Head and Neck Pathology Interactions with Clinical Outcomes
Identifieur interne : 005840 ( Istex/Corpus ); précédent : 005839; suivant : 005841Head and Neck Pathology Interactions with Clinical Outcomes
Auteurs : Ralph H. RosenblumSource :
- American journal of medical quality [ 0885-713x ] ; 1990-05.
English descriptors
- KwdEn :
- American heart association guidelines, Antibiotic, Antidepressant therapy, Bacterial endocarditis, Bacterial infections, Cancer patients, Chronic pain, Chronic sinusitis, Clinical outcomes, Complication, Dental, Dental amalgams, Dental component, Dental disease, Dental implants, Dental materials, Dental procedure, Dental therapeutics, Developmental abnormalities, Differential diagnosis, Endodontic, Endodontic infections, Foreign body reactions, Fungal, Fungal infections, Iatrogenic complications, Implant, Infection, Lesion, Medical necessity, Mutual effects, National institutes, Oncological interactions, Oral complications, Oral fluids, Oral surg, Partial denture, Root canal, Side effects, Systemic, Systemic infection, Treatment schedules, Viral.
- Teeft :
- American heart association guidelines, Antibiotic, Antidepressant therapy, Bacterial endocarditis, Bacterial infections, Cancer patients, Chronic pain, Chronic sinusitis, Clinical outcomes, Complication, Dental, Dental amalgams, Dental component, Dental disease, Dental implants, Dental materials, Dental procedure, Dental therapeutics, Developmental abnormalities, Differential diagnosis, Endodontic, Endodontic infections, Foreign body reactions, Fungal, Fungal infections, Iatrogenic complications, Implant, Infection, Lesion, Medical necessity, Mutual effects, National institutes, Oncological interactions, Oral complications, Oral fluids, Oral surg, Partial denture, Root canal, Side effects, Systemic, Systemic infection, Treatment schedules, Viral.
Abstract
The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations.
Url:
DOI: 10.1177/0885713x9000500206
Links to Exploration step
ISTEX:B0FFC930692861A8076694B470499EA3ECF2B9EFLe document en format XML
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Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>endodontic</json:string><json:string>implant</json:string><json:string>viral</json:string><json:string>fungal infections</json:string><json:string>fungal</json:string><json:string>antibiotic</json:string><json:string>bacterial endocarditis</json:string><json:string>foreign body reactions</json:string><json:string>systemic infection</json:string><json:string>bacterial infections</json:string><json:string>national institutes</json:string><json:string>medical necessity</json:string><json:string>lesion</json:string><json:string>dental amalgams</json:string><json:string>side effects</json:string><json:string>differential diagnosis</json:string><json:string>clinical outcomes</json:string><json:string>dental procedure</json:string><json:string>american heart association guidelines</json:string><json:string>partial denture</json:string><json:string>root canal</json:string><json:string>endodontic infections</json:string><json:string>iatrogenic complications</json:string><json:string>chronic sinusitis</json:string><json:string>treatment schedules</json:string><json:string>oncological interactions</json:string><json:string>oral fluids</json:string><json:string>dental therapeutics</json:string><json:string>cancer patients</json:string><json:string>mutual effects</json:string><json:string>oral complications</json:string><json:string>developmental abnormalities</json:string><json:string>dental implants</json:string><json:string>chronic pain</json:string><json:string>dental component</json:string><json:string>dental materials</json:string><json:string>antidepressant therapy</json:string><json:string>dental disease</json:string><json:string>oral surg</json:string><json:string>complication</json:string><json:string>systemic</json:string><json:string>dental</json:string><json:string>infection</json:string></teeft></keywords><author><json:item><name>Ralph H Rosenblum JR D.D.S., FACURP, ABQAURP</name></json:item></author><articleId><json:string>10.1177_0885713x9000500206</json:string></articleId><arkIstex>ark:/67375/M70-Z0C8H3HS-9</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. 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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Rosenblum</surname><given-names>Ralph H</given-names><suffix>JR</suffix></name><degrees>D.D.S., FACURP, ABQAURP</degrees></contrib></contrib-group>
<pub-date pub-type="ppub"><month>05</month><year>1990</year></pub-date><volume>5</volume><issue>2</issue><fpage>58</fpage><lpage>62</lpage><abstract><p>The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations.</p></abstract><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>58 Head and Neck Pathology Interactions with Clinical Outcomes SAGE Publications, Inc.1990DOI: 10.1177/0885713x9000500206 Ralph H JRRosenblum D.D.S., FACURP, ABQAURP The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations. Dental and craniofacial disease processes may lead to general medical complications with associated increases in moribidty and mortality. Conversely, side effects of accepted medical practice may create dental pathoses. These apparently unrelated problems can affect the speed and accuracy of a differential diagnosis, alter desired treatment schedules, increase length of stay and cost outliers, and contribute to overutilization of resources with associated decrease in quality of care. Awareness of the impact of head and neck pathology on clinical outcomes has great consequences to all health care professionals, particularly those involved in quality assurance and utilization review. PERIODONTAL AND ENDODONTIC INFECTIONS Pain and sensitivity as a result of periodontal (gums and bone) and endodontic (root canal) lesions make it difficult for patients to maintain proper nutrition, contributing to generalized malaise and decrease in resistance to other diseases (1). Periodontal and endodontic infections are the two most common dental sources of generalized systemic infections (2). An undetected, isolated periodontal or endodontic abcess that drains into the cardiovascular system may result in a fever of unknown origin and/or remote abcesses. BACTEREMIAS AND ANTIBIOTICS Bacteremias from these and other areas are of particular consequence for patients susceptible to endocarditis (3). Any dental procedure, even one as superficially minor as a rubber-cup prophylaxis (cleaning), will create a shower of bacteria entering the bloodstream. All patients with chronic, rheumatic or congenital heart disease; damaged heart valves; granulo- cytopenia ; arteriovenous shunts for renal dialysis or a history of intravenous drug abuse must be advised to follow the American Heart Association guidelines for prophylaxis for prevention of endocarditis (4). This means that the physician must inform the patient and any consulting dentist that this regimen is mandatory for all dental procedures. The dentist must also ignore any advice to the contrary and insist on antibiotic prophylaxis when treating patients with any of these complications. A therapeutic serum level of antibiotics at the time of any dental procedure will probably be sufficient to eradicate any bacteria entering the bloodstream. Failure to achieve adequate bacteriocidal levels coupled with low-level antibiotics residually present in many of today's foods may promote the systemic emergence of antibiotic resistant oral flora. Similarly, underutilization of prophylactic antibiotics in oral surgical procedures where periodontal or pericoronal infections exist or systemic conditions such as diabetes are present may lead to unnecessary and potentially life threatening musculofascial space and/or systemic infections with increased utilization of health care services (5). IATROGENIC COMPLICATIONS Dental treatment for endodontic desease can create iatrogenic complications. Overinstrumentation and/ or overfilling of the root canal can lead to perforation of the maxillary sinus with acute or chronic sinusitis and in the mandible damage to or necrosis of the inferior alveolar nerve. Untreated endodontic disease should always be considered in evaluating cases of chronic and/or acute maxillary sinusitis. 2959 A popular endodontic restorative material that has never met medical standards is the paraformaldehyde filling paste called N-2. Thirty percent of 2423 California dentists responding to a survey had used N-2 in their practices. This material contains the highly caustic fixative paraformaldehyde, radiopaque and toxic lead compounds, corticosteroids, and the connective tissue irritant phenylmercuric borate. This combination produces a long-lasting inflammatory response. It can cause apical periodontitis leading to osteomyelitis, and antigenicity with formation of auto- antibodies through sensitization by formaldehyde treated pulp. N-2 is a hapten eliciting a humoral response with resorbed, circulating particles actuating cell-mediated immunologic reactions such as chronic inflammation, resorption, foreign body reactions, an- kylosis, and necrosis (6). VIRAL AND FUNGAL INFECTIONS Viral and fungal infections can affect status and treatment progression of cancer and immunocompromised patients. Pain, inability to maintain nutrition, and increased susceptibility to infection can result in decreased patient cooperation, side effects of additional medications, and alterations in scheduled radio and chemotherapy regimens leading to increases in complications, utilization, and length of stay. Any oral infection in the immunocompromised host may present as pain, dysphagia, nutritional compromise, dehydration, or systemic infection. Viral lesions, especially HSV-1, may present as typical multiple vesicular lesions or nonspecific necrotic lesions. Oropharyn- geal-esophageal fungal infections may present as distinct pseudomembranous plaques or as erythematous, atrophic lesions that may mimic other inflammatory and infectious processes, such as HSV-1. Candidiasis, caused by the fungus Candida albicans, along with lesions of HSV-1, complicate the treatment of all patients in which it occurs (7). Patients with dental prostheses and recurring fungal infections should have their method of maintenance of the appliances evaluated. The hyphae of Candida albicans will colonize within the pores of acrylic denture bases, complete and partial. Though the oral mucosa cannot be sterilized, dental appliances can be sterilized to prevent self-recontamination via denture-borne fungi. Denture patients in general are at increased risk of nutritional deficiencies that can complicate treatment when symptomatic tissue lesions and areas of mechanical trauma occur because of poor fit of the prostheses. This impairs the patient's ability to eat and increases the potential for systemic infection due to open sores exposed to oral fluids and contaminated debris. Because of the contaminants in saliva and oral fluids remaining on materials sent to dental laboratories, dental laboratory workers are at increased occupational health risk. Without good barrier techniques in the lab when handling dental impressions and prosthetic repairs, these workers may be subject to viral, fungal, and bacterial infections. ONCOLOGICAL INTERACTIONS Diagnosis of oral cancers and dental treatment to try to control complications in all cancer patients is critical. Researchers at the Veterans Administration Medical Center, East Orange, New Jersey, reported that the absence of clinical leukoplakia (whiteness) does not preclude the diagnosis of cancer in patients at high risk. They found the majority of oral cancers to be red or predominantly red. "In a cigarette-smoking and alcohol-drinking population, an erythematous area that persists in high-risk sites (floor of mouth, lateral and ventral tongue, and soft palate complex) for 10 to 14 days or more, without apparent cause, is the earliest visible sign of carcinoma-in-situ or invasive squamous cell carcinoma" (7). An April 1989 conference sponsored by the National Institutes of Health titled "Oral Complications of Cancer Therapies : Diagnosis, Prevention and Treatment" reached some important conclusions about the oral complications and systemic ramifications of cancer treatments: 1. Prophylactic acyclovir is beneficial in selected patients to prevent herpes simplex virus reactivation. 2. Pre-existing dental problems should be identified by establishing baseline data with which all subsequent dental examinations can be compared. 3. Precise diagnosis of mucosal lesions and specific treatment of fungal, viral, and bacterial infections are essential. 4. Mucosal ulcerations should alert the cancer team to the risk of systemic infection. 5. The best treatments for chronic xerostomia should include fluorides. 6. Attention to oral hygiene and sialogogues are critical, especially during treatment. 7. Awareness of the problem of osteoradionecrosis is essential as it can be prevented, or when present, can be best managed with hyperbaric oxygen-with or without surgery. 8. In the pediatric population, it is important to recognize the long-term consequences of radia- 3060 tion therapy in addition to the dental and developmental abnormalities and secondary malignancies. 9. Major problems encountered with chemotherapy include mucositis, local or systemic infection, and hemorrhage. 10. Radiation therapy can lead to growth and developmental abnormalities, xerostomia, rampant dental caries, mucositis, taste loss, infection, dermatitis, trismus, and osteoradionecrosis. 