Kalpesh Patel

Periapical cemental dysplasia: a case of misdiagnosis

The correct diagnosis of pathological lesions of endodontic origin should allow for differentiation from those arising from other sources. A case of periapical cemental dysplasia (cementoma) is presented, whereby incorrect diagnosis resulted in not only inappropriate treatment, but an endodontic mishap and the superimposition of acute apical periodontitis in a previously disease-free site. This case report highlights the need for appropriate examination, simple special tests and diagnosis prior to management of lesions of questionable aetiology

Oral and systemic effects of prolonged minocycline therapy

The following case report shows the unfortunate side effects of minocycline therapy used in the management of facial acne. All three features of discoloration affecting the skin, bone and dentition were found. A 46-year-old patient presented with adult onset discoloration of the dentition following prolonged minocycline therapy. In addition, oral and cutaneous pigmentation were noted. Unfortunately, the undesirable cosmetic appearance of facial acne was exchanged for permanent discoloration of the dentition. When considering prolonged minocycline therapy, patients would benefit from dialogue between the medical and dental practitioners, so that the risk of this potential side effect can be assessed in a more informed way

The provision of dental implants and a fixed prosthesis in the treatment of a patient with scleroderma: A clinical report

This clinical report highlights some of the problems in providing a suitable prosthesis for a patient who suffers from systemic sclerosis. A conventional removable partial denture may not have been suitable because of the lack of denture bearing area, changing peripheral seal, and insufficient teeth to support and retain the denture. An implant-retained FPD overcame these difficulties. One would hope that, with regular maintenance and monitoring, quoted prosthesis success of 15 years can be achieved.

Structural and functional changes in HDL with low grade and chronic inflammation

OBJECTIVE HDL functionality has been shown to be impaired in inflammatory conditions, including coronary artery disease. The present study aims to determine the impact of low grade and acute inflammation on HDL function and structure. APPROACH AND RESULTS i) The endothelial protective effects of HDL were compared between 26 periodontal patients and 26 age and sex matched controls by measuring paraoxonase activity in serum and nitric oxide bioavailability and superoxide production in endothelial cells. Paraoxonase activity and nitric oxide bioavailability were reduced, while superoxide production was increased (p<0.01) in periodontal patients compared to controls. ii) HDL function, including cholesterol efflux and vascular cell adhesion molecule-1 expression, was subsequently measured in the periodontal patients following an inflammatory stimulus. There was an acute deterioration in HDLs endothelial protective function, without change in cholesterol efflux, after 24h (p<0.01 for all). These functional changes tracked increases of inflammatory markers and altered HDL composition. Finally, HDL function returned to baseline levels after resolution of inflammation. CONCLUSION This study demonstrates that even minor alterations in systemic inflammation can impair the endothelial protective effects of HDL. These functional changes were independent of cholesterol efflux and were associated with remodeling of the HDL proteome. All measures of HDLs endothelial protective functions recovered with resolution of inflammation. These findings suggest that HDL dysfunction may represent a novel mechanism linking inflammation with progression of atheroma.

Association Between Short Leukocyte Telomere Length, Endotoxemia, and Severe Periodontitis in People With Diabetes: A Cross-Sectional Survey

OBJECTIVE Shortened leukocyte telomere length (LTL) and diagnosis of periodontitis are associated with an increased risk of complications and mortality in diabetes. This study investigated the association between LTL, endotoxemia, and severity of periodontitis in a large cohort of people with diabetes. RESEARCH DESIGN AND METHODS Six hundred thirty individuals (371 with type 2 and 259 with type 1 diabetes) were recruited from the University College Hospital in London, U.K. During a baseline visit, blood was collected for standard biochemical tests and DNA extraction, while a dental examination was performed to determine diagnosis and extent of periodontitis. LTL was measured by real-time PCR, and endotoxemia was assessed by the limulus amoebocyte lysate method. RESULTS Two hundred fifty-five individuals were diagnosed with gingivitis, 327 with periodontitis (114 with moderate and 213 with severe disease), and 48 with edentulous. Diagnosis of periodontitis was associated with shorter LTL (P = 0.04). A negative association between LTL and endotoxemia was found in the severe periodontitis and type 2 diabetes groups (P = 0.01 for both). Shorter LTL was associated with increased extent of periodontitis (P = 0.01) and increased insulin resistance (homeostatic model assessment). Multiple adjustments for biochemical, anthropometric, and medication-use variables did not affect the results. CONCLUSIONS LTL is associated with endotoxemia and diagnosis of periodontitis in people with diabetes. LTL shortening might represent a novel biological pathway accounting for previous epidemiological data that documented higher prevalence of diabetes and its complications in people with periodontitis and vice versa.

Resin-retained Bridges Re-visited Part 1. History and Indications

Resin-retained bridges have been used clinically since the 1970s, and offer a more conservative approach to the restoration of edentulous spaces than conventional bridgework. They are easy to place, cheap to fabricate and have been shown to be cost effective. Despite this, they are not frequently used in general dental practice and they have an undeserved reputation for failure. Since their initial introduction, they have undergone a number of changes to their method of retention, and the materials used in their construction. This has resulted in a predictable, aesthetic restoration which, barring the use of implants, is often the treatment of choice where teeth adjacent to an edentulous space are minimally or not restored. This first article details the history, advantages, indications, and designs of resin-retained bridges.

