Pathology and Diagnostic Posts

Digital photography and documentation techniques in Dentistry and Dental Technology

Digital photography and documentation techniques in Dentistry and Dental Technology



The digital image is completely different from the chemical (analog) one to which many were used to, the characteristics are different. The terms below are the basics or the minimum you need to know to make the best use of any camera you already have, that you want to buy or replace. These pages are a stimulus to photographically document all cases of which you should have documentation, and the reasons are many, I will express only a portion of the digital information needed for anyone who is about to start to document, but I will also give information on the practical use for the more experienced. The intention is to continue with more articles, more detailed and specific for doctors and technicians. For every important topic that I will be using multiple images to be as comprehensive as possible, so that anyone should be able to understand and put into practice the information needed to make the most of their own equipment. You have to know the subject, “Digital Photography”, which is not just about cameras, lenses and flash, but also computer terms that are often found in the menu settings of digital cameras. Some settings are often overlooked or, not having some knowledge of ??computer terms, are incomprehensible. The topics with the most images will be mainly the settings and functions that can benefit medical records which, if clearly understood (the examples with pictures are often the most understandable), may also be useful for the use of the camera outside of the medical office or laboratory.


Clinical records have always been essential and have now developed to the point where we find applications both in the medical and technician offices, the reasons are many, I will mention the most important: use pictures to train or communicate with staff, exchange of information with dental technician, to show patients the work to be carried out in their mouth with photos (“now called marketing”), consultation among colleagues and, last but not least, for any medical-legal issues. Only good documentation with photos, x-rays and models can prove that we have done good work before any judge. All the archived documentation of the treated cases have allowed those who have been working as a lecturer or speaker to pass on their own experience. The increased use of the computer in the office allows all dentists and dental technicians to be able to document their work, digital documentation has big advantages over the “old” analog (on film) documentation. I would say that the possibility to see the pictures in real time and store them later directly in the patient’s file, or with the new “WI-FI” card we can transmit and store them directly in the patient’s file at the time they are taken, this allows us to view them on the screen (or on a screen positioned on the wall visible to the patient, or on the monitor now applied on many treatment units) and to discuss them in real time with the patient. If we want, we can also print them immediately, all this can be done with the patient sitting on our chair. If we want we can make a copy of the images to give to the dental technician or the patient, these copies will be exactly the same as the originals and, no matter the type of media you use to record images, such as: Compact-Flash, SD, Memory-Stick , XD-Picture, etc. All media will be readable on any computer. With analog equipment this was not possible, so I abandoned both film and analog cameras more than fifteen years ago. The choice of digital cameras is endless, among digital compact and dSLR we can choose between three hundred different models, but here we will quote the most widely used in medical and dental technician’s offices. Digital cameras fall into three categories:

The “Compact”, are, more or less, the size of a pack of cigarettes, and vary from one compact to another or from the difference of the lens or from the sensor, often, however, among the compact cameras only some fully meet our needs.
Fig. 001 compatta

Then we have the “Bridge” ,that is, a cross between a compact and a dSLR, as some are almost as big as a dSLR with a standard lens.
Fig. 002 bridge
Lastly, the “dSLR” are bodies on which you can mount all the lenses that the camera’s manufacturer produces.

Fig. 003 reflex nikon

The reflex, if equipped with a dedicated macro lens and appropriate flash for macro photography, gives good results, or if we use the best macro lenses and the latest flashes that can be used wireless (cordless) on brackets with movable arms to direct the light where we need it the most, the results that can be achieved are outstanding.

Bisphosphonates in Dentistry and Osteonecrosis of the Jaws

Bisphosphonates in Dentistry and Osteonecrosis of the Jaws


Osteonecrosis of the jaws is a rising issue of multidisciplinary medical interest, unknown until the last decade of the 20th century, that has also had great resonance in the field of dentistry in recent years. This phenomenon is a potential adverse reaction to drugs of the bisphosphonate class containing nitrogen (aminobisphosphonates). Although the present scientific evidence does not support the existence of a cause-effect relation between the use of the drug and the onset of the disease, many epidemiological and experimental studies confirm the strong association between IV bisphosphonates (injectable solution) pharmacological treatment and the development of osteonecrosis of the jaws. IV bisphosphonates are thought to be the major risk factors for the onset of the disease: the cumulative incidence is estimated to be between 0.8% and 12%.