11. Dental procedures should be completed 14 days before cancer therapy is initiated (8, 9). Psychosocial and physical problems following surgical resections of head and neck cancers present many complications to successful management. Oncological resolution is only the beginning of life-long care. Where surgical clefts and defects exist, an obturator must be created that allows the patient to eat and communicate. This should also be as aesthetic as possible to enable the patient to function both socially and professionally. The same problems of maintaining the mucous membranes and preventing viral, fungal, and bacterial infections exist as with any acrylic dental prosthesis. Many patients and families are not adequately prepared for the physical appearance after surgery, and require psychological support to minimize stress and maximize rehabilitation. The same dental considerations are critical in the medical management of special care and handicapped patients, aside from oncological problems. TEMPOROMANDIBULAR JOINT DISEASE Temporomandibular joint (TMJ) disease has been a misused diagnosis. This has led to overutilization and inappropriate utilization of services with no valid diagnosis to establish medical necessity. TMJ disease was originally used as a catch-all category for anything symptomatic from the clavicles up. This simply is neither acceptable nor true. The first step in an adequate differential diagnosis of TMJ disease is a complete medical history and examination designed to eliminate or identify alternative sources of chronic pain and dysfunction. The differential diagnosis includes causalgias; vascular disorders; intra or extra- cranial lesions or structural abnormalities; and rheumatic, neurogenic, or psychogenic conditions and my- ofascial pain dysfunction (though MPD could result from a bee sting). Documentation of actual intracapsular disease or degeneration is necessary to support a diagnosis labeled TMJ disease. Many dentists as- sumed that an incorrect bite relationship caused TMJ disease. There is, however, no documented or case experience showing this. Incorrect occlusion does cause a multitude of problems, but intracapsular TMJ disease does not appear to be one of them. The use of a passive oral orthotic (bite plane) can help in evaluating a dental component of chronic pain. Only if the symptoms are relieved by its use should dental evaluation be pursued. Diagnostic criteria for TMJ disease are dependent on the relative ability of different techniques to adequately visualize the joint. Good clinical judgement is the primary determinant of pursuit of a TMJ disease diagnosis. The symptomatic patient with joint sounds (though this may be a component of a normal joint) and pain on palpation of the condylar area may be a candidate for further TMJ evaluation. Normal dental radiographs are insufficient to diagnose intracapsular conditions. Panoramic and trans- cranial radiographs can be an indicator of possible fractures or degenerative changes. Dye-contrast ar- thrography, though invasive and ionizing, does adequately visualize the TMJ to confirm hard and soft tissue diagnosis. The noninvasive but ionizing CT scan is even more definitive, but the cost and availability tend to limit its use to the more diagnostically difficult cases. The MRI, noninvasive and nonioniz- ing, is probably the optimum method for assessing intracapsular TMJ disease. Arthroscopy of the TMJ has been proposed as a way to dynamically visualize the TMJ. To date, no studies are available to show that this invasive, expensive technique yields any diagnostic data superior to existing techniques, and therefore this technology at its current level of development for the TMJ is not recommended. Other technologies, such as mandibular kinesiography, have been shown to yield no valid clinical data (10). Documentation from any of the acceptable methods is necessary to validate the diagnosis of TMJ disease as a true, intracapsular condition. The choice of technique is based on the severity of the case balanced against invasive versus noninvasive approaches and the cost/benefit ratio of each procedure. The treatment of TMJ disease, once medical necessity is established, is either conservative or surgical. Unless otherwise indicated, palliative treatment (such as orthot- ics or physiotherapy) is the first choice, as some conditions will resolve with no further treatment. Active appliances or orthodontics are not appropriate until an intracapsular problem has been confirmed and a passive appliance has eliminated the symptoms. Surgical intervention is necessary only when there is demonstrated pathology of the TMJ and conservative treatment has not been successful. Inaccurate or mis- diagnosis of TMJ disease can mask other significant 3161 problems and delay treatment, while inappropriately overutilizing services (11). DENTAL IMPLANTS Dental implants are a currently uncontrolled area with significant possibilities for serious medical complications. Many advertisements by implantologists imply that a return to the function provided by natural dentition