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JADA Specialty Scan - O & M Pathology
 
O & M PathologyJADA Specialty Scan

Novel oral anticoagulants and bleeding risk in patients undergoing dental treatment

Several novel oral anticoagulants (NOACs) have been introduced to manage the treatment of patients with atrial fibrillation, pulmonary thromboembolism, and venous thrombosis. However, few studies have examined the relationship between dental procedures and the risk of bleeding in these patients. Therefore, researchers conducted a retrospective review to elucidate trends in the use of NOACs and bleeding events related to dental treatment. The study was published online April 25 in Clinical Oral Investigations.

Study participants included 120 patients (67 men and 53 women) receiving NOACs who underwent a total of 153 dental procedures in the Department of Advanced General Dentistry at Yonsei University Dental Hospital in Seoul, South Korea, from 2014 through 2017. Patients’ mean (standard deviation) age was 69.4 (11.7) years, with a range of 33 through 92 years, the authors wrote.

Inclusion criteria for this study were patients taking a NOAC (dabigatran, rivaroxaban, apixaban, or edoxaban) who underwent dental procedures associated with a moderate to high risk of bleeding (for example, periodontal scaling, curettage, tooth extraction, first and second stages of implant surgery) or procedures associated with a low risk of bleeding (for example, endodontic therapy, restoration placement, crown preparation, obtaining impressions).

The researchers divided participants into high- and low-risk bleeding groups. Of the 153 procedures in 120 patients, 138 involved a high risk of bleeding, and 15 involved a low risk of bleeding. Periodontal scaling was the most common dental procedure (n = 77), followed by simple tooth extractions (n = 38) and surgical extractions (n = 13). All procedures except for obtaining impressions were performed under local anesthesia with 2% lidocaine and 1:100,000 epinephrine.

The duration of drug discontinuation before dental treatment was 0 days in 50 patients, 1 day in 37 patients, 2 days in 23 patients, and 3 or more days in 10 patients.

Patients reported postoperative bleeding at a follow-up dental visit. Of the 153 dental procedures performed, only 9 (5.88%) were associated with postoperative bleeding; 8 of these procedures were classified as having a moderate to high risk of bleeding. The procedures associated with postoperative bleeding included periodontal scaling (n = 2), simple extraction (n = 3), the first stage of implant surgery (n = 3), and placement of a composite restoration (n = 1). Postoperative bleeding was managed by means of compression hemostasis. The onset of postoperative bleeding occurred within 24 hours in cases involving scaling. For most other dental procedures involving bone, postoperative bleeding occurred 3 to 6 days after treatment. The researchers found no significant relationship between the duration of drug discontinuation and postoperative bleeding (P = .222).

Creatinine clearance data were available for 69 of the 120 participants. The study findings showed no significant difference in the creatinine clearance rate between patients who experienced bleeding events and those who did not (P = .111).

The researchers concluded that NOAC treatment does not need to be discontinued for most dental procedures. For patients undergoing the first stage of implant surgery, multiple tooth extractions, or deep periodontal scaling, NOAC treatment should be discontinued for at least 1 day and additionally modified based on the medication’s half-life and the patient’s renal clearance rate.

Read the original article.

 

Consulting Editor: Paul C. Edwards, MSc, DDS, FRCD(C)
Editor, American Academy of Oral and Maxillofacial Pathology
Professor, Department of Oral Pathology, Medicine and Radiology
School of Dentistry, Indiana University


Associate Consulting Editor: Zoya Kurago, DDS, PhD
Chair, Research and Scientific Affairs Committee,
American Academy of Oral and Maxillofacial Pathology
Associate Professor of Oral Biology, Oral Health and Diagnostic Sciences,
Graduate Studies, Pathology
Department of Oral Health and Diagnostic Sciences
Dental College of Georgia, Augusta University

Investigating the efficacy of human papillomavirus vaccines against invasive HPV-associated cancer

Clinical trials have shown that high-risk human papillomavirus (HPV) vaccines are highly effective against HPV infection and cervical intraepithelial neoplasia grade 3. However, vaccine efficacy against invasive HPV-associated cancer has been unclear. In this letter to the editor, published online December 26 in International Journal of Cancer, researchers report the results of trials in which invasive cancer was the end point.