The overall risk to develop that condition for the patients undergoing aminobisphosphonate therapy is not yet clearly assessed; it is nonetheless possible to state, on the basis of epidemiological studies and clinical observations, that the risk is higher for the patients that have been administered the drug intravenously rather than orally.

The diagnostic criteria introduced by the American Association of Oral and Maxillofacial Surgeons for bisphosphonates-related osteonecrosis of the jaws require the concurrence of three factors: current or previous treatment with the drug, exposure of bone tissue in the maxillofacial area for more than eight weeks and absence of positive anamnesis for radiation therapy to the jaws.



Bisphosphonates, and particularly aminobisphosphonates, are drugs that present a high affinity for circulating calcium and calcium that is present on the bone surface: moreover, they remain present in the bone tissue for many years. They are strong inhibitors of bone resorption and remodeling since they stop the osteoclasts’ differentiation and their enzymatic activity (collagen degradation). At high concentrations they are able to induce the osteoclasts’ apoptosis.


Brand NameActive IngredientRoute of administration
FosamaxAlendronate sodiumOral
ActonelRisedronate sodiumOral
BonivaIbandronate sodiumOral, intramuscular
ArediaPamindronate disodiumIntravenous, intramuscular
ZometaZoledronic acidIntravenous, intramuscular
ReclastZoledronic acidIntravenous, intramuscular



  • Osteoporosis treatment
  • Paget’s disease
  • Bone metastases from solid tumors
  • Multiple myeloma
  • Malignant Hypercalcemia

Some aminobisphosphonates administered in specific concentrations are able to inhibit angiogenesis and thus have direct antitumor effect.




  • Potency
Brand nameActive Principle Relative Potency
ZometaZoledronic acid100.000
ReclastZoledronic acid100.000
  • Length of the therapy

A longer duration of the therapy is associated with an increasing risk, especially if the therapy exceeds three years. The risk for the patients is 1% during the first year of treatment and rises to 11% after 4 years. The risk for the patients taking zoledronate only is 21% after 3 years.

  • Combining two or more aminobisphosphonates

Combined administration of zoledronate and pamindronate shows a ten-fold increased risk.




How to recognize and treat this medical emergency


Systemic anaphylaxis represents the most critical and potentially fatal event within allergic manifestations (1). The phenomenon has been described in ancient medical literature and the first documented episode of anaphylaxis is reported on a hieroglyph of 2640 b.c. describing the death of pharaoh Menes from the wisp of a wasp. Nevertheless, the term anaphylaxis has been introduced only in 1902, by Charles R. Richet e Paul J. Portier, two investigators that described anaphylactic reactions in the animal experimental model. The phenomenon was initially described by the greek term a-phylaxis meaning “lack of protection” becoming for euphonic reasons anaphylaxis, a term which rapidly spread all over the world. For their studies, Richet e Portier won the Nobel prize in 1913.

There is limited knowledge about the exact prevalence and incidence of anaphylaxis in the general population. Foods and drugs including contrast media administration represent the most common elicitors of severe anaphylactic episodes (1: 5.000) (2, 3). Recent studies indicate that prevalence rates of severe anaphylaxis (1-3: 10.000 subjects) may be higher in USA and Australia, characterized by 0,65%-2% fatal events, that is 1-3 in a million of patients (4).



Anaphylaxis stricto sensu is a type I immunological reaction mediated by the interaction between IgE antibodies and a bivalent or multivalent antigen. The interaction between IgE linked to high affinity receptors (FceRI) present on the surface of effectors cells of allergic reactions (tissue mast cells and basophils) and the antigen (allergen) induces the release of vasoactive mediators (histamine, tryptase, leukotrienes, prostaglandines, platelet activating factor ecc.) (5). In addition, there are cases with very similar clinical symptomatology of anaphylaxis where immunological sensitization is not detectable and which have been called anaphylactoid or pseudo-allergic reactions (6). The mechanisms of these reactions include direct activation of mast cells and basophils not mediated by IgE antibodies, activation of the complement or other plasma protein systems (coagulation, kallikrein-kinin) as well as neuro-psycogenic reflex mechanisms. For example, it is well known that psychological stress alone can lead to increased plasma histamine levels (7). Anaphylactoid reactions can be induced by administration of contrast media, destran, protamin or general anesthetics.

