Michele De Benedittis

Prevalence and severity of oral disease in adults with chronic kidney disease: a systematic review of observational studies

BACKGROUND Oral disease may be increased in people with chronic kidney disease (CKD) and, due to associations with inflammation and malnutrition, represents a potential modifiable risk factor for cardiovascular disease and mortality. We summarized the prevalence of oral disease in adults with CKD and explored any association between oral disease and mortality. METHODS We used systematic review of observational studies evaluating oral health in adults with CKD identified in MEDLINE (through September 2012) without language restriction. We summarized prevalence and associations with all-cause and cardiovascular mortality using random-effects meta-analysis. We explored for sources of heterogeneity between studies using meta-regression. RESULTS Eighty-eight studies in 125 populations comprising 11 340 adults were eligible. Edentulism affected one in five adults with CKD Stage 5D (dialysis) {20.6% [95% confidence interval (CI), 16.4-25.6]}. Periodontitis was more common in CKD Stage 5D [56.8% (CI, 39.3-72.8)] than less severe CKD [31.6% (CI, 19.0-47.6)], although data linking periodontitis with premature death were scant. One-quarter of patients with CKD Stage 5D reported never brushing their teeth [25.6% (CI, 10.2-51.1)] and a minority used dental floss [11.4% (CI, 6.2-19.8)]; oral pain was reported by one-sixth [18.7% (CI, 8.8-35.4)], while half of patients experienced a dry mouth [48.4% (CI, 37.5-59.5)]. Data for kidney transplant recipients and CKD Stages 1-5 were limited. CONCLUSIONS Oral disease is common in adults with CKD, potentially reflects low use of preventative dental services, and may be an important determinant of health in this clinical setting.

WhatsApp: a telemedicine platform for facilitating remote oral medicine consultation and improving clinical examinations

OBJECTIVE Increased use of smartphone and related software applications has created a new era in clinical data exchange among patients and clinicians. This study describes use of the smartphone-based application WhatsApp to share clinical oral medicine information. STUDY DESIGN Clinical images and related questions were submitted by general dentists, physicians, dental hygienists, and patients to the authors via WhatsApp. For each submission, a clinical impression was made and categorized as traumatic, infective, neoplastic, autoimmune, or unclassified. Submissions were summarized by sender type, number of photographs per sender, and category of question. Patients were invited to undergo a clinical examination with biopsy, when indicated. The telemedicine impression was compared to the clinicopathologic diagnosis. RESULTS Three hundred and thirty-nine images were received for 96 patients; 92 (95.8%) patients underwent clinicopathologic examination, and 45 (49%) received a biopsy. General dentists (62%) and dental hygienists (26%) were the most frequent senders. The most common question was related to diagnosis (56%). The telemedicine impression agreed with the clinicopathologic assessment for 82% of cases. CONCLUSIONS Telemedicine applications, such as WhatsApp, can support communication about oral conditions among clinicians and patients. Telemedicine consultation reduced geographic barriers to initial clinical consultation and encouraged the significant majority of patients to pursue expert clinical examination.

Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study

BackgroundPeople with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated.Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required.Methods/designThe ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022.DiscussionThis large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

Development and Clinical Evaluation of MatrixMANDIBLE Subcondylar Plates System (Synthes)

In this article, authors report the different steps of development and clinical validation of MatrixMANDIBLE Subcondylar Plates (Synthes, Soletta, Switzerland), a specialized osteosynthesis system developed by Synthes during the past 4 years. Between 2009 and 2013, a total of 62 patients were treated for subcondylar and condylar neck fractures via a preauricular or retromandibular/transparotid approach. The MatrixMANDIBLE Subcondylar Plates System consists of a Trapezoidal Plate, a three-dimensional (3D) 4-hole 1.0-mm plate for smaller fracture areas, the Lambda Plate, a 7-hole 1.0-mm linear plate which mimics the two miniplates technique, and the Strut Plate, a 3D 1.0-mm plate with great versatility of employment. All devices satisfy the principles of a functionally stable osteosynthesis as stated by Champy et al. None of the plates broke and no macroscopic condylar displacement was noted on radiological follow-up. Clinical and functional parameters assessed at 6 months postoperative (mandibular range of motion, pain, dental occlusion) were almost restored. MatrixMANDIBLE Subcondylar Plates System (Synthes) has proved to provide sufficient mechanical stiffness and anatomically accurate fracture reduction to avoid major postoperative drawbacks of subcondylar and condylar neck fractures.

Patients' osteometabolic control improves the management of medication-related osteonecrosis of the jaw

OBJECTIVES Osteonecrosis of the jaw (ONJ) is a concern in patients taking anti-resorptive drugs. The aim of this study was to test the hypothesis that preoperative individualized pharmacologic control of the patients osteometabolic profile could lead to predictable healing of the surgically treated region and minimize the incidence of complications. STUDY DESIGN This prospective study included 95 test patients (53 with osteoporosis and 42 with cancer), and 94 control patients (49 with osteoporosis and 45 with cancer) who were on anti-resorptive therapy and were candidates for ONJ treatment. Test patients underwent osteometabolic profile assessment and personalized pharmacologic supplementation before intervention. In all cases, a drug holiday was scheduled for 3 months before and at least 3 months after the intervention. Healing was assessed clinically and radiographically. RESULTS In the test group, after a mean follow-up of 28.2 ± 7.8 months, there was only 1 ONJ recurrence, and it was successfully resolved after the pharmacologic protocol was resumed. Five patients reported minor complications. Overall, 100% treatment success was observed. In the control group, after 28.1 ± 4.9 months follow-up, 6 fistulae, 19 abscesses, and 34 dehiscences occurred. In total, 62.8% of patients in the control group had complications or adverse events. The difference between the 2 groups was highly significant. CONCLUSIONS Strict osteometabolic control should be a routine measure in the management of patients taking anti-resorptive drugs.

Periodontitis and early mortality among adults treated with hemodialysis: a multinational propensity-matched cohort study

BackgroundPeriodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure.MethodsORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index.A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries.ResultsAmong the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death.ConclusionIn contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis.