Tuesday, January 31, 2012

The Morning Drill: January 31, 2012

Good Morning!

On to today's dentistry and health headlines.

Genetic Variation That Raises Risk of Serious Complication Linked to Osteoporosis Drugs Identified

Researchers at the Columbia University College of Dental Medicine have identified a genetic variation that raises the risk of developing serious necrotic jaw bone lesions in patients who take bisphosphonates, a common class of osteoclastic inhibitors. The discovery paves the way for a genetic screening test to determine who can safely take these drugs. The study appears in the online version of the journal The Oncologist.

Oral bisphosphonates are currently taken by some 3 million women in the United States for the prevention or treatment of osteoporosis. In addition, intravenous bisphosphonates are given to thousands of cancer patients each year to control the spread of bone cancer and prevent excess calcium (hypercalcemia) from accumulating in the blood. Bisphosphonates work by binding to calcium in the bone and inhibiting osteoclasts, bone cells that break down the bone’s mineral structure.

“These drugs have been widely used for years and are generally considered safe and effective,” said study leader Athanasios I. Zavras, DMD, MS, DMSc, associate professor of Dentistry and Epidemiology and Director of the Division of Oral Epidemiology & Biostatistics at the Columbia University College of Dental Medicine. “But the popular literature and blogs are filled with stories of patients on prolonged bisphosphonate therapy who were trying to control osteoporosis or hypercalcemia only to develop osteonecrosis of the jaw.”

Osteonecrosis of the jaw, or ONJ, often leads to painful and hard-to-treat bone lesions, which can eventually lead to loss of the entire jaw. Among people taking bisphosphonates, ONJ tends to occur in those with dental disease or those who undergo invasive dental procedures.

There are no reliable figures on the incidence of ONJ in patients taking oral bisphosphonates. Estimates range from 1 in 1,000 to 1 in 100,000 patients for each year of exposure to the medication, according to the American College of Rheumatology. ONJ is more common among cancer patients taking the intravenous form of the drug, affecting about 5 to 10 percent of these individuals, noted Dr. Zavras.

Studies have suggested that genetic factors play a major role in predisposing patients to ONJ.

Aetna’s dentists get iPads to help patients stop smoking

Aetna is set to begin a trial program that equips New York City-area dentists with iPads to help them better educate their patients about tobacco use in an effort to curb smoking. The trial program includes a clinical decision support system (CDSS) that is built on a medical knowledge base, patient data, and decision support technology that provides dentists with personally targeted advice for each patient.

The trial is still in its earliest stages: Aetna is working with Columbia University to design and implement the program.

Dr. David Albert DDS, Director of the Division of Community Health at the Columbia University College of Dental Medicine in New York City, is the principal investigator for the study, which aims to determine how impactful such a CDSS system is on the patient population.

The study is called, “The Dental Tobacco Cessation iPad” and it still has undergo testing and modifications before it rolls out formally at five NYC dental offices.

“The program is designed as an innovative interface between patients and dentists and we anticipate that devices like the iPad can be used to break down barriers between clinicians’ and their patients,” said Dr. Albert. “We will evaluate if we are able to encourage and assist dentists to provide tobacco cessation advice and assistance for their patients who use tobacco products. Tobacco use poorly affects the mouth and teeth and the patient’s overall health. Helping patients to quit tobacco use is a goal that the US Public Health Service encourages all dentists to adopt.”

Jaw Necrosis Common after Radiation for Oral Cancer

Osteoradionecrosis of the jaw (ORNJ) occurred more than twice as often as reported in the literature, according to a population-based study of patients treated with radiation for oral cancer.

A review of national medical records showed that 16.1% of patients had jaw complications or interventions consistent with ORNJ compared with published rates of 5% to 7%.

However, when investigators applied the definition of ORNJ to patients who had interventions associated with jaw complications, the rate approximated the published rates, as reported here at the Multidisciplinary Head and Neck Cancer Symposium.

"The rates of all jaw complications in the SEER-Medicare database are higher than reported rates from prospective and retrospective institutional reports," said Beth M. Beadle, MD, PhD, of the University of Texas MD Anderson Cancer Center in Houston. "If we limited the definition to interventions, the rates are similar to those of published reports."

Radiation therapy has documented efficacy for locoregional control of head and neck cancer, but therapy confers a substantial risk of long-term complications, even with modern delivery techniques.

ORNJ is recognized as a potential risk of radiation therapy. Prospective and retrospective single-institution studies have suggested that 5% to 7% of patients with head and neck cancer develop ORNJ following treatment with radiation.
The frequency of ORNJ in the general population of patients with head and neck cancers has not been studied extensively. Moreover, the true impact of newer radiation techniques, such as intensity-modulated radiation therapy (IMRT), on the frequency of ORNJ has not been clearly established.

Big BP Variation Between Arms Raises Red Flag

A substantial difference in blood pressure from one arm to the other could be a warning sign for overall cardiovascular and mortality risk, a meta-analysis determined.

A systolic pressure difference of 15 mm Hg or more between the right and left arm was linked to a 70% elevated risk of death from cardiovascular causes (P=0.01), Christopher E. Clark, MSc, of the University of Exeter, U.K., and colleagues found.

That pressure differential also pointed to a 60% higher likelihood of dying from any cause (P=0.02), the group reported online in The Lancet.

The reason appeared to be the close correlation with peripheral vascular disease and cerebrovascular disease, for which a 15 mm Hg-difference had high specificity of 96% and 93%, respectively.

Such patients would likely benefit from further cardiovascular assessment and aggressive risk factor management as a high-risk group, Clark's group concluded.

Measuring both arms should become part of routine care, argued Richard J. McManus, MSc, MBBS, of the University of Oxford, U.K., and Jonathan Mant, MD, of the University of Cambridge, U.K., in an accompanying commentary.

Enjoy your morning!

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