There is a broad spectrum of elicitors of anaphylactic or anaphylactoid reactions. The most common elicitors of anaphylaxis are foods, drugs, drug and food additives, latex, microbial and physical agents ( table 1)

Table 1: Elicitors of anaphylactic and anaphylactoid reactions
Drugs (antibiotics, aspirin, ecc.)FoodsAdditivesLatex

Animal venoms


Allergen immunotherapy

Seminal fluid

Contact urticariogens

Physical agents (cold, heat, UV radiation)


Echinococcal cyst

Underlying disease

Complement factor 1-inactivator deficiency

Systemic mastocytosis


Clinical manifestations

Systemic anaphylaxis represents the most severe expression of an allergic reaction. The phenomenon represents a syndrome of different symptoms involving various organs which may develop either alone, simultaneously or subsequently. Most commonly:

  • symptoms start in the skin (pruritus, flush, urticaria, angioedema) and the neighbouring mucous membranes (pruritus and paresthesia of palat, pharynx and/or genital mucosa)
  • proceed to the respiratory tract (rhinorrhoea, sneezing, hoarseness, dysphonia, laryngeal oedema, cough, laryngeal obstruction, bronchospasm, respiratory arrest)
  • may involve the gastrointestinal system (cramps, nausea, vomitus, defecation, diarrhoea) and also miction and uterus cramps may occur
  • may be characterized by cardiovascular symptoms of different severity (tachycardia, blood pressure changes, arrhythmia, shock, cardiac arrest). Cardiac manifestations in anaphylaxis may be observed in ECG changes (T fluttering, supraventricular arrythmia, AV-block) (8,9).

Prodromic symptoms of anaphylaxis comprise paraesthesia on palms and soles, “fishy taste”, anxiety, headache or disorientation.

A grading scale for severity scoring of anaphylaxis is here illustrated (Table 2).

Allergy to local anesthetics in dental practice




Local anesthetics (LAs) are drugs widely used in clinical practice having revolutionized modern medicine from both the diagnostic and therapeutic point of view. In the first case, these drugs are used for patients’ preparation for different procedures (endoscopic, radiologic etc.) whereas in the second case they provide anesthesia for surgical interventions. As such, these agents are commonly administered in dental practice.

LAs were discovered in 1884, by a young Viennese ophthalmologist, Carl Koller that instilled cocaine, a natural agent, in his conjunctiva obtaining an anesthetic effect. A few years later, the first synthetic anesthetic Procaine, was produced (Einhorn, 1904) (1).

As LAs have been widely and increasingly used since last century, different LA agents have been synthesized. LAs can induce adverse reactions following their administration. In particular, allergic (hypersensitivity) reactions to local anesthetics have been reported; although these reactions are rare, in some cases the problem seems over-estimated being responsible for frequent therapeutic abstaining.

Therefore, this communication aims to point up the pathogenic and clinical aspects of hypersensitivity reactions to local anesthetics in order to offer a “model of behavior” for dentists who may face different adverse reactions induced by LAs in the daily clinical practice.

EBD, Impact Factor and PubMed

EBD, Impact Factor and PubMed




The studies reported in the literature used to perform systematic reviews can be briefly classified as follows.

Scientific studies can be carried out as either experiments or observations. In the former, the researcher sets all the evaluable parameters of the study while, in the latter, he merely observes the clinical events. The temporal lasting of the study can be considered as a precise moment in time (transversal studies) or as a running line over time (longitudinal studies). The latter can in turn be conducted on pre-existing data (retrospective studies) or on data which is collected over time (prospective studies).


EXPERIMENTAL STUDIES (the most significant in terms of evidence):


1. Randomized controlled clinical studies represent the gold standard. Randomization (random assignment to the test group or to the control group) and double blinding (neither the researcher nor the patient know if the patient belongs to the test group or the control group) allow the researcher to lower the risk of introducing bias.

2. Non-randomized controlled clinical studies are performed as above reported but they are not randomized.

OBSERVATIONAL STUDIES (characterized by a less important level of evidence):


1. Group or cohort studies (or prospective). Two groups are compared: one group is made up of individuals exposed to the causal treatment/agent while the other is the control group. Both are observed over time (prospective study) in order to deduce the incidence of a given pathology/condition.

2. Case/control studies (or retrospective). Two groups are monitored; only one is made up of individuals affected by a given pathology/condition. The two groups are assessed on the basis of data collected in the past (retrospective or historical study) to discover the causal agent.

