A 12-Month Randomized Clinical Trial of 38% SDF vs. Restorative Treatment.

PURPOSE: The aim of this 2-arm, parallel-group, 12-mo randomized clinical trial was to compare the effectiveness of semiannual application of 38% silver diamine fluoride (SDF) versus restorative treatment (RT) to manage cavitated caries lesions in primary teeth in a diverse population of children in Michigan. METHODS: Children aged 2 to 10 y with at least 1 soft cavitated lesion (International Caries Detection and Assessment System 5 or 6) with no pain or signs/symptoms of irreversible pulpitis were recruited and randomly assigned to 2 intervention groups. One random lesion per child received 38% SDF (twice, at a 6-mo interval) or RT. All interventions and assessments were done by calibrated dentists. Primary outcome measures were clinical failure rates: minor (e.g., reversible pulpitis, active/soft lesion or progression, restoration loss or need for replacement/repair, secondary caries) and major (e.g., irreversible pulpitis, abscess, extraction). Parent, child, and provider acceptability was also assessed. RESULTS: Ninety-eight children were enrolled and randomized, with a mean (SD) age of 4.8 y (1.8); 46% were female and their mean dmft + DMFT was 6.3 (3.9). Sixty-nine children were assessed at 12 mo (sample was within the planned 30% attrition rate). There were significantly more teeth with minor failures (SDF = 65%, RT = 23%, P ≤ 0.001) and major failures (SDF = 13%, RT = 3%, P ≤ 0.001) in the SDF group than the RT group; 74% of SDF-treated lesions were hard at 12 mo vs. 57% at 6 mo. Providers stated that SDF was easier, faster, and more preferable than RT (P ≤ 0.001). No significant differences were found in parental satisfaction and acceptability. At 12 mo, children in the RT arm felt significantly (P < 0.05) happier with their tooth appearance and stated that their visit to the dentist hurt less. CONCLUSION: At 12 mo, SDF-treated lesions had significantly more minor and major failures than RT, suggesting that SDF-treated teeth need to be closely monitored in a population at high caries risk (ClinicalTrials.gov NCT02601833). KNOWLEDGE OF TRANSFER STATEMENT: The results of this study can be used by clinicians when deciding whether to restore or apply silver diamine fluoride to cavitated lesions in primary teeth. Information on treatment outcomes and parent, child, and provider acceptability can help guide appropriate treatment decisions and need for monitoring.

Porocarcinoma of the eyelid.

PURPOSE: The purpose of this report is to describe the clinical and histopathologic findings in a patient with porocarcinoma of the eyelid. METHODS: The case of a 68-year-old woman with a nodular lesion of the eyelid was studied, and the pertinent literature reviewed. RESULTS: No previous description of porocarcinoma of the eyelid was found in the literature. The present case presented with a nodular lesion of the right lower eyelid of 1-year duration. The tumor was completely excised. Microscopic study revealed ductal structures within lobules of tumor cells. CONCLUSIONS: Porocarcinoma is a rare cutaneous adnexal tumor arising from the eccrine secretory apparatus. Because the clinical behavior of this cancer includes deep invasion, regional lymphatic spread, and distant metastases, complete surgical excision is recommended, and should be verified by either conventional frozen sections or Mohs' micrographic sections.

Juvenile ossifying fibroma of the orbit.

Juvenile ossifying fibroma is an osseous tumor encased in a sclerotic shell. We report findings of juvenile ossifying fibroma in the orbit of a six-year-old boy. The bony aspects of this tumor may be suspected on physical examination. Magnetic resonance imaging was not helpful in the diagnosis of this fibroma. In fact, the technology was misleading because it did not define clearly the bony aspects of the tumor. In this case, the less costly computerized tomography revealed the bony encasement of the tumor and best defined the borders. With the trend in health care of cost containment, it may be that computerized tomography is the appropriate primary imaging study for some suspected orbital tumors based on thorough clinical examination.

The significance of positive margins (known and unknown) at the conclusion of Mohs surgery in the orbital region.

The Mohs fresh tissue technique has provided a high rate of cure in cases of malignant tumors in the orbital region. However, in some patients, tumor may persist after Mohs surgery if margins are falsely negative or if the Mohs surgeon elects to terminate the procedure with known positive margins. We report six patients who had residual tumor present in the periorbital region after Mohs surgery. These patients have a serious prognosis associated with subsequent morbidity. Accurate communication between the Mohs surgeon and subsequent treating surgeons, combined with aggressive tumor management, may help to minimize morbidity and improve mortality.

Role of dacryocystectomy in the management of failed dacryocystorhinostomy associated with chronic dacryocystitis.

Three patients had recurrent chronic dacryocystitis but no epiphora associated with failed dacryocystorhinostomies. Dacryocystectomy was performed on all three patients. These patients were cured of dacryocystitis following dacryocystectomy and none had epiphora postoperatively. There may be a group of patients with dry eyes and chronic dacryocystitis in whom dacryocystorhinostomy is likely to fail. Such patients may respond favorably to dacryocystectomy.

Semicircle flap reconstruction "plus".

