Direct composite restorations for the worn mandibular anterior dentition: a 7-year follow-up of a prospective randomised controlled split-mouth clinical trial.

The purpose of this study was to report on the 7-year follow-up of 15 patients who took part in a prospective randomised controlled split-mouth trial to evaluate the performance and patient satisfaction of 107 direct composite restorations bonded to their worn anterior mandibular dentition. This is the continuation of a study by Poyser et al., which investigated the performance of the same direct composite restorations on this cohort of patients at 2.5 years. The results of the present study suggest that direct composite restorations bonded to the worn anterior mandibular dentition to have an approximate survival of 85% at the 7-year follow-up. Approximately 53% of patients experienced survival of all of their restorations. Pre-operative circumferential preparation did not influence restoration survival, patient satisfaction or other clinical variables (restoration staining, marginal discolouration, shade match, surface roughness and marginal adaptation). The time taken to initially build-up the restorations was shown to be statistically significant with a longer procedural time meaning less chance of the restoration being present at 7 years. This treatment modality exhibited no biological complications for the teeth, supporting periodontium or TMJ apparatus. The placement of these restorations provided an improvement in the aesthetics of the teeth, a reduction in the concern over the longevity of the worn lower anterior teeth, and improvements with regard to sensitivity experienced with hot or cold foods or drinks. Marginal breakdown was the most frequently recorded clinical complication. Thus, for the majority of patients, the restorations offered a high degree of patient satisfaction and required an acceptable level of maintenance in the 7-year follow-up period.

Antimicrobial irrigants in endodontic therapy: root canal disinfection (part 1).

This paper highlights the importance of root canal disinfection. It discusses the different endodontic irrigants available and comments on how these can be used most effectively.

The Dahl Concept: past, present and future.

The Dahl appliance was described nearly 30 years ago. This removable metal bite platform was used to create inter-occlusal space, in a localised part of the mouth, to facilitate the placement of restorations on worn anterior teeth. The Dahl concept is traditionally associated with the management of worn teeth. However, the same principles can be successfully and safely applied to a variety of clinical situations. This has simplified the management of historically complex problems. The advantages are the preservation of tooth tissue and the long-term benefits that brings. This paper reviews the literature related to the Dahl concept and how the concept has developed. There is a discussion regarding possible future applications and research.

Poor patient awareness of the relationship between smoking and periodontal diseases.

OBJECTIVE: To investigate patients' knowledge of the effects of smoking on periodontal health. DESIGN: Patient answered questionnaires, which were anonymous. SETTING: Patients who attended GKT Dental Institute, King's College, London for dental treatment. SUBJECTS: One thousand patients attending Restorative Consultant Clinics and Primary Dental Care. RESULTS: Seventy-eight per cent of patients were aware that smoking had a negative impact on health. However, 52% of these patients who were aware could not state what the negative effects were on oral health. Seven per cent of patients stated that smoking affected the gums but did not state how it affected the gums. Only 6% of respondents knew specifically of the link between smoking and periodontal disease. The only statistically significant factors associated with increased awareness were smoking status, ie being a non-smoker and being registered with a general dental practitioner. Non-smokers and those registered with GDPs were more likely to be aware of the association between smoking and periodontal diseases. CONCLUSIONS: This study highlights patients' lack of awareness of the relationship between smoking and periodontal diseases, with only 6% of respondents knowing of the link between tobacco and periodontal diseases.

Wrist fracture, heel bone density and thoracic kyphosis: a case control study.

The heel bone density measured by Broadband Ultrasound Attenuation (BUA), the thoracic kyphosis measured by a Kyphometer, height, and weight were compared between 294 women over 49 years of age who sustained a wrist fracture and 294 age-matched women who had not previous wrist, hip or spine fracture. The BUA was significantly less in the women who had wrist fracture (p less than 0.0005), though there was a considerable overlap between the two populations. The women with wrist fracture had significantly greater thoracic kyphosis (p less than 0.0005) and smaller stature (p less than 0.0005). There was no significant difference in weight. There was a significant tendency (p less than 0.0005) for women in the fracture patient group to have both poor BUA and greater kyphosis.

Carboxylation of osteocalcin in post-menopausal osteoporotic women following vitamin K and D supplementation.

The effect of vitamin supplements on bone metabolism indices in patients with osteoporosis has received scant attention in the literature. Over a 2-week period, vitamin supplements of K and K+D were given to 20 post-menopausal osteoporotic women with previous Colles fractures. Osteoporosis was confirmed by bone mass measurements that demonstrated that broadband ultrasound attenuation (os calcis) was almost as discriminatory as dual energy X-ray absorptiometry (spine and hip) in Colles fracture patients compared with matched controls. Vitamin K corrected the carboxylation defect in osteocalcin and while less marked 4 weeks later, the improvement was still detectable. The result after K+D was similar. The level of carboxylation became the same as in premenopausal women. Total osteocalcin level (bound) osteocalcin. While there was vitamin K correctable undercarboxylation of osteocalcin, simultaneously there was no evidence of undercarboxylation of prothrombin.

Pharmacological management of back pain syndromes.

The symptom of back pain may be the result of many different pathologies. As such, patients with back pain require careful assessment to determine whether the cause is from the spine or other systems. For acute mechanical back pain, treatment is often symptomatic. Symptomatic treatment may include analgesics, anti-inflammatories and/or muscle relaxants. Patients may also need hypnotics in the short term to help them sleep at night. However, drug therapy should be reduced and stopped as soon as possible. Furthermore, too much bedrest may be counterproductive. Paracetamol (acetaminophen) is the standard treatment for transient back pain. More severe pain may require the addition of an opioid, such as codeine or dextropropoxyphene. Morphine and pethidine (meperidine) may be necessary in patients with back pain due to neoplastic disease or osteoporotic fracture. However, the opioid analgesics are associated with dependence, tolerance and adverse effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic efficacy comparable with paracetamol. Individual patients respond differently to different NSAIDs, and several agents may have to be tried. Long term therapy with NSAIDs is necessary in diseases with an inflammatory component such as ankylosing spondylitis. Calcitonin reduces bone resorption and bone blood flow, and has been suggested to have central analgesic effects. As such, it has been used successfully in patients with Paget's disease, osteolytic bone disease and osteoporosis. Bisphosphonates also inhibit osteoclastic bone resorption and may be useful in Paget's disease, osteolytic metastases and osteoporotic fractures. Other drugs which may be useful in relieving back pain associated with specific circumstances include the tricyclic antidepressants, anxiolytics, antiepileptic agents, corticosteroids, colchicine and chymopapain.

Seasonal differences in biochemical parameters of bone remodelling.

AIMS: To compare bone remodelling parameters in late autumn and early spring in 20 post-menopausal women. METHODS: The parameters measured were serum osteocalcin and its apparent degree of carboxylation (measured by hydroxyapatite binding), total and bone specific alkaline phosphatase and urinary bone resorption markers, (pyridinoline and deoxypyridinoline). RESULTS: Serum osteocalcin concentrations were lower in autumn than in spring but the degree of carboxylation was similar. Total and bone specific alkaline phosphatase activities in serum were higher in autumn than in spring. These results support previous observations. However, notable and previously unreported changes in urinary bone resorption markers were observed. Pyridinoline concentrations were lower and deoxypyridinoline higher in autumn compared with spring. The ratio of pyridinoline:deoxypyridinoline was therefore very different between the seasons. CONCLUSIONS: The results clearly demonstrate that seasonal changes in these variables of bone remodelling must be taken into consideration when designing, reporting or analysing studies of bone metabolism in vivo.

Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial.