3. Transversal studies (or prevalence). The observation is limited to a given period of time.

Currently, the most important source for keeping abreast of the updates in medicine is the scientific literature. Nevertheless, when attempting to consult it, numerous problems are encountered, due to the great number of scientific articles which have accumulated over the decades.

By means of the internet it is now very practical to search for scientific articles using the MEDLINE database (Medical Literature Analysis and Retrieval System Online), run by the American NLM (National Library of Medicine). It is freely available for consultation through Entrez and the dedicated search engine Pubmed. MEDLINE contains more than 16 million index-linked articles, enabling specific searches.

The Cochrane Collaboration offers a similar method for analyzing the available medical databases. The synthetic results obtained are summarized in the so-called Systematic Reviews, published on the Internet in an electronic database named the Cochrane Library.

The expression “systematic review” refers to the results of an analysis of the scientific literature available on a whole particular topic conducted according to the EB rules (Evidence-Based). In particular, the systematic review can be distinguished from other types of analyses by the fact that the entire procedure is conducted applying the following criteria:

1) The questions must be formulated according to the so-called PICO rule (Population, Intervention, Comparison and Outcome). This methodology involves choosing one group of individuals (Population) to be subjected to a specific type of intervention (Intervention). The latter must be compared to other types of intervention or to a placebo (Comparison) in order to study and interpret the obtained results (Outcome).

2) The data collected (by consulting internet databases, printed journals or experts in the sector) is critically assessed so as to assign it a level of scientific validity. In this context, the studies can be listed on the basis of decreasing validity as follows:


a) Randomized controlled studies (RCTs);

b) Non-randomized controlled studies (CTs);

c) Cohort Studies;

d) Case/Control Studies;

e) Crossover Studies;

f) Case Studies;

g) Expert Opinions.


The level of scientific evidence has in turn been classified into 5 levels by the U.S. Preventive Services Task Force:

Level I: at least one well-planned randomized controlled study;

Level II-1: non-randomized controlled studies;

Level II-2: group studies or case/control studies, preferably conducted by more than one centre or research group;

Level II-3: case reports and series with or without the intervention. Even a dramatic result in an uncontrolled study belongs to this type of evidence;

Level III: opinions of experts based on clinical experience, from descriptive studies or from committees’ reports.


3) Analysis of the data must allow for the validity of the study to be determined, which must be of two types:

a. Internal, concerning the method used to devise the study and thus its rationality;

b. External, concerning the possibility of applying the results obtained to the general population.

Different systematic reviews can be subjected to a meta-analysis. This is a statistical analysis performed by assigning values of scientificity and reliability by means of the characteristics used to design and realize the study. Meta-analyses allow for the comparison of different studies and enable general and validated clinical information to be extracted.

4) The final results of a systematic reviews are critically examined in order to provide practical indications and to identify the basis for further investigations.

5) A Consensus Report is supplied by groups of researchers and clinicians with experience, stature and International credibility, who are requested to create the report on a specific topic. This is done by answering the following questions:

a. Do you believe that the systematic review is complete and accurate?

b. Does new information exist which came to light after the preparation work ended?

c. Can the reviewers’ interpretations and conclusions be shared?

d. What research is still necessary in the field examined?

e. Are the results of the systematic review useful for the treatment of patients?

In particular, the answer to point “e” classifies the practical usefulness of the results.

This usefulness is categorized on the basis of the level of evidence of the studies which produce the results. The evidence is defined as follows:

a. Strong: level I coherent studies;

b. Moderate: level II-1 or II-2 coherent studies or extrapolations from level II-1 studies;

c. Limited: level II-3 studies or extrapolations from level II-1 or II-2 studies;

d. Incomplete or insufficient: non-coherent or non conclusive studies of any level, anecdotal evidence or level III.


Bisphosphonates in Dentistry

Bisphosphonates in Dentistry


Bisphosphonate therapy and the manifestation of a rare and severe complication, namely the osteonecrosis of the maxillary bone, are currently very important topics to which increasing attention is being given by specialists. The dental surgeon’s awareness and concern toward this pathology, together with a degree of alarmism, is justified by the increasing number of cases that since 2003 till today have enabled observing and studying the clinical and anatomo-pathologic case history, the localization of the pathology, the associated risks and the possible development and consequences of the osteonecrosis lesions. Epidemiological data are more unclear as they do not actually consent defining the exact prevalence and incidence of the phenomenon, the pathogenic hypothesis and the causal relationship related to the use of the bisphosphonates.