From 2002 through 2005, the first 2 cohorts were recruited and enrolled in 2 phase 3 trials: FUTURE II (Females United to Unilaterally Reduce Endo/Ectocervical Disease; NCT00092534) and PATRICIA (PApilloma TRIal against Cancer In young Adults; NCT00122681). The trials were continued in Finland as a passive, long-term follow-up study (NCT01393470). Participants in the FUTURE II study consisted of 866 Finnish women who were vaccinated at ages 16 and 17 years against 4 HPV types: HPV-6/11/16/18. The PATRICIA study comprised 2,465 Finnish women vaccinated at ages 16 and 17 years against high-risk HPV-16/18. In addition, 15,665 unvaccinated 18- and 19-year-old Finnish women who were ineligible for the clinical phase 3 trials were enrolled in a passive, comparison cohort. The analysis also included the community-randomized phase 4 trial (NCT00534638) from 2007 through 2008 consisting of 6,198 girls aged 14 and 15 years who received the HPV-16/18 vaccine and 2,173 girls, also aged 14 and 15 years, who received a hepatitis B vaccine, but not the HPV vaccine.

An age-aligned, countrywide Finnish Cancer Registry–based follow-up of these cluster or individually randomized cohorts for comparable, up to 7-year periods from June 2007 through December 2015 ensured that vaccinated and unvaccinated participants were the same age during follow-up.

The researchers found 10 cases of invasive carcinomas (8 cervical cancers, 1 oropharyngeal cancer, and 1 vulvar cancer) established a priori as cancers caused by high-risk HPV infection. All 10 cancer cases occurred in women who had not received an HPV vaccination. The overall 100% efficacy estimate for the HPV vaccine is statistically significant, although the confidence intervals (CIs) were somewhat wide (95% CI, 16 to 100), apparently due to the low end-point frequencies. In contrast, the incidence rates for other, non-HPV associated common cancers did not differ between unvaccinated and HPV-vaccinated women.

The authors concluded that, to their knowledge, this is the first intention-to-treat trial evidence of the protective effect of vaccination against invasive HPV-associated cancer.

Read the original letter.

 
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The risk of oral tongue cancer in organ transplant recipients and people with HIV

In recent years, the incidence of oral tongue cancer has increased significantly among young, white adults in the United States. However, the reasons for this increase are unknown. In a study published online April 12 in Cancer, researchers examined the risk of developing oral tongue cancer and other head and neck cancers in 2 immunosuppressed populations: recipients of solid organ transplants and people with HIV. The researchers hypothesized that a virus may cause oral tongue cancer; consequently, immunosuppressed populations would be expected to be at an elevated risk.

The authors collected data from the ongoing Transplant Cancer Match (TCM) study and the HIV/AIDS Cancer Match (HACM) study. These studies link population-based cancer registries with the US Scientific Registry of Transplant Recipients or state HIV registries.

Study participants consisted of 242,022 transplant recipients and 465,429 people with HIV. Most transplant recipients in the TCM group were male (61%), white (61%), and younger than 50 years (53%) at the time of surgery. The kidney was the most commonly transplanted organ. In the HACM study, 52% of participants had received a diagnosis of AIDS at the start of follow-up. A large proportion of HACM participants were male (72%), African American (50%), and younger than 50 years at study entry (82%). The largest proportion of participants (33%) in the HIV risk group were men who have sex with men (MSM).

Among transplant recipients, the researchers observed 36 oral tongue squamous cell carcinomas (SCCs), 203 oropharyngeal SCCs, 86 other oral cavity SCCs, and 48 non-Hodgkin lymphomas of the oral cavity/pharynx. Compared with the general US population, the incidence of all specified head and neck cancers was significantly elevated in this group.

In the group of people with HIV, the authors observed 70 oral tongue SCCs, 311 oropharyngeal SCCs, 117 oral cavity SCCs, and 144 oral cavity/pharynx non-Hodgkin lymphomas. The incidence of all specified head and neck cancers also was significantly elevated among people in this group.

The study results showed that the risk of oral tongue SCC among transplant recipients was similar across sex and race, and it increased with age and the time since transplantation. However, the risk of other specified head and neck cancers was significantly higher among men and whites in this group. The authors did not observe any significant difference in cancer risk according to use of specific immunosuppressive drugs or human leukocyte antigen–mismatch status.

Among participants with HIV, the risk of oral tongue SCC was similar in men and women; however, the risk was higher among whites and increased with age and time since AIDS onset. The researchers also observed a significantly higher risk of developing oral tongue SCC among MSM than among other HIV groups (incidence rate ratio, 2.0; 95% confidence interval, 1.2 to 3.4). In this study, nearly one-half of oral tongue SCCs (n = 34) among people with HIV occurred in the MSM group.

The risk of oral tongue, other oral cavity, and oropharyngeal SCCs was modestly elevated among people with immunosuppression compared with the general US population, the authors wrote. Thus, the study findings suggest that the “etiology underlying oral tongue SCC, similar to that of oropharyngeal and other oral cavity SCCs, is not greatly impacted by immunosuppression.” However, there appears to be a subtle role for chronic long-term immunosuppression, as the incidence of head and neck cancers increased over time in the study populations.