OBJECTIVES: To establish whether the early use of sophisticated imaging techniques influences the clinical management and outcome of patients with low back pain (LBP) and whether it is cost-effective. DESIGN: A pragmatic multicentre randomised controlled trial using a standard two parallel group approach incorporating an economic evaluation. For a subgroup of trial participants, a controlled 'before and after' approach was used to assess the impact of 'early imaging' on clinicians' diagnostic and therapeutic confidence. SETTING AND PARTICIPANTS: A total of 782 participants who had been referred by their general practitioner to a consultant orthopaedic specialist or neurosurgeon because of symptomatic lumbar spine disorders. The study included 14 hospitals in Scotland and one in England over a 24-month period. RESULTS: Participants in both groups reported an improvement in health status at 8 and 24 months with the 'early imaging' group having statistically significantly better outcome. Other than the proportion of participants receiving imaging (90% versus 30%), there were few differences between the groups in the management received throughout the 24-month follow-up. The total number of outpatient consultations in the two groups was similar although more people in the 'early imaging' group had return outpatient appointments during the 8-month follow-up. Clinicians' diagnostic confidence, between trial entry and follow-up, increased significantly for both groups with a greater increase in the 'early imaging' group. The cost of imaging was the main determinant of the difference in total costs between the groups and it was estimated that 'early imaging' could provide an additional 0.07 quality-adjusted life-years (QALYs), at an additional average cost of 61 British pounds over the 24-month follow-up. Using non-imputed costs and QALYs but adjusted for baseline differences in EQ-5D score, the mean incremental cost per QALY of 'early imaging' was 870 British pounds. The results were sensitive to the costs of imaging and the confidence intervals surrounding estimates of average costs and QALYs. CONCLUSIONS: The early use of sophisticated imaging does not appear to affect management overall but does result in a slight improvement in clinical outcome at an estimated cost of 870 British pounds per QALY. Imaging was associated with an increase in clinicians' diagnostic confidence, particularly for non-specialists. Further research is required to determine if more rapid referral to sophisticated imaging and secondary care is important in the acute episode and whether the use of imaging would be more beneficial for particular categories of LBP.

Double-level cauda equina compression: an experimental study with continuous monitoring of intraneural blood flow in the porcine cauda equina.

Compression of the spinal nerve roots may occur clinically at multiple levels at the same time; however, the basic pathophysiology of multi-level compression is largely unknown. In this study, the intraneural blood flow was analyzed continuously in the uncompressed segment between two compression balloons, with a pig used as an experimental model and a thermal diffusion method. At 10 mm Hg compression, there was a 64% reduction of total blood flow in the uncompressed segment compared with pre-compression values. Total ischemia occurred at pressures 10-20 mm Hg below the mean arterial blood pressure. After two-level compression at 200 mm Hg for 10 min, there was a gradual recovery of the intraneural blood flow towards the baseline. Recovery was less rapid and less complete after 2 h of compression. Double-level compression of the cauda equina can thus induce impairment of blood flow, not only at the compression sites, but also in the intermediate nerve segments located between two compression sites, even at very low pressures. These findings may have clinical importance in the understanding of the pathophysiology of multiple-level cauda equina compression.

Intradural primary chondroblastic osteosarcoma: case report.

We report a rare case of intradural primary osteosarcoma (IPOS) in a 74-year-old man with aphasia and right-sided hemiparesis. Radiologic workup revealed a large, partially calcified, left-sided frontotemporal intracranial mass lesion. At surgery, the tumor was found to be entirely intradural; it involved the brain and subarachnoid space of the left sylvian fissure. The adjacent dura was uninvolved. Neuropathologic findings confirmed the diagnosis of chondroblastic osteosarcoma. To our knowledge, this is the sixth reported case of IPOS and the first reported case of the chondroblastic subtype.

Xanthogranulomas of the third ventricle.

Two patients with xanthogranuloma of the 3rd ventricle are described. In each instance the tumor obstructed the interventricular foramina and caused dilatation of the lateral ventricles and signs of increased intracranial pressure; computerized tomography demonstrated the dense, nonenhancing lesion in the anterior 3rd ventricle. The pathogenesis of these rare tumors is discussed. These cases affirm the need to consider xanthogranuloma in the differential diagnosis of anterior 3rd ventricle tumors in adults.

