Lorenzo Favero

Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study.

Following favourable results from a previous study, a large, multicentre, prospective, case-control study was performed to further assess the incidence of bleeding complications after dental extraction in patients taking oral anticoagulant therapy (OAT). Four hundred fifty-one patients being treated with warfarin who required dental extraction were compared with a control group of 449 non-anticoagulated subjects undergoing the same procedure. In the warfarin-treated group, the oral anticoagulant regimen was maintained unchanged, such that the patients had an International Normalised Ratio ranging between 1.8 and 4, and local haemostatic measures (i.e. fibrin sponges, silk sutures and gauzes saturated with tranexamic acid) were adopted. All the procedures were performed in an outpatient setting. Seven bleeding complications occurred in the OAT group and four in the control group; the difference in the number of bleeding events between the two groups was not statistically significant (OR=1.754; 95% CI 0.510 - 6.034; p=0.3727). No post-operative late bleeds requiring hospitalisation and/or blood transfusions were recorded, and the adjunctive local haemostatic measures were adequate to stop the bleeding. The results of our protocol applied in this large, multicenter study show that dental extractions can be performed easily and safely in anticoagulated outpatients without any modification of the ongoing anticoagulant therapy, thus minimising costs and reducing discomfort for patients.

Surface electromyography of jaw muscles and kinesiographic recordings: diagnostic accuracy for myofascial pain

The present investigations attempted to assess the diagnostic accuracy of commercially available surface electromyography (sEMG) and kinesiography (KG) devices for myofascial pain of jaw muscles. Thirty-six (n = 36) consecutive patients with a research diagnostic criteria for temporomandibular disorders (RDC/TMD) axis I diagnosis of myofascial pain and an age- and sex-matched group of 36 TMD-free asymptomatic subjects underwent sEMG and KG assessments to compare EMG parameters of the masseter and temporalis muscles as well as the jaw range of motion and the interarch freeway space. EMG data at rest were not significantly different between myofascial pain patients and asymptomatic subjects, while the latter achieved significantly higher levels of EMG activity during clenching tasks. Symmetry of muscle activity at rest and during clenching tasks, KG parameters of jaw range of motion and the measurement of the interarch vertical freeway did not differ between groups. Receiver operating characteristics curve analysis showed that, except EMG parameters during clenching tasks, all the other outcome sEMG and KG measures did not reach acceptable levels of sensitivity and specificity, with a 30·6-88·9% percentage of false-positive results. Therefore, clinicians should not use sEMG and KG devices as diagnostic tools for individual patients who might have myofascial pain in the jaw muscles. Whether intended as a stand-alone measurement or as an adjunct to making clinical decisions, such instruments do not meet the standard of reliability and validity required for such usage.

Toward the Validation of Visual Analogue Scale for Anxiety

Anxiety is a relevant problem in dental practice. The Visual Analogue Scale for Anxiety (VAS-A), introduced in dentistry in 1988, has not yet been validated in large series. The aim of this study is to check VAS-A effectiveness in more than 1000 patients submitted to implantology. The VAS-A and the Dental Anxiety Scale (DAS) were administered preoperatively to 1114 patients (459 males and 655 females, age 54.7 ± 13.1 years). Statistical analysis was conducted with Pearson correlation coefficient, the receiver operating characteristic (ROC) curve, and McNemar tests. A close correlation between DAS and VAS-A was found (r  =  0.57, P < .0001); the VAS-A thresholds of dental anxiety and phobia were 5.1 and 7.0 cm, respectively. Despite a significant concordance of tests in 800 cases (72%), disagreement was found in the remaining 314 cases (28%), and low DAS was associated with high VAS-A (230 cases) or vice versa (84 cases). Our study confirms that VAS-A is a simple, sensitive, fast, and reliable tool in dental anxiety assessment. The rate of disagreement between VAS-A and DAS is probably due to different test sensitivities to different components of dental anxiety. VAS-A can be used effectively in the assessment of dental patients, using the values of 5.1 cm and 7.0 cm as cutoff values for anxiety and phobia, respectively.

