Showing posts with label Dental. Show all posts
Showing posts with label Dental. Show all posts

Thursday, April 20, 2017

ILC 2017: Severe gum disease strongly predicts higher mortality in cirrhosis presented at The International Liver Congress™ 2017

ILC 2017: Severe gum disease strongly predicts higher mortality in cirrhosis 

Inflammatory gum disease was associated with higher mortality in patients with cirrhosis, with an even stronger association due to the complications of cirrhosis 

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April 20, 2017, Amsterdam, The Netherlands: Results presented today from a prospective study in patients with irreversible scarring of the liver (cirrhosis) demonstrates that severe periodontitis (an inflammatory gum disease) strongly predicts higher mortality in this population, after adjustments for various risk factors. The study was presented at The International Liver Congress™ 2017 in Amsterdam, The Netherlands.

In Europe, cirrhosis is responsible for 1-2% of all deaths and is the leading cause of liver transplantation.1,2 Periodontitis is a bacterially induced inflammatory disease that affects the supporting tissues of the teeth, characterised by the deepening of periodontal pockets due to loss of connective tissue attachment and bone. Untreated, periodontitis may result in tooth loss. Periodontitis is prevalent in the adult population, with over 35% having periodontitis and 10-15% having severe forms of the disease.3,4 Several studies have assessed the association between periodontitis and cardiovascular diseases, cirrhosis, chronic kidney disease, diabetes mellitus, and respiratory diseases, and an increasing number of studies have suggested that periodontitis may affect the course of systemic diseases.5 Poor oral health and periodontitis are very frequent in patients with cirrhosis.5 In addition, studies have suggested that periodontitis is involved in the progression of liver diseases, and that it has a negative impact on the clinical course after liver transplantation.6,7 

“Our study showed that severe periodontitis strongly predicted higher mortality in cirrhosis,” said Lea Ladegaard Grønkjaer, PhD, RN, Aarhus University Hospital, Denmark, and lead author of the study. “Periodontitis may act as a persistent source of oral bacterial translocation, causing inflammation and increasing cirrhosis complications. As it can be treated successfully, however, we hope that our findings motivate more trials on this subject.”

The study enrolled 184 consecutive patients with cirrhosis in whom oral health was assessed. Severe periodontitis was defined by standard periodontology criteria4 and patients were clinically followed-up for one year on average.

At study enrolment, 44% of patients had severe periodontitis. Nearly half of the included patients died during follow up. The association of periodontitis with mortality was adjusted for age, gender, cirrhosis etiology, Child-Pugh score, Model of End-Stage Liver Disease score, smoker status, present alcohol use, comorbidity, and nutritional risk score. The analyses demonstrated that severe periodontitis was associated with higher all-cause mortality. Mortality was mostly attributable to complications of cirrhosis.

“This study demonstrates the association between gum disease and risk of death in patients with liver disease – further studies are now required to determine if improving gum care can

improve outcomes in patients with liver cirrhosis,” said Prof Philip Newsome, Centre for Liver Research & Professor of Experimental Hepatology, University of Birmingham, United Kingdom, and EASL Governing Board Member. 

About The International Liver Congress™ This annual congress is the biggest event in the EASL calendar, attracting scientific and medical experts from around the world to learn about the latest in liver research. Attending specialists present, share, debate and conclude on the latest science and research in hepatology, working to enhance the treatment and management of liver disease in clinical practice. This year, the congress is expected to attract approximately 10,000 delegates from all corners of the globe. The International Liver Congress™ 2017 will take place from April 19 – 23, at the RAI Amsterdam, Amsterdam, The Netherlands.

About The European Association for the Study of the Liver (EASL) (www.easl.eu) Since its foundation in 1966, this not-for-profit organisation has grown to over 4,000 members from all over the world, including many of the leading hepatologists in Europe and beyond. EASL is the leading liver association in Europe, having evolved into a major European Association with international influence, with an impressive track record in promoting research in liver disease, supporting wider education and promoting changes in European liver policy.

Onsite location reference Session title: Late breaker poster session Time, date and location of session: 08:00 – 18:00, Thursday 20 April to Saturday 22 April, Hall 1 Presenter: Lea Ladegaard Grønkjaer, Denmark Abstract: Severe periodontitis predicts higher cirrhosis mortality (LBP-524)

Author disclosures None.  
References 1 EASL. The burden of liver disease in Europe. A review of epidemiological data. Available from: http://www.easl.eu/medias/EASLimg/Discover/EU/54ae845caec619f_file.pdf. Last accessed: April 2017. 2 European Liver Transplant Registry. Specific results by disease. Available from: http://www.eltr.org/Specific-results-by-disease.html. Last accessed: April 2017. 3 Eke PI, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. Journal of Dental Research. 2012;91:914-920. 4 Page, et al. Case definitions for use in population-based surveillance of periodontitis. Journal of Periodontology. 2007(Suppl.);78:1387-1399. 5 Grønkjaer LL. Periodontal disease and liver cirrhosis: A systematic review. SAGE Open Medicine. 2015;3:2050312115601122. 
6 Åberg F, et al. Association between dental infections and the clinical course of chronic liver disease. Hepatology Research. 2014;44:349-353. 7 Han P, et al. Interaction between periodontitis and liver diseases (review). Biomedical Reports. 2016;5:267–76.

