Cyril Meyerowitz

Preliminary results of a pilot study using WR-2721 before fractionated irradiation of the head and neck to reduce salivary gland dysfunction☆

PURPOSE Based on in vivo evidence of radioprotection of the salivary glands using WR-2721, a pilot study was undertaken to determine the feasibility, toxicity, and salivary function of patients receiving WR-2721, while undergoing radiation therapy to the head and neck. METHODS AND MATERIALS Patients undergoing radiation therapy for cancer of the head and neck were eligible if the major salivary glands received more than 45 Gy. WR-2721 was administered over 6 min IV, 10-15 min prior to each dose of radiation five times per week. Saliva was collected and measured prior to radiation therapy, weekly during radiation therapy, 1 month postradiation therapy, and every 3 months thereafter. Flow rates of unstimulated whole saliva, stimulated whole saliva, and stimulated parotid saliva were measured using standard techniques. 99mTc salivary scintiscans were performed prior to radiation therapy, 1 month postradiation therapy and every 3 months thereafter. Nine patients are presently enrolled on the first dose level (100 mg/m2) of this study. Eight completed per protocol, two with minor decreases of total WR-2721 doses. Two patients progressed with distant metastases soon after completion of therapy. All available data are included in the analysis. Median follow-up for all patients is 18 months. RESULTS Flow rates of unstimulated whole saliva decreased significantly during radiation therapy reaching 5.6% of baseline at 9 months postradiation therapy, subsequently recovering to 20% of baseline, then remaining stable over time. Stimulated whole salivary flow rate similarly decreased during radiation therapy and reached its nadir (11% of baseline) at 3 months postradiation therapy, improving to 27% of baseline by 2 years. The stimulated parotid flow rate decreased during radiation therapy to 1.4% of pretreatment levels. Significant recovery took place 6 months postradiation therapy and by 18 months values had recovered to 54% of baseline. 99mTc salivary scintiscans confirmed this rebound of parotid function postradiation therapy. Toxicity was minimal with the exception of one patient who received only 27% of the planned total drug dose due to grade 3 hypotension after the eighth treatment. No recovery of salivary function has been seen in this patient; flow rates remain zero in all three areas tested 21 months after radiation. CONCLUSIONS Administration of WR-2721 prior to each dose of radiation was feasible and without significant toxicity at 100 mg/m2. Salivary gland function improved over time after completion of radiation, particularly the parotid. Future directions include escalation of WR-2721 dose to 200 mg/m2 and then 300 mg/m2, and a Phase III randomized trial will be undertaken once the optimal dose is established.

Use of an Intra-oral Model to Evaluate 0.05% Sodium Fluoride Mouthrinse in Radiation-induced Hyposalivation

The present study was undertaken to evaluate the effect of a twice-daily topical application of a 0.05% NaF mouthrinse on de- and remineralization in the oral cavities of subjects suffering from radiation-induced hyposalivation. Six subjects each wore a bonded intra-oral appliance containing a sound and a demineralized human enamel slab for four weeks. During that period, the subjects used 0.05% NaF rinses, twice daily, instead of the 1.1% NaF gel that had previously been a part of their preventive regimen. Salivary flow rates, plaque pH profiles following a 10% sucrose rinse, S. mutans and lactobacillus counts, fluoride clearance, and enamel microhardness were determined during the study. Sound enamel samples displayed no evidence of demineralization, and the previously demineralized enamel showed remineralization in the outer 50 μm in three of the six subjects. The results suggest that a twice-daily oral rinse with 0.05% NaF can prevent demineralization and enhance remineralization in subjects with radiation-induced hyposalivation.

