July 01, 2008

Dear Doctor,

The bondage of trust and belief coming straight from your heart has alwaysbeen the spiritual inspiration for our Medical Newsletter. Over the years wehave created this wonderful friendship, by sharing the knowledge of medicalscience as well as promoting good health care in the community. So often, wesuffer from several oral disorders not knowing what to do and where to go.Attending such oral emergencies can be a difficulty as traditionally oral anddental care has always been apart from general medicine. That is why we havediscussed some conditions of oral and dental health in this issue under thebanner of ‘Orodental Problems’ which may help the physicians in general practiceto handle some emergencies before referring to an expert.

Human brain and its activity remained a medical mystery for thousands of yearsand still continue to puzzle us with its distinctive behavior. Seizure is such acondition that puts the physicians into challenging situation raising questionsabout how to manage the first ever seizure occurring in a previously healthyperson. We have discussed this through 'The First Seizure and Its Management' sothat this may provide some help in successful management of seizure. The thirdand last topic of our trio-series highlights the recent technologicaladvancements of diagnosing vascular complications. By giving a basicintroduction of these procedures through the 'Non-invasive methods of Arterial andVenous Assessment' we hope to provide some ideas about how these technologieshelp us in detection and treatment of vascular diseases.

'Days to Remember' is one of our unique ways of celebrating the special eventson medical and health issues happening all over the world. This time we haveenlightened the importance of giving blood for human life by celebrating 'WorldBlood Donor Day', as well as the major ongoing worries about existence ofhumankind on 'The World Environment Day'. ‘Environment Alert’ gives us a view ofwhat we are doing to our Mother Earth through the pictures taken fromdifferent parts of the world as these are the witness of the horrifying humanactivity progressively making the environment hostile for living. By observingthese pictures, we should realize and also make others realize that it is high timefor us to take an oath of acting responsibly to save our habitat. 'News fromInternet' as usual has provided some useful researches on medical science.

Thank you all for helping us create this bond of trust and friendship and onceagain we wish your kind co-operation for making our Medical Newsletter asuccessful contribution towards a healthy society.

With regards,

Prof. Farida HuqMBBS, M.Phil, FCPS, Ph.D.(London)Medical DirectorBeximco Pharmaceuticals Ltd.

Dr. Selina AkhtarSenior ManagerMedical DepartmentBeximco Pharmaceuticals Ltd.

3

ORODENTAL PROBLEMS

While the eyes may be the window to the soul,mouth is a window to the body's health. Thestate of oral health can offer lots of clues

about the overall health of human being. Very oftenthe first sign of a disease shows up in mouth. Oralhealth is essential to general health and well-being atevery stage of life. Every year, oral diseases rangingfrom cavities to cancer, cause pain and disability formillions all over the world. Moreover, there isdefinitive research which shows the connectionbetween poor oral health and certain systemicdiseases. But most of the oral diseases are preventable.This emphasizes the necessity of understanding theoral diseases, what they are, how to recognize themand most importantly how to prevent such diseaseconditions. This article highlights about some of thecommon orodental problems.

Oral Health and Certain Disease and BodyConditions

The mouth is normally packed with certain bacteriabut these can be kept under control with good oralhygiene. When the gums are healthy, bacteria usuallydo not enter the bloodstream. Unhealthy or diseasedgums may provide bacteria a port of entry towardsbloodstream which ultimately results in infecting thegums. Also there are some major health conditionswhich may be linked with oral health.

Cardiovascular diseases: Some primary researchshows that several types of cardiovascular diseasemay be linked to oral health. These include heartdisease, clogged arteries, stroke and bacterialendocarditis as the bacteria entered through theinfected gum into the bloodstream may travel all theway to arteries in the heart. But more studies areneeded to confirm this with certainty.

Pregnancy and birth: The organisms causing oraldiseases in pregnant woman can wind up in theplacenta or amniotic fluid, possibly causing prematurebirth. Unfortunately treating periodontal diseaseduring pregnancy may be too late because theinfection may have already spread in the mother'sbody. This is one of many reasons that make it vital tomaintain excellent oral health before conceiving.

Diabetes: Diabetes increases the risk of gum disease,cavities, tooth loss, dry mouth, and a variety of oralinfections. Conversely, poor oral health can makediabetes more difficult to control. Infections may raisethe blood sugar level and increases the insulinrequirement to bring it under control.

HIV/AIDS: One of the first signs of AIDS sometimesappears in mouth presenting with severe guminfection. Also persistent white spots or unusuallesions over tongue or mouth may develop as a signfor suspecting HIV infection.

Osteoporosis: The first stage of bone loss may appearin teeth. Dental experts are able to spot this on routinedental X-rays. Early detection may lead to earlyconsultation with physicians as well as early diagnosisand treatment, ultimately preventing further bone loss.

Common Dental Problems

Most oral emergencies relate to pain, bleeding ororofacial trauma which should be attended by dentalpractitioners. However, absence of accessibility todental care is seen everywhere around the worldparticularly in developing and underdevelopedregions where facilities like dental care are randomlyignored. With limited number of physicians let alonespecialized physicians, the general medicalpractitioners are usually expected to provide somehelp for combating these diseases.

Dental caries or Sequelae: Caries and inflammatoryperiodontal disease are the most prevalent oraldiseases, both a result of the activity of dentalbacterial plaque. The main causative organism isStreptococcus mutans. Fermentation of sucrose andother non-milk extrinsic sugars by plaque bacteria arethe main cause of tooth decalcification and decay.Most dental pain occurs as a result of caries. Initially,caries presents as a painless white spot which isfollowed by cavitations and the appearance of

Oral Health and Disease

4

ORODENTAL PROBLEMS

brownish discoloration. Once caries reaches thedentine, pain may result from thermal stimulation orfrom sweet or sour food and beverages. Untreatedcaries can progress through the dentine to the pulp,which becomes inflamed producing severe persistentpain or toothache. The pulp then eventually undergoesnecrosis, abscess formation, granuloma, or cyst.

Tooth erosion and tooth wear: Tooth erosion is anincreasing problem from consumption of carbonatedand fruit drinks and occasionally from gastricregurgitation or repeated vomiting (as in bulimia,alcoholism, and gastro-esophageal reflux). Usually itresults in little more than a loss of normal enamelcontour, but in severe cases dentine or pulp may bedamaged.

Early loss of teeth: Early tooth loss is usually becauseof extraction as a result of dental caries or, in adults,periodontal disease. Teeth, particularly incisors, mayalso be lost through trauma, such as from sports,assaults, or other injuries. Unexplained early toothloss in children or adults may be feature of Down'ssyndrome, diabetes, immune defects, or non-accidental injury, or of rare conditions such aseosinophilic granuloma, hypophosphatasia, orpalmoplantar hyperkeratosis.

Dental Emergencies

Dental pain: Pulpal pain is spontaneous, strong, oftenthrobbing, and exacerbated by temperature andoutlasts the evoking stimulus. Localization is poor,and pain tends to radiate to the ipsilateral ear, temple,or check. The pain may abate impulsively, but thepatient should still seek for dental advice, as the pulphas probably been necrosed resulting in acuteperiapical periodontics. Some may require toothextraction. Periapical periodontitis pain isspontaneous and severe, persists for hours, is welllocalized, and is exacerbated by biting.

The adjacent gum is often tender on palpation. Anabscess (gumboil) may form sometimes with facialswelling, fever and illness. In absence of immediatedental attention, treatment includes incision of afluctuant abscess and giving antimicrobials likeamoxicillin and appropriate analgesics. The acutesituation is usually resolved, but the abscess willrecur, since the necrotic pulp will become re-infectedunless the tooth is endodontically treated or extracted,though a chronic abscess may be asymptomatic apartfrom a discharging sinus. But rarely this may open onto the skin.

