C. Daniel Overholser

Increased morbidity associated with oral infection in patients with acute nonlymphocytic leukemia

The proper dental management of patients with leukemia is complicated by the compromised host defenses against infection. This compromised state is a result of the chemotherapeutic agents used in cancer treatment as well as the natural existing disease state. Infection remains the leading immediate cause of death in persons with leukemia. Previous reports have described oral complications secondary to this neoplasm and its medical management; however, relatively few studies of the incidence of systemic complications secondary to oral disease have been reported. This study analyzed the incidence of acute infectious episodes in patients with acute nonlymphocytic leukemia (ANLL). Thirty-eight patients were randomly selected for review; of these patients, twelve (32 percent) had identifiable acute oral infection associated with the presence of a febrile state (greater than 101 degrees F). Seven of the twelve (58 percent) had no other identifiable sources of infection. The periodontium was the oral site most frequently involved, followed by mucosal and periapical loci. Most acute oral infections were associated with profound granulocytopenia (less than 100/microliters). The data suggest that oral disease plays a clinically important role in the development of systemic complications in ANLL patients.

Effect of an antimicrobial mouthrinse on recurrent aphthous ulcerations.

Recurrent aphthous ulceration (RAU) remains a clinical problem for many patients. Efforts in prevention and/or treatment with prescription and nonprescription formulations have to date resulted in minimal success at best. A 6-month double-blind clinical study of 96 adults compared a commercially available antimicrobial mouthrinse (Listerine Antiseptic [LA], Warner-Lambert Co., Morris Plains, N.J.) and a hydroalcoholic control to evaluate the effects of vigorous twice-daily rinsing on the incidence, duration, and severity of RAU in persons prone to this disorder. LA rinse and the hydroalcoholic rinse resulted in a statistically significant reduction in the incidence of RAU occurrences from baseline. The duration of lesions and the severity of pain in subjects with ulcers during the treatment period were also significantly reduced in the LA rinse group of patients when compared with baseline. The hydroalcoholic rinse did not show a significant effect versus baseline for either severity or duration of the lesions. Rinsing therefore can be of clinical value in reducing the occurrence of RAU in susceptible patients, and LA rinse can be of significant additional value in decreasing the duration and severity of RAU.

Dental extractions in patients with acute nonlymphocytic leukemia

Dental extractions in patients with leukemia are controversial, since they may lead to hemorrhage, delayed wound healing and infection. However, the retention of diseased teeth in these patients may also lead to infectious complications during chemotherapy. With adequate hematologic values and specific surgical techniques, 119 extractions were performed on 28 patients with acute nonlymphocytic leukemia. No serious adverse sequelae occurred, and the prevalence of other adverse affects was comparable with that in nonleukemic patients. It is concluded that with proper precautions, extractions can be performed on these patients.

Effect of granulocytopenia on oral microbial relationships in patients with acute leukemia

Risk for acute infection increases as granulocyte levels decrease secondary to myelosuppressive chemotherapy in patients with acute nonlymphocytic leukemia (ANLL). Acute exacerbations of concomitant inflammatory periodontal diseases can result in systemic infections in these patients. However, host-oral bacterial relationships in the periodontium in patients with ANLL are not well understood. Twenty-one adult patients with ANLL with periodontal disease ranging from gingivitis to severe periodontitis were studied. Supragingival and subgingival plaque specimens were collected before chemotherapy (prechemotherapy), and at a defined midpoint of myelosuppression (midchemotherapy; day 14). All specimens were extensively cultured both aerobically and anaerobically. Data were submitted to a partial correlational analysis, controlling for covariation relation to oral hygiene intervention and antibiotic administration. Levels of total yeast exhibited a significant association with Staphylococcus sp. at supragingival sites midchemotherapy (r = 0.68, p less than or equal to 0.05). Levels of total yeast also correlated positively with Pseudomonas aeruginosa at subgingival sites both prechemotherapy (r = 0.70, p less than or equal to 0.01) and midchemotherapy (r = 0.61, p less than or equal to 0.05). Significant correlations of levels of Veillonella sp. with Neisseria sp. and gram-negative enteric bacilli were observed in both supragingival (r = 0.95, 0.77, p values less than or equal to 0.01) and subgingival (r = 0.69, 0.61, p values less than or equal to 0.05) plaque specimens midchemotherapy but not prechemotherapy. These data suggest that potentially pathogenic bacteria occur in plaque simultaneous with granulocytopenia in these patients. Multiple mechanisms, including intergeneric coaggregation and other symbiotic relationships, may influence infectivity of the mixed plaque flora and thus contribute to the oral ecology observed in these patients.

Dental management of leukemic patients

Three cases involving the oral management of patients with acute leukemia are described. Of particular interest is that the patients had abnormal responses to oral disease, probably related to their compromised host defenses. Because of the difficulty in treating oral disease in leukemic persons while they are undergoing chemotherapy, it is extremely important that such patients have dental evaluations and, if possible, treatment prior to initiation of medical management for their neoplasia.

Blood pressure fluctuations in hypertensive patients during oral surgery

The lability of blood pressure during oral surgical procedures and the effects of antihypertensive drugs on this lability have not been investigated sufficiently to evaluate potential medical risks. The purpose of this study was to accurately evaluate blood pressure fluctuations during oral surgical procedures in three groups of patients: normotensive patients; stratum I hypertensive patients not taking medication; and stratum I hypertensive patients taking antihypertensive medication. Blood pressure measurements were recorded by an American Heart Association certified technician at baseline, immediately prior to surgery, during administration of the local anesthetic, during the surgical procedure, and 15 minutes after surgery. Analysis of variance indicated that the blood pressure fluctuations (systolic and diastolic) among these five intervals were not statistically significant for any of the groups. The clinical significance of the above findings is that stratum I hypertensive patients experience minimal fluctuations in blood pressure that are no greater than those in normotensive patients and, therefore, may present no greater clinical risk during the dental stress associated with certain oral surgical procedures.

Experimental endocarditis following dental extractions in rats with periodontitis

This study analyzed the development of bacterial endocarditis following dental extraction in rats with periodontal disease. Periodontal disease was produced in rats by tying silk ligatures around the two maxillary first molars, and placing the animals on a high sucrose diet. Sterile aortic valve vegetations were produced by means of a transaortic catheter, and 24 hours later the maxillary first molars were extracted. The animals were killed 72 hours after the extractions. In rats with periodontal disease induced for 10 and 14 weeks, extractions resulted in an incidence of bacterial endocarditis of 24% and 50%, respectively, most of which were due to streptococcal species (two were caused by Staphylococcus [corrected] aureus). The difference, though not statistically significant (p = 0.10, chi 2 with Yates correction), shows a trend toward increased incidence of endocarditis with increasing severity of periodontal disease. This model demonstrates that one can reliably induce bacterial endocarditis after dental extractions in rats with periodontal disease.

Initial Detection and Evaluation: Intraoral Neoplasms

This chapter reviews the principles and techniques used to detect and evaluate intraoral cancer. These concepts have direct clinical importance; survival rates, which vary with site, can be improved with early detection (figure 10–1) [1–7]. In addition, many people see their dentist routinely, thereby providing the opportunity for early detection. These clinicians should thus carefully and regularly examine all intraoral structures and palpate the neck in their patients, particularly those individuals at risk. By virtue of their training, dentists are the individuals most integrally involved with oral health and disease. Thus, the responsibility for early recognition of oral pathologic changes is frequently theirs.