The authors concluded that the elevated risk of oral tongue cancer among MSM with HIV and the time since AIDS onset suggest that a sexually transmitted virus could be a cause. However, additional studies are needed to evaluate the risk factors that may be contributing to the apparent rise in oral tongue cancer in the United States.

Read the original article.

 

The influence of acculturation on the oral microbiome

The oral microbiome has been implicated as a possible factor in a number of conditions associated with chronic inflammation, including periodontitis and cancers of the stomach and liver. These conditions disproportionately affect Mexican American women. However, few studies have examined the oral microbiota in this at-risk group. The objective of a study published online April 25 in PLOS One was to characterize the 16s rDNA oral microbiome in participants enrolled in the MD Anderson Mana a Mano Mexican American Cohort Study (MACS).

The MACS is a large, ongoing, prospective population-based study of predominantly low-income, first-generation immigrants of Mexican origin living in the greater Houston, Texas, area. Investigators randomly selected 369 women participating in the MACS who were never smokers, not currently pregnant, and 20 years or older at enrollment. The median age of participants was 39 years (range, 20–78 years); more than 75% of the women were married, and 50% had less than a high school education. Eighty percent of participants were born in Mexico, but 52% had lived in the United States for at least 15 years. The rates of overweight and of obesity among participants were 36% and 47%, respectively.

On enrollment in the MACS, the women participated in a baseline in-home interview consisting of questionnaires and height and weight measurements. Investigators measured linguistic acculturation using 8 items from the Bidimensional Acculturation Scale for Hispanics. They also measured food acculturation and physical activity.

The researchers collected oral mouthrinse samples from participants during the in-home visit. A total of 511 unique operational taxonomic units (OTUs), a proxy for bacterial species, were identified in the mouthrinse samples. Assigning OTUs at the genus level, the investigators identified a core oral microbiota defined by 18 genera detected in at least 98% of samples. Streptococcus was the most abundant genus, with a mean (standard deviation) relative abundance of 37% (12%). Prevotella_7 was the second-most-abundant genus (11%), followed by Haemophilus (10%), Veillonella (6%), and Neisseria (5%).

The study findings showed an inverse relationship between age and taxonomic richness, as measured by observed OTUs and the Chao index (P < .01). According to the authors, this relationship appeared to be more pronounced in those having lived longer in the United States than in Mexico. However, the magnitudes of correlation were modest. Among participants born or raised in Mexico, taxonomic richness also was inversely correlated with years residing in the United States. Taxonomic richness was 16% higher among those immigrating at 30 years or older than among those immigrating at 18 years or younger (88.6 OTUs and 102.8 OTUs, respectively; P = .02). The authors did not observe any associations between the remaining variables—such as educational attainment, marital status, and physical activity—and alpha diversity in univariate or multivariate analyses.

The researchers also clustered samples on the basis of their oral microbiota into 3 community types: “Streptococcus,” “Fusobacterium,” and “Prevotella.” Functional analysis suggested that the Streptococcus-dominated community had a greater potential for carbohydrate metabolism, whereas the Prevotella cluster had a greater potential for biosynthesis of essential amino acids and nitrogen metabolism.

The results of this study suggest that immigration and adaptation to life in the United States are associated with changes in the oral microbial profiles of Mexican American women. Recognizing that a number of health issues encountered by Mexican American women are modulated by acculturation and adaptation, the authors suggest that the oral microbiome may present “an easily accessible biomarker of disease risk, spanning biological, behavioral, and environmental factors.”

Read the original article.

2018 AAOMP and IAOP joint meeting set for June 23-28

Join the American Academy of Oral and Maxillofacial Pathology and the International Association of Oral Pathologists at the joint meeting, “21st Century Diagnostics: Molecular Genetics to Immunohistochemistry,” June 23-June 28, 2018 in Vancouver, BC.

The meeting will feature top speakers from all over the world to speak on topics including:

  • Soft tissue and bone sarcomas of the head and neck with emphasis on ancillary studies to include IHC and molecular.
  • Tumor microenvironment.
  • Challenging cases in head and neck pathology.
  • Dermatologic tumors for oral and maxillofacial pathologists.
  • Case studies involving head and neck radiology.
  • Molecular alterations in head and neck cancer/salivary gland tumors/thyroid cancer with emphasis on diagnosis and treatment.
  • Odontogenic tumors: molecular pathology to personalized medicine.

To register or find more information on the program, schedule, exhibitors, hotel reservations visit https://aaompmeeting.org/.

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Mark your calendar for the 2018 Joint AAOMP and IAOP meeting
Join AAOMP and the IAOP for our Joint Meeting June 22-June 28, 2018 at the Westin Bayshore Hotel in Vancouver, BC, Canada. Visit www.aaomp.org for more details.

 

JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.

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