Age-Related Differences in Temporomandibular Disorder Diagnoses

Abstract The purpose of the current study was to evaluate the pattern of age distribution of temporomandibular disorders (TMD) and to identify prevalence peaks for the different diagnoses. The study sample (N = 383; F:M ratio = 3.9; mean age range 41.7±17 years) consisted of patients seeking treatment for TMD and who were assessed in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) version 1.0 guidelines.1 The sample was divided into four age groups on the basis of percentile-derived intervals to compare prevalence of different diagnoses in relation to age. The pattern of clinical diagnoses changed with increasing age. The peculiar distribution of RDC/TMD axis I diagnoses, with relation to age, mainly affected the disorders trend of groups II and III, with the former decreasing with age from about 62% to 40% and the latter increasing from 75% to almost 95%. Two distinct age peaks were identified for the prevalence of the main clinical marker of group III diagnosis of arthrosis/arthritis, viz., joint crepitus sounds (N=104, mean age range 51.9±14.5), and for the prevalence of all other diagnoses in patients without joint crepitus (N=279, mean age range 37.9±16.4). The hypothesis that TMD patient populations may be composed of at least two diagnostic subgroups in relation to age, and that the presence of clinically diagnosed degenerative joint disorders may be a key discriminating factor, was supported. The external validity of the results from this investigation needs to be confirmed by multicenter and cross-cultural studies.

Natural course of temporomandibular disorders with low pain‐related impairment: a 2‐to‐3‐year follow‐up study

To describe the natural course of temporomandibular disorders (TMD) in patients with low levels of pain-related impairment, independently by the physical diagnoses they received. Amongst all patients who attended the TMD Clinic, University of Padova, Italy, during the year 2009, those who: (i) had Research Diagnostic Criteria for TMD (RDC/TMD) axis II Graded Chronic Pain Scale (GCPS) grade 0 or 1 scores, (ii) received counselling on their signs and symptoms at the time of their first visit and suggestions on how to self-manage their symptoms, (iii) did not attend the Clinic since the time of their last visit and (iv) were visited by the same resident, were recalled for a follow-up assessment during the period from September to December 2011. Sixty-nine patients (79% females; mean age 47.4 ± 11.3 years; range 26-77) of 86 who were potentially eligible accepted to enter the study. The time span since the first visit ranged from 23 to 36 months. At the follow-up assessment, the percentage of patients with muscle disorders decreased from 68.1% to 23.1%; disc displacement with reduction remained unchanged (52.1%), whilst the 5.7% of patients who had disc displacement without reduction with limited opening then showed absence of limitation; diagnoses related to other joint disorders decreased from 30.4% to 14.4% for arthralgia and from 27.5% to 24.6% for osteoarthritis/osteoarthrosis. In a sample of patients TMD with low pain-related impairment followed up with a single recall assessment at 2-to-3 years, the natural course of disease was generally favourable.

Safety of dental implant surgery in patients undergoing anticoagulation therapy: a prospective case-control study.

OBJECTIVES Several studies have described oral surgical procedures in patients receiving anticoagulant therapy, but no prospective studies on dental implant surgery during anticoagulant treatment are currently available, and only a limited number of case reports refer to endosseous dental implant treatment in these patients. In the setting of oral surgery, it has been suggested that anticoagulant treatment is not required when the International Normalized Ratio (INR) is <4 and local haemostatic measures are applied. The purpose of this preliminary study was to evaluate the incidence of bleeding complications following surgical implant therapy in a group of 50 consecutive patients receiving oral anticoagulant therapy (warfarin) without interruption or modifications to their therapy (group A). MATERIALS AND METHODS One hundred and nine otherwise healthy patients comparable for age, sex, extent and site of the implant surgical procedure formed the control group (group B). In both groups, a standard protocol of local haemostasis, including non-reabsorbable sutures and compressive gauzes soaked with tranexamic acid, was applied. Surgeons, blind to the group allocation, performed all the procedures in an outpatient setting. RESULTS Two and three late-bleeding complications were reported in group A and group B, respectively, without significant difference in the bleeding risk (relative risk = 1.45; P= 0.65; 95% confidence interval 0.2506-8.4271). These complications were managed using a compressive gauze soaked with tranexamic acid at the site of the surgical wound. CONCLUSION According to our preliminary results, local haemostasis in dental implant surgery is able to prevent bleeding complications in patients on oral anticoagulants, allowing these surgical procedures to be performed on an outpatient basis.

