Eosinophilic sialodochitis: An emerging atopic condition.

OBJECTIVE: To report the clinical characteristics of the largest single centre cohort of patients with eosinophilic sialodochitis. METHODS: Analysis of data relating to 37 patients seen in a dedicated multidisciplinary clinic was performed. Demographic, clinical, haematological, cytological, histological and radiological features were collated. Response to trials of allergy treatment was assessed. RESULTS: Thirty-seven patients (30 female, seven male) were identified, 42% of whom were of Afro-Caribbean origin, with a mean age of 50.4 years (range 28-80 years). Mean symptom duration at presentation was 10 years (range 2-33 years). Parotid and submandibular gland involvement was equally reported. The most commonly reported symptoms were swelling (97%), itching of the overlying skin (92%), salivary gland discomfort (84%) and "string-like" mucus discharge from salivary duct orifices (76%). Twenty-three patients (62%) demonstrated atopic disease and serum IgE level elevated in 57%. All 37 patients had eosinophils present in aspirated duct contents samples while raised peripheral eosinophil count was seen in 41%. Anecdotal symptom improvement was reported with antihistamine, antileukotriene or steroid treatment. CONCLUSION: Eosinophilic sialodochitis should be considered in any patient presenting with recurrent salivary gland swelling. Further studies are needed to evaluate treatments directed at a likely allergic pathogenesis.

Predictive value of ultrasound scoring in relation to clinical and histological parameters in xerostomia patients.

BACKGROUND: Salivary gland dysfunction is one of the main clinical features of Sjögren's syndrome (SS), manifested by xerostomia with subsequent complications and well-established effects on the person's quality of life. OBJECTIVES: To determine firstly whether selected tests of salivary gland function and structure, unstimulated whole salivary flow rate (UWSFR), parotid flow rate (PFR), clinical oral dryness score (CODS) and ultrasound score (USS), can discriminate SS from non-SS sicca patients and secondly whether these tests can differentiate between patients in different subgroups of SS. METHOD: Unstimulated whole salivary flow rate, PFR, CODS and USS were determined in 244 patients comprised of SS patients (n = 118), SS patients at higher risk of lymphoma (n = 30) or with lymphoma (n = 26), and non-SS sicca disease controls (n = 70). RESULTS: All assessments showed a significant difference between the overall SS group and the disease control group, attributed mainly to the lymphoma subgroups of SS (p < 0.0001 for all parameters). There was a significant correlation (Spearman r = 0.7, p value <0.0001) and 87.3% agreement between USS and the histology focus scores of 119 patients. CONCLUSION: The results suggest that salivary gland tests including USS can aid in differentiating between SS and non-SS dry mouth, especially the subgroups of SS with lymphoma or at higher risk of developing lymphoma.

Biomarkers of systemic inflammation provide additional prognostic stratification in cancers of unknown primary.

BACKGROUND: Biomarkers of systemic inflammation have been shown to predict outcomes in patients with cancer of unknown primary (CUP). We sought to validate these findings in patients with confirmed CUP (cCUP) and explore their role alongside existing clinicopathological prognostic categories. PATIENTS AND METHODS: CUP oncologist from across the United Kingdom were invited to include patients with cCUP referred to their local CUP multidisciplinary team. Patient demographics, clinical, pathological and outcome data were recorded and analysed. RESULTS: Data were available for 548 patients from four CUP services. 23% (n = 124) of patients met clinicopathological criteria for favourable-risk cCUP. On multivariate analysis c-reactive protein (CRP) (p < 0.001) and the Scottish Inflammatory Prognostic Score (SIPS: combining albumin and neutrophil count) (p < 0.001) were independently predictive of survival. CRP and SIPS effectively stratified survival in patients with both favourable-risk and poor-risk cCUP based on clinicopathological features. CONCLUSIONS: Biomarkers of systemic inflammation are reliable prognostic factors in patients with cCUP, regardless of clinicopathological subgroup. We recommend that CRP or SIPS are incorporated into routine clinical assessments of patients with cCUP as a tool to aid investigation and/or treatment decision-making across all groups. Established clinicopathological factors can then be used to inform management pathways and specific systemic anticancer therapy selection.

The anterior loop of the inferior alveolar nerve: prevalence, measurement of its length and a recommendation for interforaminal implant installation based on cone beam CT imaging.

OBJECTIVES: Interforaminal implant surgery requires anatomical knowledge of the area and adequate information on the location of the various landmarks of significance such as the mental foramen, the anterior loop of the inferior alveolar nerve and the mandibular incisive canal. Cone beam computed tomography (CBCT) is a relatively new imaging modality that provides a multi-dimensional view of the facial skeleton with, in most instances, lower radiation dose to the patient compared to medical CT. The present study aims to use CBCT to identify and measure variation in the presence and extent of the anterior loop of the inferior alveolar nerve. This information may be used to provide recommendations to the surgeon without access to a 3D scan of the dento-alveolar region. MATERIAL AND METHODS: Ninety-three patients scanned with a Newtom VG device for a variety of clinical indications were included in this retrospective study. Using the multiplanar capabilities of the device's software the prevalence and length of the anterior loop was assessed. RESULTS: The results show that an anterior loop could be identified in 48% of the cases with a mean length (range) of 0.89 mm (0-5.7). CONCLUSIONS: In almost half of the surveyed cases an anterior loop was present. Even though in 95% of the study cases the loop was <3 mm, a 100% safety margin in the placement of anterior mandibular implants, in the absence of a CBCT scan, would only be achieved with a distance of 6 mm between the anterior border of the mental foramen and the most distal interforaminal implant fixture.

Ionizing radiation regulations and the dental practitioner: 2. Regulations for the use of X-rays in dentistry.

The first article in this series covered radiation hazards and protection. To minimize the potential harmful effects of X-rays, legislation has been introduced by a number of countries including the European Union.

Lonizing radiation regulations and the dental practitioner: 3. Quality assurance in dental radiography.

UNLABELLED: This is the last in a series of three articles on X-ray dose reduction and covers aspects of quality assurance. The first outlined radiation physics and protection and the second the legislation relating to radiation safety. CLINICAL RELEVANCE: Quality assurance is an essential part of dental radiography and is required to produce images of a consistently high standard, necessary for accurate diagnosis.

Ionizing radiation regulations and the dental practitioner: 1. The nature of ionizing radiation and its use in dentistry.

UNLABELLED: Legislation governing the use of ionizing radiation in the workplace and in medical treatment first became law in 1985 and 1988, being superseded by the Ionizing Radiations Regulations 1999 (IRR99) and the Ionizing Radiation (Medical Exposure) Regulations 2000, (IR(ME)R 2000), respectively. This legislation ensures a safe environment in which to work and receive treatment and requires that those involved in the radiographic process must be appropriately trained for the type of radiographic practice they perform. A list of the topics required is detailed in Schedule 2 of IR(ME)R 2000 and is paraphrased in Table 1, with the extent and amount of knowledge required depending on the type of radiographic practice undertaken. CLINICAL RELEVANCE: Virtually all dental practitioners undertake radiography as part of their clinical practice. Legislation requires that users of radiation, including dentists and members of the dental team, understand the basic principles of radiation physics, hazards and protection, and are able to undertake dental radiography safely with the production of high quality, diagnostic images.

Radiation protection: protection of patients undergoing cone beam computed tomography examinations.

UNLABELLED: Cone beam computed tomography is becoming a popular imaging modality in dentistry. The effective dose from these examinations is generally higher than conventional plain film radiography. This article outlines the ways of protecting patients from the harmful effects of radiation. CLINICAL RELEVANCE: Cone beam computed tomography is an emerging imaging modality. The effective doses are generally higher than conventional radiography and it is therefore important that anyone requesting or performing these investigations understands how to keep the doses to patients as low as reasonably practicable.

Diffuse sclerosing osteomyelitis: a case series and literature review.

OBJECTIVE: Diffuse sclerosing osteomyelitis (DSO) is a poorly understood chronic inflammatory disease, for which many etiologic theories and treatment modalities have been suggested. We retrospectively evaluated bisphosphonate treatment outcomes in patients with DSO and compared them with those of alternative treatment modalities and those reported in the current literature. STUDY DESIGN: This series was a retrospective analysis of patients diagnosed with DSO of the mandible. We identified a total of 11 DSO cases at Guys Dental Hospital from 1996 to 2017. Data on all treatment modalities attempted during this time were collected, with a focus on patients who underwent management with oral bisphosphonates. RESULTS: Eight of 11 patients who continued to have symptoms after failure of previous interventions were prescribed alendronic acid (70 mg once weekly) for an average of 16 months. All patients reported improvement or resolution of symptoms within 72 hours. Three patients ceased medication at 4 weeks because of medication side effects. The remaining 5 patients reported improved symptom control in comparison with prior treatment regimes. CONCLUSIONS: Oral bisphosphonates appear to provide prolonged symptom relief in patients with DSO compared with previously attempted treatment strategies; however, the exact regimen and length of use is still being debated. The positive impact of bisphosphonates may provide a potential insight into the pathophysiology of DSO.

An audit and service evaluation of the use of cone beam computed tomography (CBCT) in a paediatric dentistry department.

OBJECTIVES: CBCT exposes the paediatric patient to a higher X-ray dose and risk than normal dental radiographs. This study has two components: an audit and service evaluation. The audit aims to assess whether the use of CBCT in a Paediatric Dentistry department at a London hospital complies with European guidelines (SEDENTEXCT). The service evaluation aims to explore the influence of CBCT on treatment planning. METHODS: Two 6 month audit cycles were completed, where CBCT requests were audited to check whether image justifications comply with SEDENTEXCT. For the service evaluation, a total of 50 patient records were examined for the effect of CBCT on definitive treatment plans. RESULTS: The first audit demonstrated 94% compliance with SEDENTEXCT. After instituting staff training in CBCT, compliance improved to 100%. In the service evaluation, 100% of CBCTs were found to provide information that impacted on the clinicians' treatment planning, diagnosis and/or management. Of most significance, 44% of treatment plans were changed because of new information provided by CBCT. CONCLUSIONS: There are few studies investigating the use of CBCT in paediatric dentistry and the impact of this investigation. This service evaluation shows that CBCT can play an important role in optimising paediatric patient outcomes. The need for robust staff training in CBCT referrals to prevent over prescription is demonstrated in the audit cycles.

High-fat diets promote insulin resistance through cytokine gene expression in growing female rats.

To determine if tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6). IL-6 gene expression is influenced by amount and source of dietary fat, 30 weanling female rats were randomly assigned to a moderate-fat soybean oil (MFS; 22% of total energy fed as fat), high-fat (HF) soybean oil (HFS; 39% of total energy fed as fat), or HF tallow (HFT; 39% of total energy fed as fat) diet treatments. Oral glucose tolerance tests (OGTT) were conducted serially over 10 weeks of treatment. HFT and HFS rats gained more weight and had greater body fat than the MFS rats fed similar amounts of energy. Both groups of HF-fed rats had greater (P<.05) insulin resistance (homeostasis model assessment) than MFS-fed rats. TNF-alpha mRNA abundance quantified by real-time reverse transcriptase-polymerase chain reaction was greater (P<.05) in liver and lower (P<.05) in adipose tissue in HFT compared to HFS and MFS rats. There were positive correlations (P<.05) between hepatic TNF-alpha mRNA and insulin resistance, and negative correlations between insulin sensitivity and hepatic TNF-alpha mRNA and hepatic IL-6 mRNA. During Week 3 and Week 6 OGTTs, hyperinsulinemic responses were observed in the HFT group, after which, on Week 9, insulin secretion was diminished in response to the OGTT, suggesting impaired pancreatic insulin secretion. HFS rats exhibited insulin resistance on Week 9 OGTT. In summary, an HFT diet fed to growing female rats caused insulin resistance associated with increased hepatic TNF-alpha mRNA leading to pancreatic insufficiency. Early-onset insulin resistance related to the inflammatory process in obesity is influenced by the amount and type of fat in the diet.

Salivary Gland Diseases: Presentation and Investigation.

A number of salivary gland diseases may present with a wide variety of symptoms to the general dental practitioner, or may appear as unexpected findings on dental radiographs. Careful clinical examination in combination with appropriate imaging will assist practitioners in identifying whether further investigation or referral is required. This article explores the main types of salivary gland diseases and their potential pathology.

Masseter muscle measurement performed by ultrasound: a systematic review.

The aim of this study was to systematically review the existing scientific literature and evidence about (a) the validation of masseter muscle ultrasonography for accurate assessment of muscle thickness and (b) the reproducibility of masseter muscle thickness measures. An electronic literature search was conducted using determined keywords on specific databases. Preliminary search revealed 298 articles listed in Medline, Scopus and Web of Science. 60 duplicates were rejected, leaving 238 articles for review. After reading titles and abstracts, 31 articles remained. 23 articles were assessed for eligibility. These articles were categorized as follows: thickness, cross-section, volume and the length of the masseter muscle measured by ultrasonography. It is possible to verify the thickness of the masseter muscle in males and females in relaxation (10-15 and 9-13 mm, respectively) and contraction (14-19 and 12-15 mm, respectively). A similar tendency can also be evidenced in other measurements. Many studies evaluate masseter muscle dimensions to relate it to cephalometric analysis as such to evaluate morphological variations. It can be concluded that ultrasound is a reliable clinical tool for masseter muscle measurements, yet there is a need for standardization of methods and parameters to be recorded.

Salivary gland ultrasound abnormalities in primary Sjögren's syndrome: consensual US-SG core items definition and reliability.

OBJECTIVES: Ultrasonography (US) is sensitive for detecting echostructural abnormalities of the major salivary glands (SGs) in primary Sjögren's syndrome (pSS). Our objectives were to define selected US-SG echostructural abnormalities in pSS, set up a preliminary atlas of these definitions and evaluate the consensual definitions reliability in both static and acquisition US-SG images. METHODS: International experts in SG US in pSS participated in consensus meetings to select and define echostructural abnormalities in pSS. The US reliability of detecting these abnormalities was assessed using a two-step method. First 12 experts used a web-based standardised form to evaluate 60 static US-SG images. Intra observer and interobserver reliabilities were expressed in κ values. Second, five experts, who participated all throughout the study, evaluated US-SG acquisition interobserver reliability in pSS patients. RESULTS: Parotid glands (PGs) and submandibular glands (SMGs) intra observer US reliability on static images was substantial (κ > 0.60) for the two main reliable items (echogenicity and homogeneity) and for the advised pSS diagnosis. PG inter observer reliability was substantial for homogeneity. SMGs interobserver reliability was moderate for homogeneity (κ = 0.46) and fair for echogenicity (κ = 0.38). On acquisition images, PGs interobserver reliability was substantial (κ = 0.62) for echogenicity and moderate (κ = 0.52) for homogeneity. The advised pSS diagnosis reliability was substantial (κ = 0.66). SMGs interobserver reliability was fair (0.20< κ ≤ 0.40) for echogenicity and homogeneity and either slight or poor for all other US core items. CONCLUSION: This work identified two most reliable US-SG items (echogenicity and homogeneity) to be used by US-SG trained experts. US-PG interobserver reliability result for echogenicity is in line with diagnosis of pSS.

Developing attributes for a generic quality of life measure for older people: preferences or capabilities?

Current UK policy with respect to the provision of health and social care for older people suggests that greater integration is required. Economists' attempts to assist resource allocation decisions, however, are very health focused, with concentration on the use of health-related quality of life measures. This paper reports an attempt to determine attributes for a new index clearly focusing on quality of life for older people rather than health or other influences on quality of life. In-depth interviews were conducted with 40 purposively selected informants aged 65 and over in private households to explore their views about what is important to them in terms of quality of life. Data were analysed using Framework qualitative analysis. Initial discussions tended to concentrate upon factors influencing quality of life including activities, relationships, health, wealth and surroundings. Further probing and analysis suggested five conceptual attributes: attachment, role, enjoyment, security and control. The data also suggested that the quality of informants' lives was limited by the loss of ability to pursue these attributes. So, for example, it is not poor health in itself, which reduces quality of life, but the influence of that poor health upon each informant's ability to, say, be independent, that is important. Amartya Sen's work on functioning and capability is particularly pertinent here. Using this work, it is possible to interpret the five conceptual attributes as a set of functionings-important for older people in the UK in the 21st century-but noting that it is the capacity to achieve these functionings that appears to be of importance. This suggests that further development of this measure should focus on an index of capability rather than preference-based utility.

Interventional sialography and minimally invasive techniques in benign salivary gland obstruction.

Salivary gland obstruction is the commonest complaint affecting this organ and is usually due to the development of salivary calculi, ductal strictures, or both. Imaging has a role in the diagnosis of the cause, extent, and effects of obstruction. In recent years, the role of radiology has evolved; techniques, such as salivary stone lithotripsy, and salivary stone extraction and balloon ductoplasty are carried out under imaging guidance. This article reviews the current status of minimally invasive salivary interventions.

A revolution in the management of obstructive salivary gland disease.

UNLABELLED: Salivary gland obstruction is the commonest cause of salivary gland disease presenting to the general dental practitioner. To date, with the exception of the most surgically accessible stones found within the anterior ducts, there has been little treatment to offer patients except surgical removal of the gland, with the associated risks to the facial and trigeminal nerves. In the last 10 years, more conservative treatment modalities have been developed, opening up a range of treatment options which combine to provide an alternative management of these cases. This paper presents data from one unit in which lithotripsy, which is the destruction of stones (calculi) using shock waves, basket retrieval, a modified minor surgical technique, and balloon dilatation have been used to treat salivary gland obstruction successfully. Over 70% of stones can now be retrieved leaving a functioning gland. CLINICAL RELEVANCE: Salivary gland obstruction is a clinical problem presenting to the general dental practitioner, and requires an understanding of the range of treatment options available.

The use of intraoral ultrasound in the characterization of minor salivary gland malignancy: report of two cases.

It is generally accepted that ultrasound is now the first line of imaging of palpable lumps of the neck. Standardized protocols exist for the evaluation of thyroid, salivary gland and nodal disease, and sonography is increasingly being used in the characterization of intraoral soft tissue lesions. Here, we present two cases where intraoral sonography was invaluable in the early detection of oral malignancy.

Migrating salivary stones: report of three cases.

Patients with salivary calculi are normally managed by removal of the calculus or, if necessary, the affected gland. If it is left untreated, a stone may migrate into the adjacent tissues. We present three patients in whom salivary calculi tracked to the surface of the skin. Two were removed under local anaesthetic, and the third patient was lost to follow up.

Correlations Between Sexual Abuse Histories, Perceived Danger, and PTSD Among Intimate Partner Violence Victims.

Intimate partner violence (IPV), childhood abuse, and sexual assault in adulthood are profound public health concerns, particularly for women. Exposure to trauma can contribute to long-standing health problems and escalated medical costs. Unfortunately, these experiences are often intertwined. Sexual assault often occurs in intimate relationships in which there is concurrent IPV; likewise, many victims of IPV have experienced childhood abuse. The prevalent intersections of these struggles can lead to posttraumatic stress disorder (PTSD) symptoms. This article examines the contributions of childhood abuse histories and sexual assault to PTSD symptoms among women experiencing IPV. Findings suggest childhood abuse experiences account for more variance in PTSD symptoms than adult sexual assault. Clinical implications are discussed.