Nona Aghazadehsanai

Integrating Oral Health into the Interdisciplinary Health Sciences Curriculum

Oral health inequities for older adults warrant new models of interprofessional education and collaborative practice. The Innovations in Interprofessional Oral Health: Technology, Instruction, Practice and Service curricular model at Bouvé College of Health Sciences aims to transform health professions education and primary care practice to meet global and local oral health challenges. Innovations in simulation and experiential learning help to advance interprofessional education and integrate oral health care as an essential component of comprehensive primary health care. The Program of All-Inclusive Care for the Elderly clinic is an exemplary model of patient-centeredness and interprofessional collaborative practice for addressing unmet oral health needs of its patient population.

Prevalence of calcified carotid artery atheromas on panoramic images of individuals with primary hyperparathyroidism

OBJECTIVES Primary hyperparathyroidism (PHPT), affecting 1% of the population, is associated with increased cardiovascular morbidity and mortality. The presence of calcified carotid artery plaque (CCAP) on panoramic images is a validated risk indicator of future adverse cardiovascular events. We hypothesized that military veterans aged 50 years or older diagnosed with PHPT by increased parathyroid hormone and calcium levels would frequently have CCAP on their images. METHODS We determined the prevalence rates of CCAP on the images of patients diagnosed with PHPT and evaluated their atherogenic risk profiles, including hypertension, dyslipidaemia, diabetes and obesity. Comparisons of atherogenic risk factors were made between subjects with and without observed CCAP on their panoramic images. RESULTS Of the 60 patients (86.7% males and 13.3% females, mean age 73.2 ± 11.3 years) with PHPT, 40% had atheromas. There were no significant differences between CCAP+ and CCAP- groups in gender or race (p > 0.05). The atherogenic profile (age, body mass index, hypertension, diabetes, hyperlipidaemia) in the CCAP+ and CCAP- groups was not significantly different (p > 0.05). CONCLUSIONS Calcified carotid artery atheromas are often seen on the panoramic images of patients with PHPT. Thus, dentists must be uniquely vigilant for these lesions when evaluating these studies.

Panoramic images of white and black post-menopausal females evidencing carotid calcifications are at high risk of comorbid osteopenia of the femoral neck.

OBJECTIVES Femoral neck fractures in older females resulting from decreased bone mineral density (BMD; osteopenia) are associated with increased morbidity and mortality. Bone mineralization inhibition is probably controlled by proteins which also foster vascular calcification. Therefore, we evaluated the relationship between calcified carotid artery plaque (CCAP) on panoramic images and BMD on dual energy X-ray absorptiometry (DXA) bone scans. METHODS Images and hospital records identified by dentists defined two study groups (20 white females and 24 black females) having CCAP and an incidentally obtained bone scan. Ethnically matched (age±7 years, body mass index ±3 units) control groups with panoramic images devoid of CCAP and accompanying DXA scan were likewise constituted. A physician determined the BMD on the DXA. RESULTS Females with CCAP had significantly (p = 0.03) poorer BMD at the femoral neck than those without CCAP. Although mean femoral neck BMD was significantly lower (p = 0.009) for white than for black females, there was no significant interaction between race and CCAP (p = 0.80). CONCLUSION We observed a significant inverse association between the CCAP on panoramic images and femoral neck BMD in post-menopausal white females.

Patients Receiving Parenteral Bisphosphonates for Malignant Disease and Having Developed an Atypical Femoral Fracture Are at Risk of Concomitant Osteonecrosis of the Jaw: An Evidence-Based Review

PURPOSE The risk of developing concomitant medication-related osteonecrosis of the jaw (MRONJ) in patients who have sustained an atypical femoral fracture (AFF) in association with parental administration of a bisphosphonate osteoclastic inhibitor medication for malignant disease is unclear. Published data were searched to determine the prevalence of these concomitant adverse medication events, if any. MATERIALS AND METHODS A systematic review of published case series in the PubMed database was undertaken to ascertain the prevalence of patients having a concomitant history of AFF and MRONJ. The data were analyzed to provide prevalence rates of these events from the literature. RESULTS Two case series were identified that delineated the risk (25 and 33%, respectively) of concomitant development of MRONJ and AFF in recipients of parenteral bisphosphonate medication administered for malignant disease. CONCLUSION The published data suggest that approximately 30% of patients receiving parenteral bisphosphonates and having sustained an AFF could develop comorbid MRONJ.

Critique of American Dental Association Council on Scientific Affairs Clinical Practice Guideline: Use of Prophylactic Antibiotics Before Dental Procedures in Patients With Prosthetic Joints

Oral and maxillofacial surgeons, as dental specialists who plan the treatment of their own elective surgery patients, as well as receive emergency referrals from dentists of patients in the midst of surgery gone awry, need to be keenly aware of the relative strengths of the documentary evidence garnered by the 2014 American Dental Association (ADA) Council on Scientific Affairs in its determination that patients with prosthetic joints do not require antibiotic prophylaxis. The panel based its clinical practice guideline on literature search results and direct evidence contained in a comprehensive systematic review initially published by another ADA Panel in conjunction with the American Academy of Orthopaedic Surgeons (AAOS) in 2012 plus the results of an updated literature search that identified 3 additional ‘‘evidence-based’’ documents. Specifically, the 2012 AAOS-ADA Panel noted that a recommendation that the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures was ‘‘limited,’’ ‘‘because the quality of

Association of calcified carotid atheromas visualized on panoramic images and aortic arch calcifications seen on chest radiographs of postmenopausal women

BACKGROUND Occult atherosclerotic disease is the leading cause of death among older women. The authors hypothesized that women with calcified carotid artery plaque (CCAP) visualized on panoramic images were more likely to have aortic arch calcifications (AAC) that were visible on chest radiographs (CRs), a risk indicator of experiencing cardiovascular events, than would matched cohorts who did not have atheromas. METHODS The authors obtained the CRs of 36 female veterans (≥ 50 years) who had CCAP and atherogenically risk-matched them to those of 36 women without CCAP. A radiologist evaluated the CRs for AAC. Other study variables included age, ethnicity, body mass index and presence or absence of hypertension, diabetes and dyslipidemia. The authors computed descriptive and bivariate statistics. RESULTS Women 60 years or older who had evidence of CCAP on their panoramic radiographs were significantly (P = .022; 95 percent confidence interval, 1.298-26.223) more likely to have evidence of AAC on their CRs than were similarly aged women who did not have evidence of CCAP. This association was not evident in women younger than 60 years. Among women who were both younger and older than 60 years, there was no evident association between the presence of CCAP and the severity (on a four point scale [0-3]) of AAC calcification. CONCLUSION Prevalence of carotid plaque on panoramic images of women 60 years or older is significantly associated with presence of aortic arch calcifications on CRs. PRACTICAL IMPLICATIONS Panoramic images of women 60 years or older must be evaluated for CCAP, given their association with AAC. Patients with atheromas should be referred to their physicians for further evaluation given the systemic implications.

Do carotid atheromas on panoramic images prognosticate arterial calcifications on mammograms: acknowledged markers of future adverse cardiovascular events?

OBJECTIVE The aim of this study was to evaluate the relationship between calcified carotid artery plaque (CCAP) on panoramic images and breast arterial calcifications (BAC) on mammograms, a validated independent risk indicator of fatal myocardial infarctions and strokes. MATERIALS AND METHODS Women ≥55 years old having CCAP diagnosed by their dentists had their mammograms evaluated for BAC by a physician. Other study variables were age, ethnicity, body mass index, and medications for hypertension, diabetes, and dyslipidemia. Descriptive and bivariate statistics and logistic regression were computed. RESULTS Researchers identified 40 women (mean age 62.2 ± 6.2 years old) with CCAP, of whom 9 (prevalence rate 22.5%) also had BAC. The women with BAC tended to be older (65.1 vs 61.3 years old), more frequently hypertensive (100% vs 80.6%), and more frequently black than those without BAC, although these differences were not statistically significant (P > 0.10). CONCLUSIONS CCAP on panoramic images of women is unrelated to the presence of BAC on mammograms.

The effectiveness of antibiotic prophylaxis to prevent infectious endocarditis is not easily dismissed.

To the Editor: A recently published paper in this journal elegantly described a study in which venous blood samples were drawn at 6 time-points from individuals undergoing dental manipulation, with the recovered bacterial species cultured and identified by using 16 s ribosomal RNA gene sequencing. The authors found that the relative frequency of bacterial species associated with the development of infectious endocarditis (IE) did not significantly differ between individuals (n 1⁄4 98) brushing their teeth and patients (n 1⁄4 96) having a single tooth extracted without antibiotic prophylaxis. In the same study, these researchers also demonstrated that prophylactic antibiotics (2 g of amoxicillin) administered to patients (n 1⁄4 96) 1 hour before a single tooth extraction decreased the incidence of bacterial species most commonly associated with IE by 68%. They concluded, however, that although prophylactic antibiotics significantly decreased the incidence of bacteremia, the similarity between the incidence of IE-associated bacteria after brushing and dental extraction without antibiotics undermines the rationale for the administration of prophylactic antibiotics as an effective strategy for the prevention of IE. However, in the literature review, the authors’ omission of a project in which they had participated is quite concerning, as this may call into question the validity of their conclusions. I specifically refer to a very recent publication in Lancet entitled “Incidence of infective endocarditis in England, 2000-2013: A secular trend, interrupted time-series analysis.” In no uncertain terms, this paper documented a temporally related increase in the number of cases of IE in the United Kingdom after the institution of the 2008 National Institute of Health and Clinical Excellence guidance recommending complete cessation of antibiotic prophylaxis for patients with cardiac defects undergoing risk-prone (i.e., bacteremia-inducing) surgical procedures. We believe that the discrepancies in the findings between these 2 studies calls into question the conclusions reached by Mougeot et al regarding the effectiveness of prophylactic antibiotics in preventing distant-site infections. If nothing else, this calls for further research and reflection. Arthur H. Friedlander, DMD Associate Chief of Staff and Director of Graduate Medical Education Veterans Affairs Greater Los Angeles Healthcare System; Director of Quality Assurance Hospital Dental Service Ronald Reagan UCLA Medical Center; and Professorin-Residence Department of Oral and Maxillofacial Surgery University of California Los Angeles School of Dentistry Los Angeles 11301 Wilshire Blvd. Los Angeles CA 90073, USA