Other uncertainties predominate the scenario of the therapeutic possibilities that seem inadequate to tackle the needs of patients affected by osteonecrosis of the maxillary bone. Till now, there is no therapy leading to resolution of the lesions, neither has the suspension of the therapy, in some cases, led to improve the effects.

In the light of these considerations, the goal that dental surgery must achieve is to arm itself with whatever means possible in order to at least reduce the negative side-effects of this symptoms, often painful, and the risks of bacterial or other microorganism contaminations which worsen the case history and compromise the general health of the patient. The aim of this article is to illustrate, as a schematic overview, the current knowledge on bisphosphonates.

Definition: Bisphosphonates are non-hormonal substances, active in mineral bone homeostasis. Structural analogues of inorganic pyrophosphates but resistant to enzymatic hydrolysis, bisphosphonates are molecules able, through a rigid bond with hydroxyapatite crystals, to modulate skeletal turnover and, in particular, selectively inhibit osteoclast mediated bone reabsorption.

Commercial products



Adronate (Neopharmed)


Alendronic acid

Alendronato Pliva (Pliva Pharma)


Alendronate Ratiopharm (Ratiopharm GmbH-D)


Alendronate Teva (Teva Pharma Italy)


Alendros (Abiogen Pharma)


Dronal (Sigma-Tau)


Dronal 70 (Sigma-Tau)


Fosamax (Merck Sharp Dohme)


Genalen (Gentili)


Etidron (Abiogen Pharma)




Bondronat (Roche Registration – GB)




Bonviva (Roche Registration – GB)


Aredia (Novartis Farma)

Intravenous drug

Pamidronic Acid

Amidrox (Crinos)

Intravenous drug

Pamidronate Disodium IBP

Pharma (IBP Pharma)

Intravenous drug

Texpami (Pharmatex Italia)

Intravenous drug

Pamidronate Disodium Mayne (Mayne Pharma Italy)

Intravenous drug (for hospital use only)

Actonel (Procter & Gamble)




Optinate (Lepetit)


Clodronic Acid EG (Eg)

Intravenous drug



Clodronic Acid Sandoz (Sandoz)

Intravenous drug

Clodronic Acid

Union Health (Union Health)

Intravenous drug

Clasteon (Abiogen Pharma)


Climaclod (Mastelli)

Intravenous drug

Clodeosten (B&G)

Intravenous drug

Clodron (Fidia pharmaceuticals)


Clodronate ABC (ABC pharmaceuticals)

Intravenous drug

Clodronate Teva (Teva Pharma Italia)

Intravenous drug

Clody (Promedica)


Difosfonal (SPA)

Intravenous drug

Disodium Clodronate Alter(Alter)

Intravenous drug

Moticlod (Lisapharma)

Intravenous drug

Niklod (Savio I.B.N.)

Intravenous drug

Osteonorm (Piam)

Intravenous drug

Osteostab (Rottapharm)

Intravenous drug

Soclonat (TB Technology)

Intravenous drug

Aclasta (Novartis Europh-GB)

Intravenous drug



Zometa (Novartis Europh-GB)

Intravenous drug

Bone binding affinity and biological potency

The antireabsorptive potency of bisphosphonates depends on the bone binding affinity and their ability to inhibit osteoclast action. The binding affinity of various bisphosphonates to the bone depends on the molecular group in the R1 side chain and is increased by the presence of a group – OH or – NH2 in that position. The different affinities of the bisphosphonates influence the drug quantity accumulated, the persistence of the bone matrix and the duration of action.


In increasing order of affinity:

Clodronate, etidronate, pamidronate, risedronate, ibandronate, alendronate, zolendronate [3]

The potency of inhibition of the osteoclast action depends on the molecular group in R2. Bisphosphonates with a -NH2 group in that position (amino-bisphosphonate) are more potent than those lacking this group (non amino-bisphosphonate) as they are able to arrest the osteoclast action through the inhibition of mevalonic acid pathway (see next paragraph). The potency is also related to the three-dimensional conformation of the R2 chain and therefore, to the length of the chain and to the introduction of methyl, pentilic, imidazole and benzene groups.