Thursday, September 26, 2013

Hepatitis C - ADA Statement on Infection Control in Dental Settings

ADA Statement on Infection Control in Dental Settings

Written by Dentistry Today Thursday, 26 September 2013 07:51

CHICAGO, Sept. 19, 2013 – The American Dental Association (ADA) is deeply concerned about the first confirmed report of patient to patient transmission of hepatitis C in a dental practice setting linked to improper infection control practices. The ADA wishes to assure the public that patient health and safety are top priorities for the Association.

“This is a highly atypical and disconcerting case,” states ADA President Robert A. Faiella, D.M.D., M.M.Sc. “Every day, hundreds of thousands of dental procedures are performed safely and effectively thanks to the diligence of dentists who follow standard infection control precautions developed by the Centers for Disease Control.”

Dr. Faiella added, “While this is an isolated case, it understandably raises questions about infection control in the dental office. The ADA encourages people to talk with their dentists, who will be glad to explain or demonstrate their infection control procedures.”

The statement issued today is part of an interim status report from the Oklahoma State Department of Health and the Tulsa Health Department on the results of their joint investigation of the dental surgical practice with offices in Tulsa and Owasso. The oral surgeon involved in the case voluntarily surrendered his license to practice.

 The investigation began March 28 when public health officials notified the practice’s former patients that they may have been exposed to blood-borne viruses.

 An epidemiological investigation indicated that one case of transmission of the virus occurred in the dental practice. The transmission was described as “patient-to-patient” because improper infection control procedures caused the virus to be passed from one patient to another. Genetic-based testing of patient specimens by the Centers for Disease Control and Prevention (CDC) provided laboratory confirmation of the finding.

 The ADA has long recommended that all practicing dentists, dental team members and dental laboratories use standard precautions as described in the Centers for Disease Control and Prevention’s (CDC) Guidelines for Infection Control in Dental Health Care-Settings.
Standard precautions protect patients and health care workers by preventing the spread of disease. Examples of infection control in the dental office include the use of masks, gloves, surface disinfectants and sterilizing reusable dental devices.

 Before any patient enters the examining room, all surfaces, such as the dental chair, dental light, instrument tray, drawer handles and countertops, have been cleaned and decontaminated. Some offices may cover this equipment with protective covers, which are replaced after each patient.

Non-disposable items like dental instruments are cleaned and sterilized between patient appointments. Disposable dental instruments and needles are never re-used. Infection control precautions also require all dental staff involved in patient care to use appropriate protective garb such as gloves, masks, gowns and eyewear. After each patient, all disposable wear items, such as gloves, are discarded. Before seeing the next patient, the members of the treatment team cleanse their hands and put on new gloves.

 More information on infection control in dental offices is available online on the ADA consumer website Mouthhealthy.org.

Monday, April 1, 2013

Dental Treatment as a Risk Factor for Hepatitis B and C Viral Infection. A Review of the Recent Literature

Dental Treatment as a Risk Factor for Hepatitis B and C Viral Infection. A Review of the Recent Literature
 
download Full Article (PDF file)

Nima Mahboobi1, Stephen R Porter2, Peter Karayiannis3, Seyed-Moayed Alavian4


1) Department of Oral and Maxillofacial Surgery, Tehran University of Medical Sciences, Tehran, Iran
2) Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University College London, University of London, England
3) Department of Medicine, Imperial College, Variety Wing Floor D, St Mary's Campus, Norfolk Place, London, England
4) Baqiyatallah University of Medical Sciences, Research Center for Gastroenterology and Liver Disease, Tehran, Iran

Abstract

Background & Aim: Patients chronically infected either with hepatitis B (HBV) or hepatitis C virus (HCV) are at increased risk of developing cirrhosis, end stage liver disease and hepatocellular carcinoma. Different risk factors were found to be associated with the transmission of these viruses in various settings. HBV and HCV transmission seems to be also acquired by non-parenteral and non-sexual routes. A large number of patients infected with HCV might have non identifiable routes of viral acquisition. Hence, viral hepatitis transmission risk factors identification is the main way to reduce infection. Dental treatment may be one of such risk factors, and this aspect is addressed in the present literature review, drawing information from existing literature.

Methods:
An online database search was conducted, limited to publications from January 1999 to February 2012 on specific aspects of HBV and HCV infection, including articles on risk factors, markers of infection, dentistry, epidemiology and transmission. Relevant material was evaluated and reviewed.

