway obstruction. To the best of our knowledge, this is the first reported case of earliest haematoma after warfarin use., (2014 BMJ Publishing Group Ltd.)

Hydroxyurea (HU) is an antimetabolic agent commonly used in myeloproliferative disorders and hematological diseases as well as in severe psoriasis. Despite of usually be well tolerated, sometimes it can induce immunosuppression and mucocutaneous adverse effects associated with discomfort or pain. Nevertheless, oral mucosal adverse reactions are extremely uncommon and present as ulcers, tongue depapilation and dyschromia. Complete remission of adverse effects is usually observed after withdrawal of the medication. The aim of this paper is to report two patients with oral lesions related to HU treatment. T0 he patients were adequately managed by changing hydroxyurea with imatinib mesilate. Oral lesions are rare complications of long-term hydroxyurea treatment and may be an indication of stopping therapy and substitution with imatinib mesilate.

Introduction: Microcirculatory abnormalities are frequently observed in patients with severe heart failure and correlate to worse outcomes. We tested the hypothesis that nitroglycerin dose-dependently improves perfusion in severe heart failure and that this could be monitored by measuring central-peripheral temperature gradient and with Sidestream Dark Field imaging of the sublingual mucosa., Methods: A dose-response study was performed in 17 patients with cardiogenic shock (n = 9) or end-stage chronic heart failure (n = 8) admitted to Erasmus University Medical Center. We did hemodynamic measurements at baseline and during increasing infusion rates of nitroglycerin (up to a maximum dose of 133 microg min(-1)). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD)., Results: Nitroglycerin dose-dependently decreased mean arterial pressure (p < 0.001) and cardiac filling pressures (both central venous pressure (CVP) and pulmonary capillary wedge pressure: p < 0.001). It increased cardiac index (p = 0.01). Nitroglycerin decreased delta-T (p < 0.001) and increased sublingual PCD (p < 0.001). Significant changes in delta-T and PCD occurred earlier, i.e., at a lower doses of NTG, than changes in global hemodynamics. Macrohemodynamic and microcirculatory responses to nitroglycerin infusion were consistent in patients with either cardiogenic shock or end-stage chronic heart failure. Changes in microcirculatory parameters occurred independently of changes in cardiac index., Conclusions: Nitroglycerin dose-dependently increases tissue perfusion in patients with severe heart failure, as observed by a decrease in central-peripheral temperature gradient and an increase in sublingual perfused capillary density.

Objectives: To understand the presentation and clinical course of angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and to determine management factors associated with progression to airway compromise., Study Design and Setting: Retrospective chart review of patients taking ACE inhibitors who presented to the emergency department with angioedema between December 1999 and July 2004 (n = 228). Clinical presentation, treatment, and clinical course were analyzed., Results: The oral cavity was the most common location of upper-airway angioedema. Twenty-two (10%) patients required intubation, and all were intubated within 12 hours of presentation. Of the patients who required intubation, those who were started on an H(1)-blocker were extubated earlier than those not on an H(1)-blocker (P = 0.05)., Conclusion: The locations of swelling and drooling on admission are predictive of the need for intubation. Other aspects of presentation, treatment, and disposition can help in management decisions for this potentially fatal condition., Significance: This is the largest series to date of ACE inhibitor-related angioedema that challenges theories on the etiology and treatment of this condition.

Recurrent oral ulceration due to underlying iron-deficiency anaemia is already recognized. However, this case report describes a 78-year-old lady who developed severe ulceration of the tongue and floor of the mouth as a result of the treatment of iron-deficiency anaemia with ferrous sulphate tablets. Withdrawal of the ferrous sulphate tablets and replacement with ferrous fumarate syrup led to resolution of the lesion.

Sixty patients with tumors of the floor of the mouth or of the tongue (T2N0-1-2M0) were randomized into three treatment groups. The first two groups participated in low-dose inductive chemotherapy, surgery, and then radiotherapy, whereas the third control group underwent only surgery and radiotherapy. In all three groups, studies were made of the stage, grade, sex, localization, extents of expression of the pretreatment laminin and syndecan-1 and the cancer specific survival rate, and the correlations among these. The response to neoadjuvant chemotherapy was assessed by means of a method that we developed, involving measurement of the degree of histologic regression observed in response to chemotherapy. Immunohistochemical methods were applied to investigate the changes in degree of expression of laminin and syndecan-1 in response to the medication and their correlations with the survival. As concerns the overall tumorfree survival rate, a significant difference was not found between the two chemotherapeutic groups. However, there was a significant difference between the survival indices of those who participated in cytostatic treatment (70%) and the control group (40%). In the clinical and immunohistochemical examinations, the initial laminin and syndecan-1 levels obtained from biopsy samples could be used as prognostic factors. Our model measuring the extent of histologic regression clearly demonstrated that the survival indices of the patients who responded to the neoadjuvant cytostatic treatment with adequate tissue regression were better than those of the patients who responded to the treatment to only a decreased extent or not at all. The changes in the expressions of laminin and syndecan-1 in response to cystostatic treatment proved to be important predictive factors. The increase or stagnation of these clearly forecast a good prognosis, whereas their decrease was a definite indication of poor prognosis.

Angiotensin enzyme converting (ACE) inhibitors are a widely prescribed group of drugs used in the management of hypertension and heart failure. Several unwanted effects are associated with ACE inhibitors and this paper highlights those significant to the dental surgeon. Of particular concern is the problem of angioedema, which can be life threatening. Three case reports are presented that illustrate this problem and the management is discussed.