Preventive dentistry: practitioners’ recommendations for low-risk patients compared with scientific evidence and practice guidelines

INTRODUCTION The purpose of this article is to compare published evidence supporting procedures to prevent dental caries and periodontal disease, in low-risk patients, with the actual preventive recommendations of practicing dentists. METHODS Methods included (1) a survey questionnaire of general dentists practicing in western New York State concerning the preventive procedures they would recommend and at what intervals for low-risk children, young adults, and older adults; and (2) review of the published, English-language literature for evidence supporting preventive dental interventions. RESULTS The majority of dentists surveyed recommended semiannual visits for visual examination and probing to detect caries (73% to 79%), and scaling and polishing to prevent periodontal disease (83% to 86%) for low-risk patients of all ages. Bite-wing radiographs were recommended for all age groups at annual or semiannual intervals. In-office fluoride applications were recommended for low-risk children at intervals of 6 to 12 months by 73% of dentists but were recommended for low-risk older persons by only 22% of dentists. Application of sealants to prevent pit and fissure caries was recommended for low-risk children by 22% of dentists. Literature review found no studies comparing different frequencies of dental examinations and bite-wing radiographs to determine the optimal screening interval in low-risk patients. Two studies of the effect of scaling and polishing on the prevention of periodontal disease found no benefit from more frequent than annual treatments. Although fluoride is clearly a major reason for the decline in the prevalence of dental caries, there are no studies of the incremental benefit of in-office fluoride treatments for low-risk patients exposed to fluoridated water and using fluoridated toothpaste. CONCLUSIONS Comparative studies using outcome end points are needed to determine the optimal frequency of dental examinations and bite-wing radiographs for the early detection of caries, and of scaling and polishing to prevent periodontal disease in low-risk persons. There is no scientific evidence that dental examinations, including scaling and polishing, at 6 month intervals, as recommended by the dentists surveyed in this study, is superior to annual or less frequent examinations for low-risk populations. There is also no evidence that in-office fluoride applications offer incremental benefit over less costly methods of delivering fluoride for low-risk populations.

Novel anticoagulants: general overview and practical considerations for dental practitioners.

Currently, 4 novel Direct Oral Anticoagulants (DOACs) were approved by the FDA. This review focuses on these agents and proposes a matrix for the general dentists to assess bleeding risk in dental management of patient on DOACs. The outline covers the pharmacology of DOACs (rivaroxaban, apixaban, edoxaban and dabigatran), bleeding complications, risk associated with discontinuation, monitoring/reversal, and implications for the dental practitioners. A total of 18 randomized controlled trials were identified with mixed results in regards to the risk for bleeding. Considering the pharmacology of DOACs and challenges in monitoring and reversing their effect, the dentist should consider carefully the management of patients on DOACs as it may differ from patients on conventional anticoagulants. Based on the type of dental procedure and the medical risk assessment, several general treatment approaches can be considered: continue DOACs, time dental treatment as late as possible after the last DOACs dose, discontinue DOACs for 24hrs, or discontinue DOACs for 48hrs. Based on the current reported dental literature, limited dental surgery may benefit from the first 2 conservative options. However, this needs to be proven in comparative clinical trials.

Pre- or Post-Eruptive Effects of Strontium Alone or in Combination with Fluoride on Dental Caries in the Rat

Doses of strontium were given pre-eruptively to rats at 0.0, 2.5, 5.0 and 10.0 μg Sr/10 g body weight, with or without fluoride at 1.0 μg/l0 g body weight by esophageal intubation. In a second experiment strontium at concentrations of 0, 50, 100 and 150 mg Sr/l, with and without fluoride at 10 mg/l, were given via the drinking water post-eruptively. Caries scores were made for buccolingual, morsal, sulcal und proximal lesions in all rats. Slight reductions in buccolingual caries scores were seen in rats given 5.0 μg Sr/10 g body weight pre-eruptively. Rats given post-eruptive doses of strontium only showed marked reductions in buccolingual scores with 50 mg Sr/l, and 10 mg F/l. No effect was seen on morsal, sulcal or proximal caries scores for any of the treatment regimens. The greatest reductions in buccolingual caries scores were found when a combination of 50 mg Sr/l and 10 mg F/l was given post-eruptively.