Results:
Overall, 53 studies which met the selection criteria were evaluated. Although these studies were
from different geographical regions of varied socioeconomic status and study populations and assessed
different dental procedures, using different types of statistical analysis, we found that, although weak, there
is an all-time risk of HBV and HCV infection during dental treatment. This is more important in developing
countries where the rate of hepatitis infected individuals is higher. There is a need for more studies on this
subject, properly planned, controlled and analyzed.

Conclusion:
Dental treatment can be included among the risk factors of HBV and HCV infection. This risk can easily be eliminated using standard precautionary measures.

Key words:
hepatitis B virus (HBV) - hepatitis C virus (HCV) - dental treatment - risk factor - dentist
- review.

Tuesday, March 15, 2011

The Revolving Door Of Crucial VA Clinic Dental Outbreaks


The Revolving Door Of Crucial VA Clinic Dental Outbreaks
The past and current lack of "adherence to sterilization practices" or "inadequate practices" at VA dental centers continues to rise. This blog has put together a summary of the VA facilities involved. We begin with the 2009 to 2010 notification letters sent to 1,812 veterans who may have been exposed to hepatitis B, hepatitis C and HIV; when a breach in protocol instrument processing took place at the John Cochran Veterans Medical Center in St. Louis, MO. The Associated Press reported in March 2011 that most of the 1,812 veterans potentially exposed have been tested with no infections connected to the dental clinic.

A Lesson Ignored ?
Noted on The Department of Veterans Affairs' website, in 2010 during the Cochran exposure was this statement, "In the past 18 months, VA has implemented more stringent oversight for reusable medical equipment to ensure a safer environment for patient care". As of this July 2010 in a press release deemed; "Lessons learned from St. Louis VA Medical Center are applied VA-wide" came this VA statement; "Under the Obama Administration, in the past 18 months, VA has implemented more stringent oversight of the safety of all its medical facilities. It is this more rigorous standard that directly led VA to identify and address problems at the St. Louis Medical Center. Additional resources have been allocated and new procedures and stricter enforcements are in place to ensure the safety of all Veterans who seek care at VA facilities. VA mandates transparency and accountability in its handling of mistakes or failures to meet VA’s high standards. VA’s processes lead the nation in terms of transparency and accountability. “VA is committed to ensuring that all our health care facilities are safe,” said Shinseki “VA will continue to investigate the actions of individuals involved and the proper administrative and disciplinary measures will be taken.”
.
However, sadly enough, the Dayton VA medical center must have missed that memo. The VA system may need guidance with implementing a "working" standard infection control practice at all VA centers, void of any human errors or staff and physician negligence.

Dayton VA Medical Centers Recently the Dayton VA Medical Center "dental clinic" failed to use proper sanitary procedures. As a result 535 veterans were exposed to hepatitis B , hepatitis C and HIV. Veterans who visited the dental clinic between January 1, 1992 and July, 28 2010 may be at risk. According to the Veterans Administration nine patients who received dental care at the Dayton VA Medical Center have tested positive for Hepatitis B and Hepatitis C following preliminary testing.
In part the exposure stems from Dentist Dwight Pemberton who admitted to not washing his hands between patients. The 81 year old also failed to change his latex gloves between patients and dental procedures. VA officials have initiated actions against three employees, including dentist Dwight Pemberton, all of whom may have infected patients at the VA. However,VA officials said because of Pemberton's retirement on Feb. 11, he no longer faces administrative action by the clinic.
The media coverage on both VA medical Centers has been compiled below.

John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO and the Dayton, Ohio VA Medical Center
From OSAP;

What is OSAP?
Founded in 1984 and formally incorporated as a non-profit organization in 1985, OSAP is a unique group of dental educators and consultants, researchers, clinicians, industry representatives, and other interested persons with a collective mission to be the world’s leading advocate for the safe and infection-free delivery of oral care.

IC Compliance Breakdowns Hit The Press

DENTAL CLINIC INFECTION CONTROL PROBLEMS SERVE AS POTENT COMPLIANCE REMINDER

An apparent breach of standardized practice related to dental instrument reprocessing occurred at the John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO. The facility mailed notification letters to 1,812 veterans treated at the dental clinic between February 2009 and March 2010 stating their internal quality inspections determined that some instrument processing steps for dental instruments were not in compliance with their standard policies, creating a low risk of exposure to hepatitis B virus, hepatitis C virus and HIV. In a video interview, Dr. Gina Michael, a spokesperson for the VAMC, said that dental instruments were sterilized but the VA standardized sequence of instrument processing was not followed.

A CBSnews.com article on July 1 reported the VA Under Secretary for Health Dr. Robert Petzel saying that the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized allowing for a "phenomenally remote" chance that sterilization might not have been effective. The VA issued a press release on July 1 indicating that the lessons learned from the St. Louis VAMC are applied VA-wide.