Bleeding: Most oral bleeding results from gingivitis ortrauma. After a tooth is extracted, the socket bleedsnormally for a few minutes but then clots. Since clotsare easily disturbed, patients should be advised not torinse their mouth, disturb the clot, chew hard, take hotdrinks or alcohol, or exercise for the next 24 hours. Ifthe socket continues to bleed gauze pad across the

Trauma:• Middle facial third fractures• Mandibular fractures unless simple or

undisplaced• Zygomatic fractures where there is danger of

ocular damage

Inflammatory lesions and infections:• Cervical or facial fascial space infection• Oral infections where patient is toxic or

severely immunocompromised• Tuberculosis• Severe viral infections• Severe vesiculobullous disorders (pemphigus,

Setevens-Johnson syndrome, toxic epidermalnecrolysis)

Blood Loss:• Severe or persistent hemorrhage (particularly

in patients with bleeding tendency)

Others:• Diabetes with poor control

A. Desquamative gingivitis B. Oroantral fistula after extraction of an upper molar C. Gingival pigmentationD. Chronic dental abscess (gumboil)

A B

C D

Dental Indications for Urgent Admission to Hospital

5

ORODENTAL PROBLEMS

socket is to be placed and the patient is asked to biteon it for 15-30 minutes. If still the bleeding continuesthen surgical intervention or hemostatic agent in thesocket is required. Ultimately if not stopped, then thesocket is sutured and lastly a bleeding tendency isconsidered.

Post-surgical hazards: Some pain and swelling aftertooth extraction is common but they also ease overafter few hours. Paracetamol usually providesadequate analgesia. Failure in suppressing the painmay require further investigations to excludepathology like dry socket or jaw fracture.

Dry socket or localized osteitis occasionally followsan extraction typically a lower molar extraction. Aftertwo to four days there is increasing pain, halitosis,unpleasant taste, an empty socket and tenderness.Retained roots, foreign body, jaw fracture,osteomyelitis or other pathology, especially if there isfever, intense pain, or neurological signs (such aslabial anesthesia) should be excluded before comingto any conclusive result. Irrigating with warm saline(500C) or aqueous chlorhexidine, dressing the socketand giving analgesics and antimicrobials(metronidazole) are among effective measures.Actinomycosis is a rare and late complication usuallypresenting with a chronic purplish swelling. Suchcondition may require a three week course ofpenicillin. Antral complications include loss of toothor root into the antrum and oroantral fistula. Thisrequires further treatment.

Fractured teeth: Injuries to the primary teeth may beof little consequence with regard to emergency care,

but even seemingly mild injuries can damage thepermanent successors. Above 30% of childrendamage their permanent teeth by the age of 15.Enamel fracture needs no emergency care, but dentalattention should be sought later. More severe injuriesaffecting the dentine should be treated as urgent asthere is chance of getting pulpal infection. Emergencycare consists of placing a suitable dentine liningmaterial on to the fractured dentine, and so prompttreatment is necessary. Fractured roots requirespecialized advice.

Avulsed teeth: Avulsed permanent anterior teeth canbe replanted successfully in children below 16 yearsparticularly if the root apex is not completely formed.But avulsed primary teeth should not be replanted.The younger the child and the sooner the replantation-the better the chance of success. Teeth replantedwithin 15 minutes stand a 98% chance of beingretained after further dental attention. The avulsedtooth should be hold by the crown and not by the rootas this may damage the periodontal ligament. If thetooth is contaminated then it should be rinsed withsterile saline. If the socket contains a clot, then itshould be removed with saline irrigation.

The tooth should be replanted with the right wayround ensuring the labial surface facing forward andmanual compression of the socket. Immobilization orsplint of the tooth for 7-10 days, with no biting onsplinted teeth, soft diet, and good oral hygiene isrequired. Special dental advice within 72 hours isnecessary. Root resorption, ankylosis, and toothsubmergence (infraocclusion) are among potentialcomplications. If immediate replantation is notpossible then the tooth should be placed in an isotonicfluid (cool fresh pasteurized or long life milk, saline,or contact lens fluid).

Dislocation or subluxation of mandible: This iscommonly caused by a blow to the chin when the jawis open. The condyles are dislocated forwards andupwards anterior to the eminence, and the patient gagsopen. Fractures must be excluded first. Reduction canusually be achieved by facing the patient and placingthe thumb pads over the lower molars and applyingdownwards pressure and simultaneously, with thefingers under the chin, rotating the jaw backwards andupwards. If muscle spasm prevents reduction thenintravenous midazolam may be required. Afterreduction, wide opening of the jaw should be avoided.

Jaw fractures: These mainly result from high velocityimpact as in road traffic accidents, other accidents,

A. Orofacial swelling in an acute dental abscessB. Dental sinus opening on to skinC. ActinomycosisD. Oral and dental trauma after skateboarding accident

A B

C D

6

ORODENTAL PROBLEMS

and assaults. The immediate concern is to preserve theairway. Other immediate life threatening problemsinclude intracranial hemorrhage, severe hemorrhagefrom other sites, and cervical spine damage. The headshould be inspected for lacerations and leakage ofcerebrospinal fluid. Diagnosis of fracture is done fromthe history, pain, swelling, bruising or hematoma,bleeding (usually intraorally), mobility of fragmentsand crepitus, deranged occlusion, paresthesia oranesthesia of involved nerves, and radiographic signs.

Mandibular fractures: These are commonly owing toassault and are usually simple and not associated withserious other injuries or bleeding. If the symphysis iscomminuted the tongue could fall back and obstructthe airway which must be prevented. Most of thesefractures are managed by open reduction and internalfixation, usually with mini-plates.

Middle third or upper facial skeleton fractures: Thesecommonly arise from severe trauma particularly roadtraffic accidents. There may be airway obstruction,head injury, chest injuries, ruptured viscera, andfractured spine and long bones. Most middle thirdfractures are treated by open reduction and internalfixation with mini-plates.

Zygomatic (malar) fractures: These typically resultsfrom assaults. Orbital features are common andinclude depression of cheek, lateral subconjunctivalhemorrhage, rim stem deformities, restricted eyemovements, changes in visual acuity, variation inpupil size and reactivity, and occasionallyenophthalmos and exophthalmos.

Prevention of Common Dental Problems

Diet and lifestyle: Sugars, particularly non-milksugars in items other than fresh fruits and vegetables,are the major dietary causes of caries. Frequency ofintake is more important than the amount. Dietary

advice should start with recommending appropriateinfant feeding and weaning practice. Weaning foodsshould be free of or very low in sugars. For olderchildren and adults, snack foods and frequentconsumption of carbonated and cola type drinksshould be discouraged. Saliva buffers may counterplaque acids, and thus chewing sugar-free gum orcheese after meals may be of value. Fresh fruit andvegetables can also confer some protection againstoral cancer.

Fluorides: Fluorides protect against caries byinhibiting mineral loss, promoting remineralization ofdecalcified enamel, and reducing formation of plaqueacids. Water fluoridation has consistently been shownto be the most effective, safe, and equitable means ofpreventing caries and can reduce the prevalence ofcaries by about half. Where the water supply containsless than 700 μgm/l of fluoride, children aged over 6months (who are at high risk of caries) may be givendaily fluoride supplements as drops or tablets.

Oral hygiene: Good oral hygiene can preventperiodontal disease and oral malodor or halitosis. Themost important means of maintaining oral hygiene isusing toothbrush. Tooth brushing at least twice dailywith a small headed, medium hardness brush will helpin removing the plaque and reduce caries when usedwith fluoride toothpaste. However, this removes

Extrinsic discoloration (typically brown orblack):

• Poor oral hygiene• Smoking• Food and drink (such as tea, coffee, red wine)• Drugs (such as iron, chlorhexidine,

antimicrobials)• Chewing betel leaf along with other

ingredients

Intrinsic discoloration:Localized-

• Trauma (yellow or brown)• Caries (white, brown or black)• Restorative materials (such as black of

amalgam)• Internal resorption (pink spot)

Generalized-• Tetracyclines (brown)• Excessive fluoride (white or brown)• Rare causes (Amelogenesis imperfecta,

Entinogenesis imperfecta, Kernicterus orbiliary atresia, Porphyria)

Causes of Tooth Discoloration

7

ORODENTAL PROBLEMS

plaque only from smooth dental surfaces and not fromthe depths of contact areas, pits and fissures. Moreeffective interdental removal requires regular flossing.Products containing phosphates and phosphonatesmay help prevent calculus, but some have producedadverse reactions.

Periodontal Diseases

Gingivitis: Chronic gingivitis affects over 90% of thepopulation. If treated then the prognosis is good,otherwise it may progress to periodontitis, toothmobility and loss. Marginal gingivitis is painless butmay manifest with bleeding from gingival creviceparticularly while tooth brushing. Unless plaque isremoved and kept under control by tooth brushing andflossing and where necessary by removal of calculusby scaling and polishing, the condition recursrepeatedly. Although gingivitis has a bacterialcomponent, systemic antimicrobials have onlytransient benefit and therefore have no place intreatment.