is possible. First of all, implantology is not a recognized specialty. Not all dentists have pursued the specialized training to learn the correct clinical evaluation and technique. Implants are available by mail order catalog, with no restriction on their use. The American Dental Association (ADA), though not a regulatory body, does classify implants and other materials through its Council on Dental Materials, Instruments, and Equipment (CDMIE). To date, only one endosseous dental implant (Biotes) has been classified as acceptable and that only in the totally eden- tulous patient. The Food and Drug Administration (FDA) has regulated dental implants since passage of the Medical Device Amendment of 1976, but only under 510K premarket notification status. This means that if the FDA finds an implant substantially equivalent to one on the market before 1976 it can be sold. Only now is the FDA taking action to regulate endosseous dental implants as Class III devices, requiring scrutiny under the agency's most stringent regulatory category and, if implemented, requiring premarket approval applications (12). To advise a patient whether or not to pursue an endosseous dental implant, aside from the regulatory considerations already mentioned, evaluation of systemic health and amount of available bone are critical. Definite systemic contraindications to endosseous implants are a past medical history of hypertension, blood disorders, angina pectoris, past myocardial infarction, bacterial endocarditis, diabetes mellitus, cirrhosis, seizures, pregnancy, chronic obstructive pulmonary disease, thyroid disorders, and adrenal disorders (13). Inadequate bone or poor surgical design has resulted in implants perforating the sinus, with resulting chronic sinusitis and systemic effects; damage to the inferior alveolar nerve; perforation through the mandible; and foreign body reactions and rejection of the implant with associated bone loss. Endosseous dental implants are not yet at the point to be universally applied, and inappropriate use may create or exacerbate medical problems. BENZODIAZEPINES AND DENTAL DISEASE Dental disease can occur secondary to depression and long-term antidepressant therapy. Tranquilizers (Thorazine, Compazine, etc.) have a side effect of reduction in salivary flow. This can result in xerostomia and rampant dental caries similar to that seen after radiotherapy. A vicious circle of a depressed patient, unable to tolerate or afford extensive dental treatment, developing extensive dental disease with associated pain, decreased nutrition, and increased susceptibility to viral, fungal, and bacterial infections can occur with the patient becoming even more depressed and angry. In long-term programs utilizing tranquilizers, it is important to consider interdisciplinary consultations, artificial salivas, and frequent dental maintenance. PSYCHIATRIC AND NEUROLOGICAL Patients who exhibit abnormal facial movements must be correctly evaluated to avoid unnecessary treatments and incorrect diagnoses. A dental patient seeking treatment for cheek biting and fracturing of anterior teeth received various treatments from several general practitioners and oral maxillofacial surgeons. None of these provided explanation of or relief from the symptoms. The dental symptoms were masking the more serious underlying neurologic disorder Meige syndrome and, in cases such as this, early referral to a neurologist is essential (14). On the other hand, Dr. Joseph Vitolo has reported that in this litigious era a diagnosis of tardive dyskinesia should first be evaluated for a dental component. Habitual tongue and cheek movements may simply be to moisten and reposition dental prosthetic appliances. RESTORATIONS Dental restorations can be responsible for medical and surgical complications. Unilateral removable partial dentures, designed to replace one or two teeth in an area, were used for many years. They are currently not recommended as they are easily dislodged during speech and eating, creating the possibility for obstruction and/or laceration of the esophagus or trachea (15). A fixed bridge or bilateral removable partial denture is much less likely to create these problems and is the preferred treatment. Porcelain and plastic facings on bridges and fractured denture teeth may be radiolucent. If swallowed or aspirated, they may result 3262 in lacerations, blockage, or foreign body reactions of the airway or GI tract (16). Dental and orthodontic appliances containing nickel-bearing wire have been shown to cause painful red, macular lesions with alveolar bone loss in nickel-sensitive patients. Dental amalgams, however, have been given an