In a related story at the Dayton VA Medical Center, an employee raised concerns about infection control practices at the dental clinic while an internal VA panel was reviewing clinic operations in late July. The allegations involved improper use of protective gear such as gloves, as well as the inappropriate use of burs. The VA closed the clinic for three weeks to investigate.

CDC Guidelines and FAQ on Sterilization-Cleaning
OSAP Charts
Comparing cleaning methods
How to clean dental instruments
20 steps to proper instrument processing

Related;
Mar 10, 2011
The Associated PressPosted : Thursday Mar 10, 2011 19:28:56 EST

ST. LOUIS — Surgeries have resumed at the Veterans Affairs hospital in St. Louis more than a month after a shutdown over sterilization concerns.
The John Cochran VA Medical Center suspended surgeries Feb. 2 after surgical trays were found to be pitted with corrosion. Procedures resumed Thursday.
Hospital director Rima Nelson says investigators who examined the sterilization processing department determined it was OK to start surgeries again. Nelson says they couldn’t determine a single source for the corrosion.
The sterilization concern was the second in less than a year at the Cochran center. Faulty sterilization at the center’s dental clinic last year raised concerns that 1,812 veterans were potentially exposed to hepatitis and HIV. Most of those veterans have been tested and no such infections have been connected to the dental clinic.

Feb 10, 2011
Surgeries still on hold at St. Louis VABy Jim Salter - The Associated Press
Posted : Thursday Feb 10, 2011 16:37:39 EST

ST. LOUIS — No timetable has been set for resuming surgeries at the Cochrane VA Medical Center in St. Louis, U.S. Rep. Russ Carnahan said Thursday following a meeting with the secretary of Veterans Affairs.

The St. Louis Democrat, a member of the House Committee on Veterans’ Affairs, said he asked Veterans Affairs Secretary Eric Shinseki for a top-to-bottom review of the St. Louis hospital.

“In my years in public service, this is one of the issues that has made me madder than anything I’ve ever seen,” Carnahan said in a telephone conference call with reporters.

Surgeries at Cochrane have been on hold since Feb. 2 after potentially contaminated surgical equipment was discovered. Last year, faulty sterilization at the center’s dental clinic raised concerns that 1,812 veterans were potentially exposed to hepatitis and HIV.

Shinseki, in a statement, called the meeting “productive,” and called the sterilization problem at Cochrane an “isolated incident.”

“We must not lose sight of the fact that a VA employee had the integrity and courage to identify the problem during a routine exam and notified supervisors,” Shinseki said. “This was the responsible and right decision to assure that no veterans were put at risk.”

Sterilization problems have arisen at other VA medical facilities across the country.

Officials at the Dayton, Ohio, VA Medical Center announced Tuesday that more than 500 veterans will be offered HIV screenings to determine if they were infected by a dentist who for 18 years failed to consistently follow the infection control standard of changing latex gloves between patients. Officials said there was no indication any patients had been infected.

In 2009, the VA said 10,000 veterans treated at its hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga., were potentially exposed to HIV and hepatitis, also because of faulty sterilization of equipment used for colonoscopies and other procedures.

Carnahan said mediocrity “thrives” at the St. Louis hospital.

“That’s not good enough for our veterans,” Carnahan said. “It’s not what they deserve.”

A private sector watchdog group called The Joint Commission was inspecting the hospital Thursday.

The VA said surgeries scheduled for Cochrane have been moved to other St. Louis hospitals, with the VA paying the cost.

All but a few dozen of the veterans treated with improperly sterilized equipment in the St. Louis dental clinic have been tested or refused testing. Three veterans tested positive for hepatitis, but officials don’t know how they were infected and none of the cases have been tied to the sterilization problems. A fourth also tested positive for hepatitis, but the VA said that person’s infection occurred from another source.