Periodontitis: Chronic periodontitis is aninflammation of the gingival and periodontalmembrane commonly seen in adults. It is painless butmay be associated with bleeding, halitosis, and a foultaste. Debris and pus may be expressed from pockets,and there may be increasing tooth mobility.Periodontitis cannot be diagnosed by inspection alone.It requires periodontal probing and radiographs forconfirmed diagnosis. Scaling, polishing andsometimes curettage are required of its management.Surgical removal of the pocket wall and diseasedtissue may be needed to facilitate future cleansing.Tooth brushing and using mouthwash have limitationsas they have little effect along gum line.

Halitosis: Oral malodor predominantly originatesfrom the tongue coating, gingival crevice, andperiodontal pockets. Many foods and drinks can causemalodor such as garlic, onions etc. Cigarette smokingand alcohol intake may also be the reasons. Drugs likeisosorbide dinitrate and disulphiram can causehalitosis. Rare causes include diabetic ketoacidosis,renal or hepatic dysfunction, and psychiatric diseaseas in delusional halitosis or as a feature inschizophrenia. Management includes improving andmaintaining oral hygiene, avoidance of odiferousfoods, drugs and other substances, eating regularly,using antibacterial mouthwash or chewing sugar-freegum. In severe or recalcitrant cases, metronidazole200mg thrice daily for seven days is required.

Oral Swellings or Lumps

Usually, the first notice of a lump most often happenswhen it becomes sore. Pathological causes include arange of different lesions, but neoplasms are mostimportant. Salivary swellings are mostly caused bymucoceles in minor glands in the lower lip. These arebest removed surgically. It can be difficult to establisha salivary gland swelling particularly in obesepatients. A useful guide to confirm a parotidenlargement is to look for outward deflection of theear lobe. Diagnosis is mainly clinical, butinvestigations such as serology for autoantibodies orHIV antibodies, liver function tests, and needle oropen biopsy may be indicated.

Red Oral Lesions

Erythroplasia (erythroplakia): Erythroplasia is a rare,isolated, red, velvety lesion that affects patientsmainly in their 60s and 70s. It usually involves thefloor of the mouth, the ventrum of the tongue, or thesoft palate. This is one of the most important orallesions because 75-90% of lesions prove to becarcinoma or carcinoma is situ or is severelydysplastic. Erythroplasia should be excised and sentfor histological examination.

Erythematous candidiasis: Erythematous candidiasismay complicate treatment with corticosteroids orantimicrobials and cause widespread erythema andsoreness of the oral mucosa, sometimes with thrush.This may occasionally be seen in HIV infections,xerostomia, diabetes and particularly in smokers. Redpersistent lesions are especially noticeable on the

A. Mucocele in a typical site B. Minor apthous ulceration C. Erythema migrans D. Leucoplakia of lower gingivae

A B

C D

8

ORODENTAL PROBLEMS

palate and tongue. Erythematus candidiasis mayrespond to antifungal agents like fluconazole andspecially by avoiding smoking.

Denture induced stomatitis (denture sore mouth): Thisis a common form of mild chronic erythematouscandidiasis, usually seen after middle age as erythemalimited to the area beneath an upper denture. Dentureis mainly infested with Candida albicans.Predisposing factors include wearing denturesespecially through the night, poor oral and denturehygiene, xerostomia and carbohydrate-rich diets butnot by allergy to the denture materials. Managementincludes: a) eradicating infection by soaking denturesovernight in chlorhexidine or 1% (v/v) hypochloritesolution then using miconazole denture lacquer. Metaldentures should not be soaked in hypochlorite as theymay get discolored b) using miconazole gel (5mg),nystatin pastilles (100,000units), or amphotericinlozenges (10mg) in the mouth four times daily for upto one month c) using systemic fluconazole 50mgdaily for resistant cases and d) adjustment of dentures.

White Oral Lesions

Keratosis (Leukoplakia): This is a persistent adherentwhite patch. Keratoses are most commonly presentwith uniform white plaques or homogenousleukoplakia, prevalent in the buccal mucosae, and areusually of low malignant potential. More serious arenon-homogenous keratoses which consist of white

patches or nodules often in red, commonly eroded areaof mucosa. The presence of severe epithelial dysplasiaindicates a considerable risk of malignant development.Diagnosing a white patch can be difficult as evencarcinoma can present as a white lesion. That is whybiopsy is indicated. Although an oral biopsy is helpful,incisional biopsy is needed if there is strong suspicionfor carcinoma. Management includes reduction ofpredisposing factors like avoidance of smoking for ayear. Dysplastic lesions should be excised and thenfollow up regularly at 3-6 months interval as excisedlesions may recur sometimes.

Lichen planus: Oral lichen planus is common, mainlyoccurs after middle age, and typically presents asbilateral white lesions (papules, plaques, or reticularareas) in the buccal and lingual mucosae. Lesions maybe symptomless. Biopsy is needed to excludedysplasia, keratosis, lupus erythematosus, chroniculcerative stomatitis and other disorders. Somelichenoid lesions may be drug induced (such as bynon-steroidal anti-inflammatory drugs) oroccasionally related to factors such as materials usedin dental work, hepatitis C infection or graft versushost disease. Topical corticosteroids are useful incontrolling symptoms.

Candidiasis: Oral carriage of Candida albicans iscommon in smokers and those who are ill. Candidiasismay arise after recent use of antibiotics orcorticosteroids, immunosuppressive drugs, cytotoxicchemotherapy, or irradiation. Also it occurs in thosewith zerostomia, immunodeficiencies such asleukaemia or AIDS, malnutrition or diabetes.Management includes avoidance of smoking, treatingthe predisposing causes and improves oral hygiene.The choice of chlorhexidine or antifungal drugsdepends on the severity and extent of disease, medicalcontraindications, and other complications of animmunocompromising condition.

Pigmented Oral Lesions

Furred, brown and black hairy tongue: The tongue inhealthy children is seldom furred, but healthy adultssometimes get a coating of epithelial, food andmicrobial debris, particularly if they are edentulous,have a soft non-abrasive diet, have poor oral hygiene,smoke, are fasting or ill, or are using antimicrobials orchlorhexidine. Black hairy tongue is an extremeexample that affects mainly the posterior dorsum oftongue. The filiform papillae are long and stained byaccumulated debris. This condition can be improved

A. Carcinoma of tongue presenting as a lumpB. Carcinoma of tongue presenting with an ulcerC. Major apthous ulcerationD. Carcinoma of tongue with associated white lesion

A B

C D

by increasing oral hygiene, brushing of the tongue,using a tongue scraper, increasing dietary fruit androughage (pineapple) and also by using sodiumbicarbonate mouthwash.

Localized & Generalized hyperpigmented lesions:Hemangiomas, purpura, and Kaposi's sarcoma giverise to localized red and purple lesions. Brown orblack lesions are usually amalgam tattoos or naevi, butmelanomas must be excluded. Generalized lesions areusually racial in origin or caused by smoking or beteluse and only occasionally has a systemic cause such asdrugs, Addison's disease, or ectopic production ofadrenocorticotrophic hormone (such as bybronchogenic carcinoma).

Dry Mouth

Dry mouth has many causes and is commonlyencountered in patients with cancer. This can affectthe quality of life by causing dysphagia, loss of tasteor prolonged chewing. Dry mouth may be the result ofnasal obstruction initiating mouth breathing, poorhydration and fluid intake status, taking drugs likeopioids, tricyclic antidepressants, antihistamines,diuretics etc. These reversible causes should be treatedto overcome dry mouth. Simple measures should beapplied like sucking on pineapple slices, frequent sipsof cold orange squash or semifrozen fruit juice, andsugar-free chewing gum. But lemon juice should beavoided as it depletes the salivary glands of saliva.Pilocarpine for systemic saliva stimulation issometimes used after radiotherapy.

Orofacial Soreness and Pain

Ulcerative conditions: Mouth ulcers are common andare usually due to trauma such as from ill fittingdentures, fractured teeth, or fillings. However, patientswith an ulcer for over three weeks’ duration should bereferred for biopsy or other investigations to excludemalignancy or chronic infection. Ulcers related totrauma usually resolve in about a week after removalof the cause, use of benzydamine hydrochloride0.15% mouthwash or spray to provide symptomaticrelief and chlorhexidine 0.2% aqueous mouthwash tomaintain good oral hygiene.

Recurrent apthous stomatitis typically starts inchildhood or adolescence with recurrent small, round,or ovoid ulcers with circumscribed margins,erythematous haloes, and yellow or grey floors.

9

ORODENTAL PROBLEMS

A. Step deformity of occlusion revealing mandibular fractureB. Hemangioma of left buccal mucosaC. Lichen planus of dorsum of tongueD. Homogeneous white patch in mouth of a smoker

A B

C D

Causes of Dry Mouth

Iatrogenic Salivary gland disease

• Drugs :

Anticholinergics ( such asantidepressants, antihistamines,antihypertensives, antiretrovirals)

• Sympathomiometics (such as bronchodilators)• Irradiation damage• Graft versus host disease

• Sjogren's syndrome• HIV infection• Hepatitis C virus• HTLV-I infection• Sarcoidosis• Aplasia• Dehydration :

Uncontrolled diabetesPsychogenic

10

ORODENTAL PROBLEMS

Mouth ulcers in systemic diseases may manifestduring disorders of skin, connective tissue, blood orgastrointestinal tract. Drug induced mouth ulcersmainly results from using of cytotoxic agents,antithyroid drugs and nicorandil.

Management includes identification and correction ofpredisposing factors and control of symptoms withhydrocortisone hemisuccinate pellets or triamcinoloneacetonide in carboxymethyl cellulose paste four timesdaily but more patent topical corticosteroids may berequired. Systemic corticosteroids are given by aspecialist. Thalidomide is also effective but is rarelyindicated.

Non-ulcerative Causes of Oral Soreness: Non-ulcerative oral soreness may result from erythemamigrans, burning mouth syndrome, anddesquamative gingivitis etc. Erythema migransaffects about 10% of children and adults and ischaracterized by map-like red areas of atrophy offiliform tongue papillae in patterns that change evenwithin hours. So far there is no reliably effectivetreatment though some have reported the efficacyfor zinc supplements. Burning mouth syndromecommonly appears in people past middle age andcharacterized by a persistent burning sensation inthe tongue usually bilaterally. Discomfort issometimes relieved by eating and drinking.Reassurance and occasionally psychiatricconsultation, vitamins, antidepressants may beindicated but still they are not reliably effective.

Oral Cancer

Most mouth cancer is oral squamous cell carcinoma.This is uncommon in the developed world except inFrance, but quite commonly seen in developingnations particularly in South East Asia and Brazil.Etiological factors include tobacco use, betel use, andalcohol consumption, a diet poor in fresh fruit and

vegetables, infective agents, immune deficiency andin the case of lip carcinoma- exposure to sunlight.

Patients with oral cancer are predominantly detectedlately, with advanced disease and lymph nodemetastases. With earlier detection, treatment is lesscomplicated and survival rate also improves.Carcinomas may present anywhere in the oral cavity.It is therefore crucial not only to examine visually andmanually the whole oral cavity, but to carefullyinspect and palpate the posterolateral margins of thetongue and the floor of the mouth. There is usually asolitary chronic ulceration, red or white lesion,indurated lump, fissure or enlarged cervical lymphnode. Lip carcinoma presents with thickening,crusting, or ulceration, usually of the lower lip.Investigations include lesional biopsy, jaw and chestradiography, endoscopy and a full blood count andliver function tests.

The prognosis of oral cancer is very site dependent.Important factors to consider in management arequality of life and patient education. Oral squamouscell carcinoma is now treated largely by surgery orirradiation. With the help of radiotherapy, normalanatomy and function can be maintained. However,adverse effects are common, cure is uncommon andsubsequent surgery is more difficult and hazardouswith further reduction of survival rates.

References

1. British Medical Journal 2000; 321: 97-1002. British Medical Journal 1999; 318: 1051-10543. British Medical Journal 2000; 321: 36-394. British Medical Journal 2000; 321: 162-1655. British Medical Journal 2000; 321: 225-2286. British Medical Journal 2007; 334:5347. British Medical Journal 2000; 320: 1652-16558. British Medical Journal 2000; 321: 559-5629. British Medical Journal 2000; 320: 1717-1719

• Local disease, especially dental, mainly aconsequence of caries

• Psychogenic states

• Neurological disorders such as trigeminalneuralgia

• Vascular disorders such as migraine

• Referred pain such as angina

Orofacial Pain

11

DAYS TO REMEMBER

The clinical demand for blood is rising throughoutthe world to support advancements in medicaland surgical procedures. Though the pattern of

blood usage varies in different regions, there is still agreat need for it in the treatment of conditions likecomplications during surgery, pregnancy and childbirth,and severe childhood anemia.

Global celebration of World Blood Donor Day(WBDD) took place on 14 June 2008. This annualevent highlights the role blood donors play in savingthe lives and improving the health of millions andcreates awareness about the availability, safety andappropriate use of blood and blood products.Voluntary blood donors donate blood of their own freewill for altruistic reasons with no desire of any rewardexcept personal satisfaction. Patients receiving thisblood feel a sense of being cared by others whom theywill never meet. World Blood Donor Day is jointlycoordinated by four founding partners: World HealthOrganization, International Federation of Red Crossand Red Crescent Societies, International Federationof Blood Donor Organizations and InternationalSociety of Blood Transfusion.

This year's theme is 'Giving Blood Regularly' - aneffort to commit volunteer blood donors to donateregularly and over long-time. This sense of socialengagement and belonging displayed can be thefoundation of a stable voluntary donor pool. It is anopportunity for every country to facilitate these giversof 'life' and for national transfusion services toreaffirm their efforts in providing the quality of care.World Blood Donor Day thus provides an opportunityfor blood transfusion services to evaluate theeffectiveness of their donor care programs and involveblood donors in identifying ways of increasing donorsatisfaction and promoting donor loyalty.

Addiction is a terrible thing as it has thecapability to consume and control the humanmind, makes it deny important truths and

blinds about the consequences of their action. Todaythe world is in the grip of a dangerous carbon habit.Dependency on carbon-based energy has caused asignificant build-up of greenhouse gases in theatmosphere. Throughout the tropics, valuable forestsare being destroyed for various purposes. This notonly causes further manifestation of carbon habit butalso destroys a valuable resource for absorbingatmospheric carbon.

The environmental, economic and politicalimplications of global warming are profound.Ecosystems- from mountain to ocean, from the Polesto the tropics-are undergoing rapid change. Low-lyingcities are facing inundation, fertile lands are turninginto desert, and weather patterns are becoming evermore unpredictable. The cost will be borne by all. Thepoor will be the hardest hit by weather-relateddisasters and by soaring price inflation for staplefoods, even the richest nation face the prospect ofeconomic recession and a world in conflict overdiminishing resources. Mitigating climate change,eradicating poverty and promoting economic andpolitical stability, all demand the same solution. Thatis everyone must kick the carbon habit.

This is the theme for World Environment Day 2008.'Kick the Carbon Habit: Towards a Low CarbonEconomy.' This recognizes the damaging extent ofthis human addiction as well as shows the wayforward. Whether as an individual or an organization,a business or a government, everyone should look foralternative steps towards reducing the carbonfootprint. It is a message that all should take into theirheart in order to preserve the entire existence of allliving species on earth.

World Blood Donor Day: 14 June 2008'Giving Blood Regularly'

World Environment Day: 5 June 2008 'Kick theCarbon Habit: Towards a Low Carbon Economy'

Source: World Health Organization

Environment Alert

12

World Environment Day 5th June 2008

San Francisco: United States of America

A bird attempts to clean oil off itself, after a cargo ship spilled its fuelinto the bay water.

Jubail Coast: Iraq

An oil slick covers the waters off the jubail coast after the Persian Gulf oilspill. During Gulf war in 1990-'91, Iraq performed an act of environmental

warfare by deliberately pumping millions of gallons of crude oil into thePersian Gulf.

Guanqiao Lake: China

Large quantities of dead fish floates on Guanqiao lake. Severe pollution,caused by untreated industrial waste and continuous scorching heat causing

the death of some 5,000 kilograms of fish.

Magnitogorsk: Russia

Being the largest steel mill of the world, it employs 50,000 workers and wheregas and dust filters for the smokestacks are often missing. A third of the city's

inhabitants suffer from respiratory ailments, including asthma and chronicbronchitis.

Maripasoula: France

Massive environmental damage occurred near the city of Maripasoula due togold mining activity.

Adi Ganga River: India

Locals collect plastic from the river Adi Ganga. Emerging from centralHimalayas, the river provides water and drainage for over 350 million people.

The river emerges from the gangotri glacier, which is receding every yeardue to environmental changes in the region.

Great Barrier Reef : Australia

The brightly colored corals that makes the Great Barrier Reef one of thenature’s wonder will be largely dead by 2050 due to rising sea temperature

as a result of global warming.

Environment Alert

13

Sidoarjo: Indonesia

Massive pollution from the hot mudflow due to gas well accident. Medicalworkers report a sudden rise in the number of respiratory patients near theaccident site.

Tanganga beach: Colombia

A big stain of palm oil invades the shore of Taganga beach in Santa Martaafter 10 tons of oil was spilled from production plant of terlica. Residents ofthe area saw humongous amount of dead fish.

Tabasco: Mexico

A women fishing in a contaminated pond in Tabasco. As the oil and naturalgas reserves are diminishing rapidly in the Gulf of Mexico, PetroleosMexicanos has increased drilling operations on land and in rivers of theTabasco resulting in environmental destabilization.

Chaohu Lake: China

Chinese freshwater lakes are mainly being destroyed by untreated sewagecontaining high concentrations of nitrogen; a main ingredient in detergentsand fertilizers. More than 70% of China's waterways and 90% of itsunderground water have been contaminated by pollution.

Fen River: Taiyuan

Filth clogs the Fen River, in outer Taiyuan.

Naama Bay: Egypt

As a popular vacation destination, activities like snorkeling and diving burdenthe delicate underwater environment. Debris like plastic bags and the heavycommercial traffic are contributing degradation of this one of the most diverseunderwater tropical paradises.

Rainforest: Brazil

Trees are being randomly cut off from rainforest. Winthin few years most ofthe existing trees will die as the soil is now exposed to the drying effects ofsunlight and eroding by rain fall.

World Environment Day 5th June 2008

Source: World Health Organization

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Although diagnostic and therapeutic decisionsin patients with vascular disease are guidedprimarily by the history and physical

examination, the use of non-invasive investigationshas increased significantly in recent years, mainly as aresult of technological advances in ultrasonography.

Principles of Vascular Ultrasonography

In the simplest form of ultrasonography, ultrasound istransmitted as a continuous beam from a probe thatcontains two piezoelectric crystals. The transmittingcrystal produces ultrasound at a fixed frequency (setby the operator according to the depth of the vesselbeing examined), and the receiving crystal vibrates inresponse to reflected waves and produces an outputvoltage. Conventional B mode (brightness mode)ultrasonography records the ultrasound wavesreflected from tissue interfaces, and a two dimensionalpicture is built up according to the reflectiveproperties of the tissues.

Doppler ultrasonographyUltrasound signals reflected off stationary surfacesretain the same frequency with which they weretransmitted, but the principle underlying Dopplerultrasonography is that the frequency of signalsreflected from moving objects such as red blood cellsshifts in proportion to the velocity of the target. Theoutput from a continuous wave Dopplerultrasonograph is usually presented as an audiblesignal, so that a sound is heard whenever there ismovement of blood in the vessels being examined.

Pulsed ultrasonographyContinuous wave ultrasonography provides littlescope for restricting the area of tissue that is beingexamined because any sound waves that areintercepted by the receiving crystal will produce anoutput signal. The solution is to use pulsedultrasonography. The investigator can focus on aspecific tissue plane by transmitting a pulse ofultrasound and closing the receiver except whensignals from a predetermined depth are returning.This allows, for example, the centre of an artery andthe areas close to the vessel wall to be examined inturn.

Duplex scannersAn important advance in vascular ultrasonography hasbeen the development of spectral analysis, whichdelineates the complete spectrum of frequencies (that is,blood flow velocities) found in the arterial waveformduring a single cardiac cycle. The normal (‘triphasic’)Doppler velocity waveform is made up of threecomponents which correspond to different phases ofarterial flow : rapid antegrade flow reaching a peakduring systole, transient reversal of flow during earlydiastole, and slow antegrade flow during late diastole.

Non-invasive Methods of Arterialand Venous Assessment

Left : Doppler velocity waveforms : (a) triphasic waveform innormal artery (b) biphasic waveform, with increased velocity,through a mild stenosis (c) monophasic waveform, withgreatly increased velocity, through tight stenosis and (d)dampended monophasic waveform, with reduced velocity,recorded distal to tight stenosis. Right : Anatomical chart usedto record position of stenosis, showing three stenoses withvelocity increases of 7x, 4x, and 3x compared with adjacentunaffected arteries.

Handheld pencil Doppler used to measure ankle brachialpressure index

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Doppler examination of an artery distal to a stenosiswill show characteristic changes in the velocityprofile: the rate of rise is delayed, the amplitudedecreased, and the transient flow reversal in earlydiastole is lost. In severe disease, the Dopplerwaveform flattens; in critical limb ischemia it may beundetectable.

Examination of an arterial stenosis shows an increasein blood velocity through the area of narrowing. Thesite(s) of any stenotic lesions can be identified byserial placement of the Doppler probe along theextremities. The criteria used to define a stenosis varybetween laboratories, but a two-fold increase in peaksystolic velocity compared with the velocity in anadjacent segment of the artery usually signifies astenosis of 50% or more.

By combining the pulsed Doppler system with realtime B mode ultrasound imaging of vessels, it ispossible to examine Doppler flow patterns in aprecisely defined area within the vessel lumen. Thiscombination of real time B mode sound imaging withpulsed Doppler ultrasonography is called duplexscanning. The addition of color frequency mapping(so called color duplex or triplex scanners) makes theidentification of arterial stenoses even easier andreduces the scanning time.

Investigations of Arterial Disease

Ankle brachial pressure index Under normal conditions, systolic blood pressure inthe legs equal to or slightly greater than the systolicpressure in the upper limbs. In the presence of an

Spectral analysis of blood velocity in a stenosis, andunaffected area of proximal superficial femoral artery. Thevelocity increases from 150 to 300 m/s across the stenosis.

Color duplex scanning of blood flow through stenosis ofsuperficial femoral artery. Color assignment (red or blue)

depends on direction of blood flow and color saturation reflectsvelocity of blood flow. Less saturation indicates regions of

higher blood flow and deeper colors indicate slower flow; theabsence of flow is coded as black.

Patient survival according to measurements of ankle brachialpressure index (adapted from McKenna et al. Atherosclerosis

1991; 87 : 119-28).

Pole test for measurement of ankle pressure in patients withcalcified vessels : the Doppler probe is placed over a patent

pedal artery and the foot raised against a pole that iscalibrated in mmHg. The point at which the pedal signal

disappears is taken as the ankle pressure.

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arterial stenosis, a reduction in pressure occurs distalto the lesion. The ankle brachial pressure index, whichis calculated from the ratio of ankle to brachialsystolic pressure, is a sensitive marker of arterialinsufficiency.

The highest pressure measured in any ankle artery isused as the numerator in the calculation of the index;a value > 1.0 is normal and a value <0.9 is abnormal.Patients with claudication tend to have ankle brachialpressure indexes in the range of 0.5-0.9, whereas thosewith critical schemia usually have an index of <0.5.The index also has prognostic significance because ofthe association with arterial disease elsewhere,especially coronary heart disease.

Diabetic limbsSystolic blood pressure in the lower limbs cannot bemeasured reliably when the vessels are calcified andincompressible- for example, in patients withdiabetes- as this can result in high ankle pressuresfalsely. An alternative approach is to use either thepole test or measurement of toe pressure. Normal toesystolic pressure ranges from 90-100 mmHg and is80-90% of brachial systolic pressure. A toe systolicpressure <30 mmHg indicates critical ischemia.

Walk testExercise testing will assess the functional limitationsof arterial stenoses and differentiate occlusive arterialdisease from other causes of exercise induced lowerlimb symptoms- for example, neurogenicclaudication secondary to spinal stenosis. A limitedinflow of blood in a limb with occlusive arterialdisease results in a fall in ankle systolic blood pressureduring exercise induced peripheral vasodilatations.

The walk test is performed by exercising the patientfor 5 minutes, ideally on a treadmill, but walking thepatient in the surgery or marking time on the spot areadequate. The ankle brachial pressure index ismeasured before and after exercise. A pressure drop of20% or more indicates significant arterial disease. Ifthere is no drop in ankle systolic pressure after a 5minute brisk walk, the patient does not have occlusivearterial disease proximal to the ankle in that limb.

Duplex scanningDuplex ultrasonography has a sensitivity of 80% anda specificity of 90-100% for detecting femoral andpopliteal disease compared with angiography, but it isless reliable for assessing the severity of stenoses inthe tibial and peroneal arteries. Duplex scanning isespecially useful for assessing the carotid arteries and

Use of Color Duplex Scanning

Arterial

• Identify obstructiveatherosclerotic disease :

CarotidRenal

• Surveillance ofinfrainguinal bypassgrafts

• Surveillance of lowerlimb arteries afterangioplasty

Clinical Use of Transcranial Doppler Scanning in Adults

• Intraoperative monitoring during carotid endarterectomy:Shunt functionCerebral perfusion

• Postoperative monitoring after carotid endarterectomy :Detection of emboliFormation of carotid thrombus

• Detection of intracranial vasospasm after subarachnoidhemorrhage

• Detection of middle cerebral artery disease

• Evaluation of collateral circulation in patients with carotiddisease

• Evaluation of arteriovenous malformations of the brain

Relation Between Increased Blood Velocity and Degree of Stenosis

Diameter ofstenosis (%)

Peak systolicvelocity* (m/s)

Diameter ofstenosis (%)

∗∗ Internal :common carotidartery velocity ratio

0-394-5960-7980-99>99 (critical)

<1.11.1-1.491.5-2.492.5-6.1Extremely low

<0.45<0.450.45-1.4>1.4NA

<1.8<1.81.8-3.7>3.7NA

* Measured in lower part of internal carotid artery** Ratio of peak systolic velocity in internal carotid artery

stenosis relative to proximal measurement in commoncarotid artery

Venous

• Diagnosis of deep veinthrombosis above theknee

• Assessing competence ofvalves in deep veins

• Superficial venous reflux :Assessing patient withrecurrent varicose veinsIdentify and locate reflux atsaphenopoliteal junction• Preoperative mapping of

saphenous vein

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for surveillance of infrainguinal bypass grafts wheresites of stenosis can be identified before completegraft occlusion occurs and before there is a fall inankle brachial pressure index. The normal velocitywithin a graft conduit is 50-120 cm/s. As with nativearteries, a two-fold increase in peak systolic velocityindicates a stenosis of 50% or more. A peak velocity<45 cm/s occurs in grafts at high risk of failure.

Identification of distal vessels for arterial bypassgraftingIn critically ischemic limbs, where occlusive diseasetends to be present at multiple levels, arteriographyoften fails to show patent calf or pedal vessels aspotential outflows for femorodistal bypass grafting.Alternative non-invasive approaches have beendeveloped for preoperative assessment, includingpulse generated run off and dependent Dopplerassessment.

Transcranial doppler ultrasonographyLower frequency Doppler probes (1-2MHz) can beused to obtain information about blood flow in arteriescomprising the circle of Wills and its principalbranches. Mean flow velocities >80 cm/s in themiddle cerebral artery, or >70 cm/s in the posteriorand basilar arteries, indicate a serious stenosis.Transcranial Doppler scanning has severalapplications but is especially useful for intraoperativeand postoperative monitoring of patients havingcarotid endarterectomy.

Helical or spiral computed tomographySpiral computed tomography is a new, minimallyinvasive technique for vascular imaging that is madepossibly by combining two recent advances : slip

ring computed tomography (which allows the X-raytube detector apparatus to rotate continuously) andcomputerised three dimensional reconstruction. Ahelical scan can cover the entire region of interest(for example, the abdominal aorta from thediaphragm to the iliac bifurcation) in one 30-40second exposure, usually in a single breath hold. Thisminimizes motion artifact and allows all the scandata to be collected during the first pass of anintravenous bolus of contrast through the arterialtree- that is during the time of maximal arterialopacification. A large number of finely spaced slicesfrom one scan can then be reconstructed to producehigh quality two or three dimensional images of thecontrast enhanced vessels.

Magnetic resonance angiographyMagnetic resonance angiography has developedrapidly over the past five years. It has the advantage ofimaging a moving column of blood and does notrequire ionizing radiation or iodinated contrast, but thetechnique has obvious drawbacks in terms of costefficiency and accessibility to scanners. A variety ofimaging sequences are used depending on the vesselsbeing studied and the field strength of the machine.The most commonly used techniques include time offlight, two and three dimensional angiography andphase contrast.

Use of a magnetic resonance imaging scanner with ahigh field strength (which allows rapid acquisition ofdata) and a carefully timed bolus of gadoliniumcontrast enables high quality angiographic images tobe obtained in a single breath hold. Magneticresonance angiography is well established forexamining the cerebral vessels and the carotid arteries,and its role in other territories is being extended.

Spiral computed tomogram of both carotid systems showinga tight stenosis in the proximal segment of left internal

carotid artery.

Fall in ankle brachial pressure index with exercise in patientwith intermittent claudication and normal subject (adapted

from Creager, Vasc Med 1997; 2 : 231-7).

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Investigations of Venous Disease

Venous thrombosisColor Duplex scanning is both sensitive and specific(90-100% in most series) for detecting proximal deepvein thrombosis. Deep veins and arteries lie together

in the leg, and the normal vein appears as an echo-freechannel and is usually larger than the accompanyingartery. Venous ultrasonography is a very accuratemethod of identifying deep vein thrombi from thelevel of the common femoral vein at the groin creaseto the popliteal vein, but is less reliable for diagnosiscalf vein thrombosis.

Criteria for diagnosis of deep vein thrombosis:

• Failure of vein to collapse on direct compression• Visualization of thrombus within lumen• Absent or abnormal venous pulsation on Doppler

scanning

Venous refluxColor duplex scanning has revolutionized theinvestigation of the lower limb venous systembecause it allows instant visualization of blood flowand its direction. Thus, reflux at the saphenofemoraljunction, saphenopopliteal junction, and within thedeep venous system, including the popliteal veinbeneath the knee and the gastrocnemius veins, can bedetected without invasive techniques. Althoughvenous reflux can be assessed with a pencil Doppler,this technique misses 12% of saphenofemoral and20% of saphenopopliteal junction reflux comparedwith color duplex scanning.

Adapted from:Non-invasive methods of arterial and venous assessment:Richard Donnelly, David Hinwood, Nick J M; BritishMedical Journal, 2000;320:698-701

Color duplex scanning of saphenopopliteal junction. The calfmuscle are manually compressed producing upward flow in thevein (top), which appears as a blue color for flow towards the

heart (panel A). Sudden release of the distal compressioncauses reflux, seen as a red color indicating flow away from

the heart (panel B).

Magnetic resonance angiogram using an intravenous bolus ofgadolinium contrast showing normal renal arteries.

Ultrasound detection of deep vein thrombosis. The probe isheld tightly on the skin and advanced along the course of the

vein (left). Pressure is applied every few centimeters bycompressing the transducer head against the skin. The vein

collapses during compression if no thrombus is present(middle) but not if a deep vein thrombus is present (right).

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NEUROLOGY

Aseizure is a sudden change in behavior due toan excessive electrical activity in the brain.Seizures may be acute symptomatic or

unprovoked. Acute symptomatic seizures are seizuresoccurring at the time of a systemic insult or in closetemporal association with a documented brain insult.Unprovoked seizures are seizures occurring in theabsence of precipitating factors and may be caused bya static injury (remote symptomatic seizures) or aprogressing injury (progressive symptomaticseizures). Unprovoked seizures may be single orrecurrent (epilepsy).

A first ‘grandmal’ convulsion is frightening, yetprospective, population-based studies indicate that weall face an 8-10% lifetime risk of one seizure and a 3%chance of epilepsy. It seems likely that everyone couldhave a seizure if a particular set of circumstancesoccur- but some people have a lower seizurethreshold than others. A first seizure caused by anacute disturbance of brain function (acutesymptomatic or provoked) is unlikely to recur (3-10%). However if a first seizure is unprovoked, meta-analyses suggest that 30-50% will recur; and after asecond unprovoked seizure, 70-80% will recur,justifying the diagnosis of epilepsy. When a personpresents to the healthcare system with a first seizure,it is almost always a convulsive seizure, eithergeneralized or focal. Other seizure types such asabsence or complex partial seizures typically occurseveral times before the person or family becomeconcerned.