Geriatric dentistry and prevention: research and public policy (reaction paper).

The population of older adults is heterogeneous and can be divided into many subgroups: the young-old, the old-old, the healthy, the sick, the frail, the mentally and physically handicapped, the ambulatory, the chair-bound, house-bound or institution-bound, and the economically advantaged and disadvantaged. This diversity is extremely important to the discussion of the oral health needs, preventive health strategies, and research agenda for the elderly. As life expectancy increases, more attention is being paid to disease prevention so that the quality of life in old age can be improved. However, the link among oral health, systemic disease, and quality of life in the elderly needs to be better-defined. There is some evidence in the literature that indicates that coronal and root caries appear to be major health problems for the elderly. This needs to be corroborated in longitudinal studies. Although periodontal disease prevalence and severity are high in some subgroups of the elderly, these appear to be in decline in the general population. Dental health-care workers must be cognizant of the oral conditions associated with systemic disease and the use of medication, a major concern in older adults. Prevention of oral disease in the elderly requires early intervention, education of the dental health team, and innovative uses of well-established preventive agents such as fluoride. An extensive research effort is needed to answer basic and applied questions regarding the oral health needs of the elderly. Federal and private funding will be necessary. The dental profession will have to demonstrate and be persuasive that money spent on research and care for the elderly is money well spent.

Effect of Sucralose – Alone or Bulked with Maltodextrin and/or Dextrose – on Plaque pH in Humans

Sucralose is a safe, intensely sweet, noncaloric sucrose derivative that has been shown to be noncariogenic. The purpose of the present study was to compare the effects on plaque pH in vivo of sucralose in iced tea (alone or bulked with maltodextrin or with maltodextrin/dextrose) with sucrose in iced tea. Fourteen subjects, with DMFT > 7 and an acidogenic plaque, participated in the study. Plaque pH response to one of five solutions: unsweetened tea, tea with sucralose (final concentration 0.007% by weight), tea with sucralose/maltodextrin (final concentrations 0.007% and 0.59% by weight, respectively), tea with sucralose/maltodextrin/dextrose (final concentrations 0.007, 0.018 and 0.57% by weight, respectively) and tea with sucrose (final concentration 4.7% by weight); was assessed in five experimental sessions. All solutions, except the unsweetened tea, had a sweetness equivalent to 2 teaspoons of sucrose in 6 OZ of beverage. Using a touch electrode, plaque pH was measured at baseline and at specific time intervals up to 60 min after rinsing with the test solution for 1 min. Comparisons between groups were done for minimum pH, delta pH, and area under the pH curve (AUC), by using the nonparametric Friedmans test and the Wilcoxon signed rank test. Rinsing with tea and sucrose resulted in significantly lower minimum pH, higher delta pH and larger AUC than rinsing with the solutions containing sucralose. It can be concluded that sucralose alone or in combination with maltodextrin or with maltodextrin/dextrose is significantly less acidogenic than sucrose when used as a sweetener in iced tea.

Provision of specific dental procedures by general dentists in the National Dental Practice-Based Research Network: questionnaire findings.

BackgroundObjectives were to: (1) determine whether and how often general dentists (GDs) provide specific dental procedures; and (2) test the hypothesis that provision is associated with key dentist, practice, and patient characteristics.MethodsGDs (n = 2,367) in the United States National Dental Practice-Based Research Network completed an Enrollment Questionnaire that included: (1) dentist; (2) practice; and (3) patient characteristics, and how commonly they provide each of 10 dental procedures. We determined how commonly procedures were provided and tested the hypothesis that provision was substantively related to the three sets of characteristics.ResultsTwo procedure categories were classified as “uncommon” (orthodontics, periodontal surgery), three were “common” (molar endodontics; implants; non-surgical periodontics), and five were “very common” (restorative; esthetic procedures; extractions; removable prosthetics; non-molar endodontics). Dentist, practice, and patient characteristics were substantively related to procedure provision; several characteristics seemed to have pervasive effects, such as dentist gender, training after dental school, full-time/part-time status, private practice vs. institutional practice, presence of a specialist in the same practice, and insurance status of patients.ConclusionsAs a group, GDs provide a comprehensive range of procedures. However, provision by individual dentists is substantively related to certain dentist, practice, and patient characteristics. A large number and broad range of factors seem to influence which procedures GDs provide. This may have implications for how GDs respond to the ever-changing landscape of dental care utilization, patient population demography, scope of practice, delivery models and GDs’ evolving role in primary care.