John Cochran Veterans Administration Medical Center (VAMC) in St. Louis, MO
June 29, 2010
By: Mike Owens
St. Louis -- A failure in cleaning dental instruments properly at the John Cochran Veterans Administration Hospital on Grand may have but 1,812 dental clinic patients at risk. The patients started getting certified letters Tuesday, advising them they may have been exposed to viruses: hepatitis and HIV.
July 2, 2010
ST. LOUIS (AP) — The chief of dental services at the St. Louis VA Medical Center is defending his staff and says he welcomes a Veterans Affairs inquiry into a mistake that might have exposed nearly 2,000 veterans to viruses. The VA said yesterday it was placing the dental chief on administrative leave while it investigates the sterilization procedure mistake. The VA said the risk of exposure is very minimal.
Still, the agency on Monday sent letters to 1,812 veterans who had dental procedures at the St. Louis facility from Feb. 1, 2009, through March 11 of this year, when the problem was uncovered.The VA is offering free tests to screen for hepatitis B, hepatitis C and HIV. Nearly 200 people had signed up for, or already had, testing. No illnesses have been found.The VA didn’t name the dental chief, but Danny Turner came forward to the St. Louis Post-Dispatch.
Turner told the newspaper in today’s edition that he stands behind his staff and that he blames politics for distorting the situation. “I have a lot of information that proves we were doing things correctly,” Turner said.
The VA warning prompted an outcry from politicians from both Missouri and Illinois — the five VA centers in the St. Louis area serve veterans from both states. “Things are done to get votes, and that’s a shame,” Turner, 63, said.Turner denied a claim made by a former employee that she saw dental instruments with dried blood even after they had gone through the cleaning process. “Our dental instruments are never that way,” he said. “I don’t know what she was talking about.”VA Undersecretary for Health Robert Petzel said yesterday the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized. He said that allowed for a “phenomenally remote” chance that sterilization might not have been effective.

Dayton VA Medical Center
March 15, 2011
Employees’ fear may have put vets’ health at risk
By Ben Sutherly,
Staff Writer Updated 10:10 AM Tuesday,
March 15, 2011

DAYTON — A culture of fear may have kept workers and supervisors at the Dayton VA Medical Center’s dental clinic from disclosing the unsafe practices of one dentist over 18 years, a congressman said Monday.

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, said the clinic is compact and open, so employees’ activities can be easily viewed by their coworkers.
Miller is concerned there may be a widespread culture at the VA in which employees are afraid to speak up when they see issues that affect patients’ health and safety. Dental clinic employees and supervisors had known of the dentist’s infection control lapses for several years, but it wasn’t until July 2010 that two employees reported the problem to an outside VA panel, triggering an investigation.

“For very few people to have stepped forward is troubling to me,” said Miller, who toured the facility Monday with U.S. Rep. Mike Turner, R-Centerville.
Continue Reading........

March 11, 2011
New VA hospital director an award-winning administrator
By Tom Beyerlein
, Staff Writer Updated 11:00 PM Friday, March 11, 2011
DAYTON — Department of Veterans Affairs officials on Friday said they coaxed an award-winning hospital administer out of retirement to help the Dayton VA Medical Center recover from the scandal surrounding a dentist’s unsanitary practices that may have led to hepatitis infections of nine dental clinic patients.
William Montague, who headed six VA hospitals including the Louis Stokes VA Medical Center in Cleveland, becomes the Dayton VA’s acting director Monday, replacing Director Guy Richardson, who was reassigned to a job at regional headquarters in Cincinnati.

Contact this reporter at (937) 225-7457 or bsutherly@Dayton
DailyNews.com.

March 2, 2011
9 Dayton Veterans Test Positive For Hepatitis
Updated: 4:44 pm EST March 2, 2011
DAYTON, Ohio --
The Veterans Administration said Wednesday that at least nine patients who received dental care at the Dayton VA Medical Center tested positive for Hepatitis B and Hepatitis C following preliminary testing.
The Dayton VA has contacted 527 of 535 veterans seen by a dentist who failed to use proper sanitary procedures at the dental clinic.
The dentist, Dwight M. Pemberton, is accused of failing to change his latex gloves and sterilize instruments between patients.
Officials said of 375 patients tested so far, there have been seven Hepatitis C cases, two Hepatitis B cases and no cases of HIV.

February 26, 2011
Dayton VAMC Dentist Under Investigation Named
February 26, 2011 by Robert L. Hanafin ·
In early February Veterans Today (VT) reported that the Dayton VA Medical Center in Ohio was notifying Veterans who may have been exposed to Hepatitis or HIV/AIDS. Veteran’s activist Darrell Hampton has been a thorn in the side of Dayton VAMC management long before this investigation began, and he has worked closely with investigative reporters ...

November 23 , 2010
Another U.S. Department of Veterans Affairs' (VA) dental clinic has come under scrutiny for possible infection control issues.
The Dayton VA Medical Center's dental clinic in Ohio was temporarily closed from August 19 to September 10 after employees raised concerns about infection control practices during an internal VA panel review of clinic operations in July, according to Todd Sledge, a spokesman for the VA Healthcare System of Ohio. It was reopened September 19 after the staff was updated regarding infection control requirements.
"With the volume of work that goes through the Dayton clinic, we wanted to make sure the concerns were thoroughly investigated to determine if there was any basis to them and if they were accurate," Sledge told DrBicuspid.com.