The provision of occlusal splints in primary dental care.

Occlusal splints (Michigan splints, night/bite guards or bite-raising appliances) can be an effective, inexpensive and reversible treatment for a wide range of dental problems. Objective The aim of this study was to analyse retrospectively the provision of occlusal splint (‘Michigan’ type) in general dental practice, following a prescription by a restorative dental consultant. Method One hundred patients were recruited from consultant clinics in a department of conservative dentistry during 1995 and 1996. All patients were prescribed a maxillary, full-coverage, heat-cured, acrylic-resin splint (Michigan splint) as part of a treatment plan. An explanatory letter and questionnaire were sent to all patients and to their referring general dental practitioner in 1997 and 1998. Results A response rate of 79% was achieved in obtaining completed questionnaires from both patients and general dental practitioners. Of respondents 43% (34/79) received an occlusal splint of some form. A small proportion of the respondents (16.5% [13/79]) received a Michigan splint as prescribed. Irrespective of the type of appliance provided, most patients (82% [28/34]) found them helpful. Of those who did not receive an occlusal splint, 38% (17/45) of patients felt financial implications deterred them from obtaining an appliance. Other common reasons for non-provision included: patients felt that symptoms had improved (18% [8/45]) and patients did not agree with treatment (18% [8/45]). The general dental practitioners had similar opinions to their patients. Discussion These findings raise some serious doubts on the efficacy of consultant clinic advice in the prescription of occlusal splints in general dental practice. The financial and educational issues raised by this study will need to be addressed to improve service provision. Conclusion The results of this study indicate that 16.5% of patient respondents prescribed a Michigan splint at a consultant clinic received such an appliance in general dental practice.

Resin-retained bridges re-visited. Part 2. Clinical considerations.

Resin-retained bridges have been used clinically since the 1970s, and offer a more conservative approach to the restoration of edentulous spaces than conventional bridgework. They are easy to place, cheap to fabricate and have been shown to be cost-effective. Despite this, they are not frequently used in general dental practice and they have an undeserved reputation for failure. Since their initial introduction, they have undergone a number of changes to their method of retention, and the materials used in their construction. This has resulted in a predictable, aesthetic restoration which, barring the use of implants, is often the treatment of choice where teeth adjacent to an edentulous space are minimally or not restored. This article hopes to show the clinical techniques required to produce predictable resin-retained bridgework in general practice.

Systemic effects of periodontitis treatment in patients with type 2 diabetes: a 12 month, single-centre, investigator-masked, randomised trial

BACKGROUND Chronic inflammation is believed to be a major mechanism underlying the pathophysiology of type 2 diabetes. Periodontitis is a cause of systemic inflammation. We aimed to assess the effects of periodontal treatment on glycaemic control in people with type 2 diabetes. METHODS In this 12 month, single-centre, parallel-group, investigator-masked, randomised trial, we recruited patients with type 2 diabetes, moderate-to-severe periodontitis, and at least 15 teeth from four local hospitals and 15 medical or dental practices in the UK. We randomly assigned patients (1:1) using a computer-generated table to receive intensive periodontal treatment (IPT; whole mouth subgingival scaling, surgical periodontal therapy [if the participants showed good oral hygiene practice; otherwise dental cleaning again], and supportive periodontal therapy every 3 months until completion of the study) or control periodontal treatment (CPT; supra-gingival scaling and polishing at the same timepoints as in the IPT group). Treatment allocation included a process of minimisation in terms of diabetes onset, smoking status, sex, and periodontitis severity. Allocation to treatment was concealed in an opaque envelope and revealed to the clinician on the day of first treatment. With the exception of dental staff who performed the treatment and clinical examinations, all study investigators were masked to group allocation. The primary outcome was between-group difference in HbA1c at 12 months in the intention-to-treat population. This study is registered with the ISRCTN registry, number ISRCTN83229304. FINDINGS Between Oct 1, 2008, and Oct 31, 2012, we randomly assigned 264 patients to IPT (n=133) or CPT (n=131), all of whom were included in the intention-to-treat population. At baseline, mean HbA1c was 8·1% (SD 1·7) in both groups. After 12 months, unadjusted mean HbA1c was 8·3% (SE 0·2) in the CPT group and 7·8% (0·2) in the IPT group; with adjustment for baseline HbA1c, age, sex, ethnicity, smoking status, duration of diabetes, and BMI, HbA1c was 0·6% (95% CI 0·3-0·9; p<0·0001) lower in the IPT group than in the CPT group. At least one adverse event was reported in 30 (23%) of 133 patients in the IPT group and 23 (18%) of 131 patients in the CPT group. Serious adverse events were reported in 11 (8%) patients in the IPT group, including one (1%) death, and 11 (8%) patients in the CPT group, including three (2%) deaths. INTERPRETATION Compared with CPT, IPT reduced HbA1c in patients with type 2 diabetes and moderate-to-severe periodontitis after 12 months. These results suggest that routine oral health assessment and treatment of periodontitis could be important for effective management of type 2 diabetes. FUNDING Diabetes UK and UK National Institute for Health Research.