Management of dentin hypersensitivity by practitioners in the National Dental Practice-Based Research Network

BACKGROUND Dentin hypersensitivity (DH) is a condition commonly encountered in clinical dental practice. The authors conduct a study to identify the treatments recommended to manage DH among dentists in the United States. METHODS The authors conducted a multicenter study of 1,862 patients with DH who received a diagnosis and were treated by 171 dentists with The National Dental Practice-Based Research Network. RESULTS The most common treatment recommended was desensitizing over-the-counter (OTC) potassium nitrate toothpaste (alone or in combination with other treatments) for 924 of 1,862 patients (50%). This was followed by an application of fluoride varnish (FV) for 516 patients (28%) and a prescription for fluoride toothpaste for 314 patients (17%). Restorative treatments were recommended to 151 patients (8%). The most common single treatment recommendation was desensitizing OTC potassium nitrate toothpaste, recommended to 335 patients (18%). The most frequent combination of 2 treatment modalities was FV and desensitizing OTC potassium nitrate toothpaste, recommended to 100 patients (5%). A total of 890 of 1,862 patients (48%) with DH received a recommendation for 1 treatment modality, and 644 of 1,862 patients (35%) received a recommendation for a combination of 2 treatment modalities, most frequently an application of FV along with desensitizing OTC potassium nitrate toothpaste (100/1,862; 5%). CONCLUSIONS Desensitizing OTC potassium nitrate toothpaste and fluoride products were the most widely recommended products to manage DH in the practice setting. PRACTICAL IMPLICATIONS Our results suggest that most network clinicians preferred noninvasive treatment modalities when treating DH.

Management of Dentin Hypersensitivity by National Dental Practice-Based Research Network practitioners: results from a questionnaire administered prior to initiation of a clinical study on this topic

BackgroundDentin hypersensitivity (DH) is a common problem encountered in clinical practice. The purpose of this study was to identify the management approaches for DH among United States dentists.MethodsOne hundred eighty five National Dental Practice-Based Research Network clinicians completed a questionnaire regarding their preferred methods to diagnose and manage DH in the practice setting, and their beliefs about DH predisposing factors.ResultsAlmost all dentists (99%) reported using more than one method to diagnose DH. Most frequently, they reported using spontaneous patient reports coupled with excluding other causes of oral pain by direct clinical examination (48%); followed by applying an air blast (26%), applying cold water (12%), and obtaining patient reports after dentist’s query (6%). In managing DH, the most frequent first choice was desensitizing, over-the-counter (OTC), potassium nitrate toothpaste (48%), followed by fluorides (38%), and glutaraldehyde/HEMA (3%). A total of 86% of respondents reported using a combination of products when treating DH, most frequently using fluoride varnish and desensitizing OTC potassium nitrate toothpaste (70%). The most frequent predisposing factor leading to DH, as reported by the practitioners, was recessed gingiva (66%), followed by abrasion, erosion, abfraction/attrition lesions (59%) and bruxism (32%).ConclusionsThe majority of network practitioners use multiple methods to diagnose and manage DH. Desensitizing OTC potassium nitrate toothpaste and fluoride formulations are the most widely used products to manage DH in dental practice setting.