For more information visit the VA Watchdog.com
In late 2008 and early 2009, the VA was plagued by a rash of reports about contaminated endoscopic equipment, including devices used to perform the colonoscopy procedure.
In some cases, the VA felt there may have been a risk of infection, so they notified veterans who had specific procedures performed at some VA facilities to be tested for possible exposure to HIV, and hepatitis B and C.
Because of variations in equipment cleaning procedures and variations in VA's self-reporting guidelines on how the equipment was cleaned, questions were raised about a possible nationwide problem with contaminated equipment.
On this page, we are posting all of the articles about VA's contaminated equipment. We will add more information is at becomes available... and, we will go back and research any earlier incidents of contamination and post that information as well.

Support For Veterans
READ ME to learn about what's on the site and how to use it to develop your claim. You'll find the required small print and a few other details here. The address and instructions on how to contact your Department of Veterans Affairs Central Office is here.

Veterans Support Foundation is a 501 (c) (3) Nonprofit humanitarian and educational organization founded to improve the quality of life for deserving veterans and their families. The Foundation's office is located in Silver Spring, Maryland.

The VSO operates Veterans' Support Organization chapters that serve our nation's veterans across the United States, from Texas to Florida and north to Maine.

HCV Vets Forum
Welcome to HCVets.com Forum
A Message Board for People with Past/Present Military Backgrounds & Hepatitis C.

About Me

Winter Springs, Florida, United States
Wife of Vietnam veteran. Over 25 years of veterans outreach focusing on Post Traumatic Stress Disorder. Author For the Love of Jack, DAV Chapter 16 Auxiliary Chaplain, PTSD Consultant, Staff Writer Veterans Today. Editor and Publisher of Wounded Times. Also see website at http://www.namguardianangel.com/ . Student at Valencia Community College, Digital Media and Post Production.

Wednesday, September 29, 2010

Dental problems delaying the initiation of interferon

Dental problems delaying the initiation of interferon therapy for
HCV-infected patients


Yumiko Nagao1§and Michio Sata1,2*1Department of Digestive Disease Information & Research, Kurume University School ofMedicine, Kurume, Fukuoka, 830-0011, Japan2Division of Gastroenterology, Department of Medicine, Kurume University School ofMedicine, Kurume, Fukuoka, 830-0011, Japan*contributed equally to this work§Correspondence authorEmail addresses:Nagao Y: nagao@med.kurume-u.ac.jp
Sata M: msata@med.kurume-u.ac.jp

Abstract
There has been little discussion about the importance of oral management and interferon (IFN) therapy, although management of the side effects of therapy for chronic hepatitis C has been documented. This study determined whether dental problems delayed the initiation of IFN therapy for hepatitis C virus (HCV)-infected patients.

Results
We analyzed 570 HCV-infected patients who were admitted to our hospital from December
2003 to June 2010 for treatment consisting of pegylated IFN (Peg-IFN) monotherapy or
Peg-IFN/ribavirin combination therapy. The group comprised 274 men and 296 women with
a mean age 57.2 years. Of the 570 patients, six could not commence Peg-IFN therapy,
despite their admission, because of dental problems such as periodontitis, pupitis, and
pericoronitis. The ages of six whose dental problems delayed the initiation of Peg-IFN
ranged from 25 to 67 years, with a mean age of 47.3 ± 15.2 years. IFN therapy was deferred
for 61.3 ± 47.7 days. Among the six subjects for whom IFN treatment was delayed, only one
had a salivary flow that was lower than the normal value.


Conclusions
Treatment of dental infections is required before IFN therapy for HCV infection can be started. To increase the depth of understanding of oral health care, it is hoped that dentists and medical specialists in all areas will hold discussions to generate cooperation.

Abbreviations
HCV, hepatitis C virus; HCC, hepatocellular carcinoma; IFN, interferon; Peg-IFN, pegylated
IFN; SVR, sustained virological response; TR, transient response; NR, non-responder


Background
In Japan, hepatocellular carcinoma (HCC) is the fourth leading cause of death in males and the
sixth in females according to a recent survey. The incidence of HCC has increased in Japan
throughout the past several decades [1]. Hepatitis C virus (HCV) is the major cause of HCC
in Japan, with 70% of cases being HCV-related. It is assumed that between one and two
million Japanese people are chronically infected with HCV [1].

Interferon (IFN) therapy for chronic hepatitis C is the only treatment for completely eliminating
the virus. Combination therapy with pegylated IFN (Peg-IFN) and ribavirin has been
recommended widely as the first choice for chronic hepatitis C patients with high viral loads.
The sustained virological response (SVR) rate after 48 weeks of treatment at a standard dose is
approximately 40 to 50% [2-5]. It has been shown that IFN therapy decreases the rate of
development of HCC and improves the long-term prognosis [6-9].

Although IFN therapy has therapeutic benefits, the treatment produces a number of
well-described side effects that are dominated by fatigue, influenza-like syndrome and
neuropsychiatric symptoms [2-5, 10-12] and management of such side effects is required during therapy. Among the side effects in a Japanese Phase III trial of Peg-IFN alfa-2a / alfa-2b and
ribavirin, dental problems have been documented in patients with chronic hepatitis C.