The semicircle flap is an excellent method for reconstructing upper and lower eyelid defects. The procedure may be combined with recognized techniques such as skin grafts, tarsal flaps, and other surgical manipulations. Five such additions to the semicircle flap are described. These combined techniques can expand the range of the procedure, increase its versatility, and improve the results.

Eye banking: techniques for eye preservation in selected neoplasms encroaching on the globe.

Removal of the globe and associated structures has been advocated for tumors invading the periorbital bone and periosteum, orbital fat, or extraocular muscles. In some patients with cancerous tumors encroaching on the globe, however, it may be possible to remove the tumor and save the eye. Tenon's fascia is a firm fibrous sheath surrounding the entire globe except the cornea. If the neoplasm spreads along fascial planes rather than through them, and if this layer remains free of tumor involvement, preservation of the globe can be considered. Oculoplastic reconstructive techniques may limit exposure and diplopia, allowing the eye to be "banked" in vivo, and saved as a spare for the future. Six patients with malignant tumors encroaching on the globe have had definitive surgical extirpation with preservation of the eye. Three patients have had the globe uncovered successfully. Five of six patients remain disease-free, with followup from 6 months to 6 years. No globes have been removed. These techniques appear to be therapeutically sound, preserve function and appearance, and improve patient morale. The indications and limitations of this approach to certain cases of periorbital cancer are discussed.

Primary nonkeratinized epithelial ('conjunctival') orbital cysts.

The types of orbital cysts that are most familiar to ophthalmologists are epidermoid and dermoid cysts, both of which are lined by keratinized stratified squamous epithelium. We studied six patients who had orbital cysts lined by nonkeratinized epithelium that resembled normal conjunctiva. Compared with epidermoid and dermoid cysts, these primary nonkeratinized cysts tend to cause symptoms later in life, occur preferentially in the superonasal aspect of the orbit, and are less likely to be associated with underlying bony changes.

Atypical fibroxanthoma of the eyelid.

Atypical fibroxanthomas are tumors that arise in the skin, show strikingly atypical cytologic features, but usually follow a benign clinical course. The authors present a case of atypical fibroxanthoma involving the eyelid. Although early reports noted a favorable prognosis, these tumors can recur aggressively and metastasize. Therefore, complete excision is recommended for atypical fibroxanthomas around the eye.

Distention of the lacrimal sac in neonates.

We present seven cases of neonatal lacrimal sac distention, ranging from sterile dacryocystocele, subacute dacryocystitis, and acute dacryocystitis. Three patients were cured by probing, one by digital pressure decompression, and two by silicone tube intubation.

Periocular malignant fibrous histiocytoma.

We present a case of periocular cutaneous malignant fibrohistiocytoma that invaded the orbit. Complete excision is recommended for atypical fibrohistiocytic tumors around the eye. Examination of specimen margins by frozen section should be undertaken with caution. It is recommended that frozen section evaluation be performed by a pathologist familiar with spindle cell neoplasm to ensure complete removal of this tumor.

Complications of eyelid reconstruction using a semicircular flap.

Complications of the semicircular flap technique of eyelid reconstruction include lateral canthal webbing, ectropion, lid notching, symblepharon, and tissue fullness of the lateral lid. These difficulties occur infrequently and rarely cause significant problems. Attention to surgical details, however, can minimize unfavorable results. It should be emphasized that the semicircular flap remains a superb technique for reconstruction of defects involving up to 80% of the lower eyelid.

Large periocular keratoacanthoma: the case for definitive treatment.

Keratoacanthoma can usually be distinguished from squamous cell carcinoma. However, some tumors share certain characteristics of both lesions. There is a large group of actinic keratoacanthomas cytologically identical to squamous cell carcinomas. In locations other than the ocular adnexae, conservative therapy is often recommended for keratoacanthomas since these lesions tend to regress spontaneously. Two patients with large periocular keratoacanthomas illustrate some of the diagnostic and therapeutic dilemmas related to rapidly growing potentially malignant lesions about the eye. Extensive tissue destruction and possible recurrence following excision favor definitive surgical therapy in these cases.

Subtotal reconstruction of the upper eyelid. A one-stage procedure eliminating temporary lid closure.

Subtotal reconstruction of the upper eyelid may be achieved by using a semicircular flap at the lateral canthus combined with a medial sliding tarsal flap covered with a skin graft. This is a single-stage procedure that does not necessitate prolonged closure of the lids postoperatively.

Malignant Merkel cell neoplasm of the eyelid.

Malignant Merkel cell neoplasms of the eyelid are most commonly found in elderly patients. They occur most frequently on the upper eyelid and are seen as large, nontender , red or violaceous masses with intact overlying skin. Differential diagnosis includes lymphoma and oat cell carcinoma. Conventional light microscopic features are usually distinctive, but tissue should be saved for electron microscopy and immunocytochemical studies, since the presence of dense-core neurosecretory granules and perinuclear microfilaments on electron microscopic examination and positive staining for neuron-specific enolase, are strongly suggestive of malignant Merkel cell neoplasm. Because of the diffuse infiltrative growth pattern and early lymphatic spread of this tumor, treatment requires careful examination of regional lymph nodes and wide surgical excision of the tumor with frozen-section control of margins.