undeserved bad reputation by marginally scientific practioners. They have attributed leaching of mercury from amalgam restorations as contributing to "heavy metal poi- soning" and have profited from the sale of "counter- acting" medicaments and services. All scientific evidence to date shows that the mercury in dental amalgams remains in a safe and stable bound state (17). These restorations, if a casting is not necessary, remain the treatment of choice for posterior teeth. CONCLUSION Quality assurance and utilization review specialists have the responsibility of knowing their own areas of expertise and the interactions of other disciplines. The mutual effects between craniofacial and other medical pathologies and treatments, though not always obvious, may be very significant. An awareness of these mutual effects is essential when making a diagnosis and planning treatment to avoid a negative impact on clinical outcomes. References Gant DA, Stern IB, Listgarten MA Periodontics. St. Louis, MO, Mosby , 1988. Seltzer, S.: Endodontology, Biologic Considerations in Endodontic Procedures. Philadelphia, Lea & Febiger, 1988. Nelson CL, Van Blaricum CS, Physician and dentist compliance with American Heart Association Guidelines for prevention of bacterial endocarditis. JADA 1989;February: 169-173. Council on Dental Therapeutics. Prevention of bacterial endocarditis: A committee report of the American Heart Association. JADA 1985;January: 98-100. Lynch MA, Brightman VJ, Greenberg MS: Burket's Oral Medicine. Philadelphia, Lippincott, 1984. Cohen S., Burns RC: Pathways of the Pulp. St. Louis; MO, Mosby, 1987. Dentists first to see oral signs of HIV, cancer. Dental Management. 1989;April: 7. National Institutes of Health. National Institutes of Health consensus development conference statement: Oral complications of cancer therapies: diagnosis, prevention, and treatment . JADA 1989;July: 179-183. Jakush J.: Dental care "vital" to cancer patients. ADA News 1989;May 15:14,15. Feine JS, Hutchins MO, Lund JP: An evaluation of the criteria used to diagnose mandibular dysfunction with the mandibular kinesiogragh. J Prosthet Dent 1988;60(3):374-380. Rosenblum RH , Jr: TMJ: Medical necessity or litany of myth . ACURP Newsletter 1989;16:1-4. Jones SA: Implants face stiffer regulation. Dentist 1989;May: 1. Misch C.: Analysis of medical history pinpoints conditions that contraindicate implants . Dentist 1989;March:23-24. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Head and Neck Pathology Interactions with Clinical Outcomes</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Head and Neck Pathology Interactions with Clinical Outcomes</title></titleInfo><name type="personal"><namePart type="given">Ralph H</namePart><namePart type="family">Rosenblum</namePart><namePart type="termsOfAddress">JR</namePart><namePart type="termsOfAddress">D.D.S., FACURP, ABQAURP</namePart></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">1990-05</dateIssued><copyrightDate encoding="w3cdtf">1990</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">The relationships between craniofacial and other medical pathologies are not always obvious but may be very significant as they influence the extent of disease, accuracy of differential diagnoses, treatment schedules, and appropriateness and utilization of health-care resources. Among the relationships dis cussed are periodontal and endodontic infections, bacteremias and antibiotics, iatrogenics, viral and fungal infections, oncological interactions, temporo mandibular joint disease, dental implants, antide pressant therapy, psychiatric and neurological influ ences, and dental restorations.</abstract><relatedItem type="host"><titleInfo><title>American journal of medical quality</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">0885-713x</identifier><identifier type="eISSN">1555-824X</identifier><identifier type="PublisherID">AJM</identifier><identifier type="PublisherID-hwp">spajm</identifier><part><date>1990</date><detail type="volume"><caption>vol.</caption><number>5</number></detail><detail type="issue"><caption>no.</caption><number>2</number></detail><extent unit="pages"><start>58</start><end>62</end></extent></part></relatedItem><identifier type="istex">B0FFC930692861A8076694B470499EA3ECF2B9EF</identifier><identifier type="ark">ark:/67375/M70-Z0C8H3HS-9</identifier><identifier type="DOI">10.1177/0885713x9000500206</identifier><identifier type="ArticleID">10.1177_0885713x9000500206</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/B0FFC930692861A8076694B470499EA3ECF2B9EF/metadata/json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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