Meanwhile, it has been reported that hepatitis C infected patients have significant oral health
needs [13-16] and that experience of dental caries is significantly worse for HCV-infected
patients than patients in general [13].

Therefore, in the present study, we determined whether dental problems delayed the initiation of IFN therapy for HCV-infected patients.
Methods

Patients
A total of 570 HCV-infected patients who admitted to the Kurume University Hospital from
December 2003 to June 2010 for treatment with Peg-IFN monotherapy or Peg-IFN/ribavirin
combination therapy were studied (Table 1).
The 570 patients were 274 men and 296 women with a mean age of 57.2 ± 11.6 years. They were consulted by one oral surgeon for each patient about presence of oral infection before commencing IFN treatment.
All HCV-infected patients treated with IFN therapy at our hospital were required to undergo hospitalization for two weeks for therapeutic management and education about liver diseases.
We determined whether dental problems delayed the initiation of IFN therapy for these patients.

Patients who underwent Peg-IFN therapy during dental treatment were excluded. Informed
consent was obtained from all patients after the purpose and methods of the study were
explained.

Salivary flow
We used a simple and low-cost test for xerostomia detection, which requires chewing on a piece
of gauze for 2 min. The results from 531 of 570 patients were quantified using the Saxon test.
A salivary flow rate ≤ 2g / 2min was judged as decreased salivary secretion.

Serological assays
Serum samples were examined for the presence or absence of markers of HCV and HBV
infection. The HCV RNA level before IFN therapy was analyzed by quantitative PCR assay
(COBAS AMPLICOR HCV MONITOR v 2.0 Test, COBAS AmpliPrep/COBAS TaqMan HCV
Test, Roche Molecular Systems, New Jersey, US) [17, 18]. HCV genotype was determined by
polymerase chain reaction assay, using a mixture of primers for the subtype, as reported
previously [19].

Therapeutic response was judged after IFN therapy as: SVR - normalization of alanine
aminotranferase (ALT) levels and HCV RNA negative for six months or more after treatment;
transient response (TR) - normalization of ALT levels and undetectable HCV RNA during IFN
treatment but HCV RNA-positive after IFN treatment; non-responder (NR) - neither normal nor negative results for six months or more.

As shown in Table 1, chronic hepatitis C with HCV genotype 1b was the most common.
Patients with genotypes 2a/2b underwent Peg-IFN monotherapy and those with genotypes
1a/1b, a combination of Peg-IFN and ribavirn.


Results

Dental problems delayed the initiation of IFN therapy

Of 570 patients with HCV-related liver diseases, we documented six whose dental problems
delayed the initiation of Peg-IFN therapy. Their ages ranged from 25 to 67 years, with a mean
age of 47.3 ± 15.2 years.
There were two men and four women (Table 2).
These six patients could not commence IFN therapy, despite their admission for this treatment, and their therapy was deferred for 61.3 ± 47.7 days.
Patient no. 1 had an acute odontogenic periostitis, resulting from periapical inflammation of endodontic origin. This was treated successfully by nonsurgical endodontics and administration of antibiotics.
Patient no. 2 had an acute alveolar abscess, resulting from periodontal disease. His four molars were extracted after local anti-inflammation treatment.
Patient no. 3 had a periapical periodontitis of the right mandibular second molar. The molar was extracted.
Patient no. 4 had multiple dental problems with pain. After extirpation of dental pulps and extraction of teeth, she received IFN treatment.
Patient no. 5 had apical periodontitis with gingival abscess, consequently her teeth
were endodontically treated.
Patient no. 6 had trismus and painful swallowing caused by pericoronitis of her wisdom tooth and she had a high white blood cell count of 10,200/mm3 on the day of admission.

All six patients received IFN treatment after their dental treatment was
completed. Nobody suffered from diabetes mellitus. The outcome of the patients was
classified into three groups: SVR (n=4), TR (n=1), and NR (n=1).

Salivary flow
The level of total saliva production, measured using the Saxon test, was 4.26 ± 1.91 g/2 min.
The salivary flow rate was below the normal value in 54 patients (10.2%). Among the six
subjects for whom IFN treatment was delayed, only one had a salivary flow that was lower than
the normal value.

Discussion
The results indicate that oral health care may be required before HCV-infected patients undergo
IFN therapy. In our study, dental problems delayed the initiation of IFN therapy for a
maximum of 105 days. HCV-infected patients treated with IFN therapy should be managed by
intensive oral care because of lower resistance to infection during the therapy.

Poor of oral health has been reported for HCV-infected patients [13-16]. Coates et al. reported
that the dental caries experience of HCV-infected subjects was significantly worse than that of
patients in general, that the number of teeth missing from patients with hepatitis C infection also was significantly higher than for patients in general, and that periodontal health tended to be
poor [13].