Is it a seizure?

The differential diagnosis for a first seizure is wide. Inexperience most important are syncope (includingbreath holding and pallid syncope), transient ischemicattacks, metabolic encephalopathy (includinghypoglycemia or electrolyte disturbance), sleepwalking, night terrors, complex migraines, cardiacarrhythmias, and pseudoseizures. ‘Convulsivesyncope’ presents a particular challenge when syncopeprovokes a post-anoxic convulsion. A detailed historyfrom both patient and witness is paramount, but nosingle feature is diagnostic. Tongue biting is notcommon but is fairly specific for a convulsive seizure,

while postictal confusion suggests a seizure. If thefirst event is ambiguous, waiting for a recurrence forclarification is generally advocated. From experience,and as outlined in a thoughtful review, it is evident thatmisdiagnosis of an ‘epileptic’ seizure may be morestigmatizing than a delayed diagnosis of epilepsy.

Is the first seizure truly epileptic?

The diagnosis of an epileptic seizure is mostly clinicaldepending on a precise history reported by the patientand the eyewitnesses. There is a plethora of eventsaffecting the brain primarily or secondarily known as‘imitators’ of epilepsy. Typically, imitators like theloss of postural tone in atonic seizures and cataplexiahave misleading clinical similarities. It is estimatedthat 20-30% of cases are indeed misdiagnosed asepileptic seizures. It is only after the second event thata correct classification becomes possible. Syncope is acommon clinical condition mimicking an epileptic

The First Seizure and Its Management SEIZURE

Box 1: Essential Diagnostic Procedures in Patients With A First Seizure

• Clinical examination• Assessment of seizure semiology• Routine laboratory tests (depending on clinical circumstances)• Examination of Cerebrospinal fluid (if encephalitis orsubarachnoid hemorrhage is suspected)

• Drug screening (depending on clinical circumstances)• Early standard electroencephalography, if possible within 24hours

• Sleep deprived electroencephalography within 1 week• High resolution magnetic resonance imaging, if possible

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NEUROLOGY

seizure and in some cases its incorrect diagnosis canlead to premature death. Therefore, some medicalsocieties recommend that patients with a suspecteddiagnosis of epileptic seizure should be seen by aneurologist or an epilepsy specialist before thediagnosis is made.

What investigations are needed?

A practice parameter noted little justification forroutine investigations of blood, urine, andcerebrospinal fluid in children; however, thecircumstances of a first seizure should directinvestigations. For example, a child with insulindependent diabetes must be assessed forhypoglycemia, while an adult with fever and headacheis candidate for a lumbar puncture to excludeencephalitis. If a first seizure is unprovoked, largecase series support the value ofelectroencephalography (EEG), and often magneticresonance imaging (MRI), to identify the cause. Suchimages cannot be used to diagnose the event-thediagnosis can only be made from the patient's history.The value of EEG is to point to focal lesions(especially localized slow waves), predict recurrence,

and indicate a specific epilepsy syndrome (spikepattern). When performed within 24-48 hours of a firstseizure EEG shows substantial abnormalities in about70% of cases. The yield may be lower with longerdelays after the seizure. When standard EEG isnegative, systematic case series have shown that sleepdeprived EEG will detect epileptiform (spike)discharges in an additional 13-31% of cases. Sleepdeprived EEG may be carried out in any routine EEGlaboratory. While not always available, MRI is thebest method for structural imaging. Several case seriescomparing it with computed tomography in the samepatient indicate that the latter may not detect smalltumours or other subtle pathologies. After a firstseizure, abnormalities detected by MRI that leaddirectly to intervention are more common in adultsthan children. In a series of 166 adults with a firstseizure, the most common etiologies diagnosed withboth computed tomography and MRI werecerebrovascular lesions (26%), brain tumours (12%),traumatic scar formations (5%), and other conditions(4%). Subcortical vascular encephalopathy itself isalso associated with an increased risk for seizures. Inelderly people, a first seizure may be caused by asilent stroke only recognizable by MRI.

If the seizure was unprovoked, does the personhave an epilepsy syndrome?

Once an acute provoking cause has been excluded, thenext step is to decide if the first seizure indicated a

SPECT scan shows the area where a seizure begins(colored circles)

Table 1. Comparative Clinical Features ofEpileptic Seizure and Syncope

Syncope Epileptic seizure

Provocation by prolongedstanding, hunger, heat, pain,micturation, cough, etc.

In the context of sleep deprivation,drugs or alcohol withdrawal,intermittent flashes, etc.

Prodrome: visual and/orauditory progressive fading,pallor, diaphoreris

Aura: olfactory, gustatoryhallucination, epigastric risingsensation, dysmnesicphenomena (‘déjà-vu,’ etc.).Auditory, visual positivehallucination (noise, music,flash, colors, figures, etc.)

No automatism Oro-alimentary, manualautomatisms, complex behavior

Flaccidity, with or withoutbrief myoclonus,opisthotonus (rare)

Strained cry, tonic-clonic jerks,severe tongue biting,incontinence, limb posturing

Duration: 10-30 s Duration: 1-2 min

Postictal phase: minimal(few seconds)

Postictal phase: several minutes

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focal or generalized epilepsy syndrome- a criticaldistinction if drug treatment is considered. Anepilepsy syndrome can be diagnosed after one seizure,even though a single seizure is insufficient for thediagnosis of epilepsy. The diagnosis of epilepsyaddresses recurrence risk, whereas epilepsy syndromeis a broader concept encompassing age of onset,etiology, prognosis, and response to treatment. Forexample, a child with a first nocturnal seizure andtypical EEG spikes can be diagnosed as having benignrolandic epilepsy, a disorder of genetic etiology thatconstitutes 15% of childhood epilepsy and nearlyalways remits. In a prospective study of 300 olderchildren and adults with a first seizure a syndromediagnosis could be made in 80%: clinical details plusfamily history allowed diagnosis in 47%, EEGallowed diagnosis in an additional 30%, and plus MRIallowed diagnosis in another 4%.

Risk of recurrence after a first unprovoked seizure

The risk of recurrence after a first unprovoked seizurehas been examined in numerous observational studiesand two large, high-quality randomized trials. Overall,in untreated individuals, 40-50% can expect arecurrence within 2 years of the initial seizure.Treatment may reduce this risk by as much as half.Those at the greatest risk of recurrence have either anabnormal EEG or an identifiable neurologicalcondition or symptoms. Status epilepticus and ahistory of febrile seizures may be associated with anincreased risk of recurrence in individuals withsymptomatic seizures. The great majority of people(~90%) who are seen for a first unprovoked seizureattain a one to two year remission within 4 or 5 yearsof the initial event.

The treatment of the first seizure: The benefits & the risks

Drug treatment after a first seizure is controversial. Apractice parameter about first seizures in childrenconcluded that antiepileptic drugs decrease but do noteliminate seizure recurrence and have no effect onlong term remission. Two large recent randomizedstudies of children and adults compared antiepilepticdrugs with no treatment after a first seizure and cameto an identical conclusion. Any decision to starttreatment must weigh the risk of another seizureagainst the risks of side effects from chronic drugtreatment.The risks associated with prescribingantiepileptic drugs (AEDs) in a person who had asingle unprovoked seizure fall into three domains: 1.)the risk that treatment will not be effective inpreventing seizure relapse, and the consequencesthereof 2.) the risks of a person's life being affectedby the psychological, social, and legal aspects ofreceiving treatment for a seizure disorder 3.) thehealth risks associated with intake of antiepilepticmedication. Serious or life-threatening adversereactions are very uncommon in people started onAEDs, although some (e.g., teratogenic effects) canbe a major concern in specific patient groups.Nonserious adverse reactions leading to withdrawalof treatment are relatively common, although in mostcases these are reversible following removal of theoffending agent. Adverse effects associated withprolonged treatment and not leading to drugwithdrawal are an important concern, because sucheffects are often under-recognized and may affect thequality of life significantly. Additional risks relate tothe occurrence of drug-drug interactions. In all cases,risks can be minimized by careful selection of the AEDto be used (with particular consideration of individual

Box 2: Reported Risk Factors for Seizure Recurrence

• Remote symptomatic etiology (pre-existing static brainabnormalities that are, by implication, causative)

• Focal neurological findings• Focal seizure phenomenology (including Todd's paresis)• Focal or generalised epileptiform activity on EEG• Tumors or other progressive lesions as the underlying

pathology• Status epilepticus• Family history of epilepsy• Previous febrile seizures

A 44 year old woman with a first seizure had an apparentlynormal computed tomogram (left), whereas the correspondingmagnetic resonance image (right) was obviously pathological,

revealing a right hemispheric glioma—and showing thesuperiority of MRI for structural imaging

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NEUROLOGY

characteristics which contraindicate a specific AED,or predispose to specific adverse effects), gradual dosetitration, choice of an appropriate target dose and,most important of all, careful monitoring of clinicalresponse.