Predictive factors of hyaluronic acid injections short-term effectiveness for TMJ degenerative joint disease

This study attempted to identify baseline predictors of positive outcome of arthrocenteses plus hyaluronic acid injections in degenerative temporomandibular joint disease (TMJ DJD). Ninety (n=90) consecutive patients with Research Diagnostic Criteria for Temporomandibular Disorders TMJ osteoarthritis (RDC/TMD 1.0 Axis I Group IIIb) underwent a cycle of five arthrocenteses with injections of 1mL hyaluronic acid and were followed up for 3months. Eight potential predictors of positive treatment outcome (sex, age, pain duration, baseline pain at chewing, presence of uni- or bilateral arthritis, presence of other concurrent RDC/TMD diagnoses, type of intervention and tolerability of treatment) were included in a logistic regression model to identify baseline predictors of treatment effectiveness. At follow-up, 85·6% of patients improved with respect to baseline VAS values, and 64·4% had a 50% or more decrease (positive outcomes). Correlation with positive outcomes existed only for unilateral osteoarthritis, and the logistic regression identified the side of arthritis (unilateral/bilateral) as the only predictor of positive treatment outcome (P=0·032). The achievement of any treatment improvement was predicted by high baseline pain levels (P=0·016). The regression models explained only 7·7-15% of the variance in the outcome variable. The attempts to find predictors of positive treatment outcome with HA injections for TMJ degenerative joint disease have been successful only in part. The search for other outcome predictors is likely to benefit from the assessment of psychosocial features associated with TMJ disorders.

Surface Electromyography Findings in Unilateral Myofascial Pain Patients: Comparison of Painful vs Non Painful Sides

OBJECTIVES To answer the clinical research question: in patients with myofascial pain, are there any differences in the surface electromyography (sEMG) activity of muscles of the painful and nonpainful sides that can be detected by commercially available devices? METHODS The study sample (N = 39; 64% F, mean age 35.7 ± 15 years) consisted of patients seeking for temporomandibular disorders Temporomandibular Disorders (TMD) treatment and meeting Research Diagnostic Criteria for TMD (RDC/TMD) diagnosis of myofascial pain, with pain referred only in muscles on one side. They underwent sEMG of jaw muscles to record levels of standardized sEMG activity at rest, as well as during maximum clenching on teeth for the four investigated muscles, viz., bilateral masseter and temporalis. The existence of differences between sEMG values of muscles of the painful and nonpainful sides during the standardization test (i.e., clenching on cotton rolls) at rest and during clenching on teeth was assessed. RESULTS At the study population level, differences between the sEMG values of muscles of the painful and nonpainful sides were not significant in any conditions, viz., either at rest or during clenching tasks. At the individual level, the difference between the sEMG activity of painful and nonpainful sides was very variable. CONCLUSIONS The above findings were not supportive of the existence of any detectable difference in sEMG activity between jaw muscles of the painful and nonpainful sides in patients with unilateral myofascial pain. Centrally mediated mechanism for pain adaptation may explain these findings, and the role of sEMG as a diagnostic tool for muscle pain needs to be carefully reconceptualized.

Odontostomatologic involvement in juvenile localised scleroderma of the face.

Aim:  Localised scleroderma of the face (LSF) can lead to significant aesthetical and functional abnormalities. Despite their quite frequent clinical observation, the odontostomatologic complications are not thoroughly described. Aim of the study was to describe the clinical features of the most frequent odontostomatologic abnormalities of LSF and to propose clinical and radiologic criteria for the assessment and follow‐up of these complications.

Kinesiographic recordings of jaw movements are not accurate to detect magnetic resonance–diagnosed temporomandibular joint (TMJ) effusion and disk displacement: findings from a validation study

OBJECTIVE The aim of this study was to perform a validation study assessing the correlation between magnetic resonance (MR) findings of temporomandibular joint (TMJ) disk displacement and effusion and some parameters drawn from kinesiographic (KG) recordings of jaw motion, i.e., deflection, deviations, incisures. STUDY DESIGN Thirty-one patients with TMJ disorders underwent a kinesiographic recording in the same day in which the MR was performed. Regression analysis was performed to assess the correlation between the MR and KG findings. RESULTS MR findings were not correlated with KG parameters (P > .05). The accuracy of all KG variables for diagnosing MR-detected signs was low. KG deflection ranged from 38.7% to 54.8%, KG deviation from 42% to 54.8%, and KG incisures from 9.6% to 71%. Specificity and positive predictive values were far from acceptable levels for all KG variables. CONCLUSIONS The findings do not support the usefulness of jaw-tracking devices in dental practices that diagnose and manage temporomandibular disorders.