Griffin et al. found that patients with rheumatoid arthritis, diabetes or a liver
condition were twice as likely to have an urgent need for dental treatment as patients who did not have these diseases and documented a high burden of unmet dental care needs among patients with chronic diseases [16]. The authors showed that HCV was the strongest predictor of patients reporting poor oral health.
Japanese HCV-infected patients tend to be older than those in other countries and their older age favors the onset of HCC, leading to an increased mortality rate [1]. Peg-IFN-ribavirin
combination therapy is the standard treatment for chronic hepatitis C.
Meanwhile, the frequency of adverse events in combination therapy is relatively high (20-64%) .

In a Japanese Phase III trial of Peg-IFN alfa-2a and ribavirin involving 199 patients with chronic hepatitis C, including 99 patients with IFN treatment-naive genotype 1 and 100 patients with patients whom had not had a SVR after IFN therapy,

The oral side effects were:

gingival bleeding and gingival swelling (6%),
toothache (4.5%),
gingivitis and periodontitis
(3%), dental
caries (1.5%),
stomatitis and cheilitis (19.1%),
disorder of taste (15.6%), dry mouth (6.5%),
glossalgia and glossitis (4.5%),
perioral paresthesia (2.5%), oral pain (0.5%), oral mucosal
damage (0.5%), oral lichen planus (0.5%),
oral hemorrhage (0.5%), dry lip (0.5%), and bulla of lip (0.5%).

On the other hand, in a Japanese Phase III trial of Peg-IFN alfa-2b and ribavirin
involving 332 chronic hepatitis C patients, including 269 patients for 48 weeks treatment duration with genotype 1b and high virus load, and 63 patients for 24 weeks treatment duration with others,

Oral side effect were:
dental pulpitis, gingivitis, and periodontitis (8.9%),
toothache (7.1%), dental abnormity (1.1%),
stomatitis and cheilitis (26.8%),
disorder of taste (26.8%),
dry mouth (15.6%), glossitis (5.9%), oral discomfort feeling (2.6%),
oral hemorrhage (0.4%), oral pain (0.4%), dry tongue (0.4%),
decreased secretion of saliva (0.4%).

These findings indicate that dental management of HCV-infected patients is required before
IFN therapy. However, in Japan the importance of oral health is often overlooked in
HCV-infected patients and has not been discussed in detail up to now.

Several studies have shown an association between HCV and sicca symptoms [20, 21].
Patients with chronic HCV infection also have been reported to be at a greater risk of
developing insulin resistance [22, 23]. Severe periodontal disease causes insulin resistance
[24]. The reasons that HCV-infected individuals had problems such as dental caries and oral
health care may include a decreased salivary flow rate, elicitation of periodontal disease by
insulin resistance and difficulties for radical dental treatment of patients with liver disease who
may have problems such as prolonged bleeding.

Henderson et al. reported HCV-infected cases and suggested the possibility of occasional
discrimination by practitioners. They concluded that more effective oral health education is
required for HCV-infected patients and dental practitioners [15].

We distributed a questionnaire to 209 patients who visited our hospital for liver disease treatment to determine whether patients with HCV or hepatitis B virus (HBV) disclosed their disease status to the personnel in dental clinics. We found that 59.8% always did so, 12.0% sometimes did so and 28.2% never did so.

The main reason for nondisclosure was failure of dental healthcare
workers to ask whether patients had systemic disease. Other reasons included fear of negative
reactions from healthcare workers and not wanting dentists or staff to know their specific liver
ailment [25]. To increase the depth of understanding of oral health care, it is hoped that
dentists and medical specialists in all areas will hold discussions to create cooperation.

Conclusions
In conclusion, the results of this study show that the treatment of dental infection is required
before IFN therapy for HCV infection. On the basis of our results, we introduced systems in
our hospital from November 2009 to ensure complete dental treatment before IFN therapy.
We should enhance mutual understanding of various issues related to HCV-infected persons
between the patient and the physician.
Also See: HCV: Dry Mouth and Sjögren’s
Dental Management of the Organ Transplant Patient


Competing interests
The authors declare that they have no competing interests.

Authors' contributions
YN carried out most of the data collection and drafted the manuscript. MS contributed to data
analysis. All authors read and approved the final manuscript.

Acknowledgements
This study was supported in part by a Grant-in-Aid for Scientific Research (C) (No. 22592354)
from the Ministry of Education, Culture, Sports, Science and Technology of Japan, and was
supported in part by Health and Labour Sciences Research Grants for Research on Hepatitis
from the Ministry of Health, Labour and Welfare of Japan.

See All Contributions/Authors PDF

ISSN 1743-422X
Article type Research
Submission date 22 July 2010
Acceptance date 17 August 2010
Publication date 17 August 2010

Article URL http://www.virologyj.com/content/7/1/192
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