Treatment may be justified when the risk ofrecurrence is high, such as with a focal structural braindeficit and corresponding EEG epileptiform activity(as after a stroke or brain abscess); when the risk ofinjury from a recurrent seizure is high (such as forthose with a spinal cervical fracture, with severeosteoporosis, or taking anticoagulants); or when therisk of economic hardship from a recurrence is high(such as loss of employment).

If drug treatment is considered, which drug is preferred?

If drug treatment is considered after a first seizure, thechosen antiepileptic drug should have high efficacy,long term safety, good tolerability, and low interactionpotential and allow a good quality of life, especiallysince half of all patients would never have anotherseizure without treatment. The starting dose should bein the lower range. Phenytoin and barbiturates shouldbe avoided because of neurotoxic and cognitive sideeffects.

If an underlying epilepsy syndrome has beenestablished, the following antiepileptic drugs areavailable (listed alphabetically because there are noavailable comparative trials after a first seizure): • For focal seizures-carbamazepine, clobazam

(especially children), gabapentin, lamotrigine,oxcarbazepine, topiramate, valproate

• For generalised seizures-lamotrigine, topiramate,valproate.

Drug choice should be individualized, andconsideration given to factors such as teratogenicity,the patient's cognitive abilities, drug interactions, thedoctor's familiarity with the drug, and cost.

How long should drug treatment be continued?

In childhood epilepsy (as opposed to first seizure)drug treatment is usually continued until the child hasbeen free of seizures for one to two years. If a childstarts drug treatment after a first seizure, there is littlejustification for continuing treatment beyond one yearfree from seizures, except in the case of a few epilepsysyndromes, such as juvenile myoclonic epilepsy, that

usually require long term treatment. There are nopublished data to guide length of treatment after a firstseizure in adults. Each case must be viewed individually,including consideration of the medical and socialconsequences of another seizure. It is tempting to useEEG and neuroimaging to help with this decisionbecause persistent EEG abnormalities, and adocumented etiology, are associated with a higher risk ofrelapse when antiepileptic drugs are withdrawn afterseveral years of remission (affirmed by a meta-analysis).It would seem prudent for adult patients to decide theparameters for discontinuing before starting treatment. Ifdrug treatment is started after a first seizure in adults, atleast one year of treatment is suggested, except for thoseat low risk for recurrence, when six months withoutseizures may be sufficient.

Conclusions

A first seizure means an uncertain future for theindividual, but the consequences of a recurrence varybetween individuals in different geographical areasand social situations. Treatment decisions must takeinto account medical issues and patient and familypreferences. The ultimate goal of assessment andtreatment is to optimise quality of life and achieve agood balance between feeling almost healthy and yetpractising some caution for at least a year. Hopefully,individualized coping strategies will be improved bycareful counseling.

References1. British Medical Journal 2006;332:339-3422. Epilepsia 2008;49(suppl. 1):1-61 3. Medicine Plus Medical Encyclopedia

Box 3: Steps for the Family Doctor

• On the basis of the history and physical examination, besure that the event was a first seizure

• Exclude acute provoking factors by history andscreening laboratory tests

• Arrange electroencephalography and magneticresonance imaging (if available)

• Review on an individual basis the risk of a recurrenceand the potential social and psychologicalconsequences of a recurrent seizure

• Review restrictions for the person's activities, especiallyfor driving

• For unprovoked seizures, discuss but usually do notprescribe antiepileptic drug treatment

• Seek expert consultation for diagnosis of epilepsysyndrome and management of provoking factors

New United States Guidelines for TreatingResistant Hypertension

P atients with resistant hypertension, bloodpressure that remains above goal despite taking 3antihypertensive medications, or high blood

pressure that is controlled but requires 4 or moremedications to do so, may benefit from specializeddiagnostic and therapeutic treatment by healthcareproviders according to the guidelines. Confirmingtreatment resistance is the first step in evaluatingdifficult-to-treat high blood pressure. The researcherssaid that successfully treating resistant hypertensionrequires patients to modify lifestyle factors includingusing less salt, losing weight, and drinking less alcohol.It also requires physicians to better diagnose and treatsecondary causes of high blood pressure (such asobstructive sleep apnea, renal parenchymal disease,primary aldosteronism, or renal artery stenosis) andmore effectively use multiple-drug treatments. They alsoadded that older age and obesity are 2 of the strongestrisk factors associated with resistant hypertension.Persons with resistant hypertension are at increased riskfor cardiovascular diseases, including heart attacks andstrokes. The researchers recommended a long-actingdiuretic be part of the treatment regimen of all patientswith resistant hypertension in order to reduce fluidretention and thereby blood pressure. They also includedthat some patients may also benefit from addingmineralocorticoid receptor antagonists to their treatmentregimens.

http://www.pslgroup.com

Researchers Link Bacterial Infection to SuddenUnexpected Death in Infancy (SUDI)

Arecent study, reports a possible correlation betweenbacterial infection and SUDI. Researchersperformed a systematic retrospective case review

of autopsies, between 1996 and 2005, of 546 infants aged7 to 365 days who died suddenly and unexpectedly. Casesof SUDI were categorized as unexplained, explained withhistological evidence of bacterial infection, or explainedby noninfective causes. Microbial isolates gathered atautopsy were classified as nonpathogens; group 1

pathogens, organisms usually associated with anidentifiable focus of infection; or group 2 pathogens,organisms known to cause septicemia without an obviousfocus of infection. Significantly more isolates from infantswhose deaths were explained by bacterial infection, andfrom those whose death was unexplained, contained group2 pathogens than did the isolates from infants whose deathwas explained by a noninfective cause. Also, significantlymore cultures from infants whose deaths wereunexplained contained Staphylococcus aureus orEscherichia coli than did the cultures from infants whosedeaths were of a noninfective cause. Although manypostmortem bacteriological cultures in SUDI yieldorganisms, most seem to be unrelated to the cause ofdeath. The high rate of detection of group 2 pathogens,particularly S aureus and E coli, in otherwise unexplainedcases of SUDI suggests that these bacteria could beassociated with this condition.

http://www.pslgroup.com

Medication for Severe Chronic Constipation

Anew medication appears to offer significant reliefto patients with severe chronic constipation whileminimizing the likelihood of cardiac-related side

effects, according to results of a study. The trial involved38 medical centers. Patients with an extreme butcommon version of constipation, called severe chronicconstipation, were randomly assigned to receive eitherof 2 dosage levels of prucalopride, a medication thatstimulates protein receptors involved in contraction ofthe colon, or a placebo. Many more of the patients takingprucalopride were able to have spontaneous bowelmovements without having enemas or taking laxatives,as compared to those who were given placebo, accordingto the researchers. The time it took to have a first bowelmovement was much shorter, and quality of life andother abdominal symptoms also were improved for thosetaking the study drug. Only 1.5% and 4.4% of patientstreated with 2 mg and 4 mg of prucalopride,respectively, stopped the drug due to diarrhea. Thecardiac risk issues that have been raised about relateddrugs for constipation, including tegaserod, appear to beless of a concern for prucalopride. The researchersexplained that prucalopride is highly selective in itseffect, and doesn't interact significantly with otherprotein receptors, such as those involved in regulatingheart rhythm. They conducted electrocardiogram testingduring the study and did not find heart rhythm issues,although 2 of the 3 patients who withdrew from thestudy did have symptoms, palpitations and dizziness thatmay have been attributable to an effect on thecardiovascular system. The researchers suggested thatresults from other studies will need to be compiled andpublished. The safety and efficacy data was submitted tothe United States Food and Drug Administration forreview.

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