Myelopathy after the intrathecal administration of hypertonic saline.

The neuropathological effects of intrathecally administered hypertonic saline have not been described previously. We report a patient who, within a day of receiving 20 ml of hypertonic (7.5%) saline intrathecally, developed flaccid paraplegia and complete sensory loss below the umbilicus. Subsequently, there was some transitory return of motor and coarse sensory function. The patient died 16 months after the injection. At autopsy, there was peripherally accentuated loss of myelinated fibers within the spinal cord from T12 downward, as well as dense collagenous thickening of the dorsal leptomeninges from T9 to T11. The findings in this case, coupled with observations made by others, serve to emphasize the need for extreme caution whenever planning any form of intrathecal therapy.

De novo formation of a central nervous system cavernous malformation: implications for predicting risk of hemorrhage. Case report and review of the literature.

The authors present a documented sporadic de novo cavernous malformation of the central nervous system (CNS) in a patient undergoing follow-up magnetic resonance imaging after resection of an acoustic neuroma. The authors believe that this is the first report of a de novo cavernous malformation in a patient without a familial history of this disease or a history of treatment with cranial radiation. The occurrence of de novo lesions invalidates the common assumption that cavernous malformations are congenital lesions. The use of this assumption to calculate bleeding risks retrospectively in patients with cavernous malformations is likely to underestimate the risk of symptomatic hemorrhage significantly. Consequently, the de novo formation of cavernous malformations may be more common than appreciated and may explain the higher bleeding rates reported in prospective compared with retrospective studies of these lesions.

Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report.

Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The authors present the case of a 70-year-old man with 9 years of progressive right-sided cervical and scapular pain but no history of trauma. Computerized tomography myelography and magnetic resonance imaging revealed an ovoid mass in the right C3-4 intervertebral foramen. The patient underwent a right C-3 and C-4 hemilaminectomy and a complete C3-4 facetectomy. A pulsatile vascular structure was found compressing the right C-4 nerve root. The bone overlying the vascular structure was removed, producing decompression of the nerve root. Immediate postoperative angiography showed that this lesion was a focal vertebral artery loop. The patient's symptoms resolved after surgery, supporting the use of vascular decompression of a cervical nerve root compressed by a vertebral artery loop for the relief of radicular symptoms.

Cavernous malformations of the brainstem: experience with 100 patients.

OBJECT: In this study the authors review surgical experience with cavernous malformations of the brainstem (CMBs) in an attempt to define more clearly the natural history, indications, and risks of surgical management of these lesions. METHODS: The authors retrospectively reviewed the cases of 100 patients (38 males and 62 females; mean age 37 years) harboring 103 lesions at treated a single institution between 1984 and 1997. Clinical histories, radiographs, pathology records, and operative reports were evaluated. The brainstem lesions were distributed as follows: pons in 39 patients, medulla in 16, midbrain in 16, pontomesencephalic junction in 15, pontomedullary junction in 10, midbrain-hypothalamus/thalamus region in two patients, and more than two brainstem levels in five. The retrospective annual hemorrhage rate was most conservatively estimated at 5% per lesion per year. Standard skull base approaches were used to resect lesions in 86 of the 100 patients. Intraoperatively, all 86 patients were found to have a venous anomaly in association with the CMB. Follow up was available in 98% (84 of 86) of the surgical patients. Of these, 73 (87%) were the same or better after surgical intervention, eight (10%) were worse, and three (4%) died. Two surgical patients were lost to follow-up review. Incidences of permanent or severe morbidity occurred in 10 (12%) of the surgically treated patients. The average postoperative Glasgow Outcome Scale score for surgically treated patients was 4.5, with a mean follow-up period of 35 months. CONCLUSIONS: The natural history of CMBs is worse than that of cavernous malformations in other locations. These CMBs can be resected using skull base approaches, which should be considered in patients with symptomatic hemorrhage who harbor lesions that approach the pial surface. Venous anomalies are always associated with CMBs and must be preserved.

Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome.

Thirty patients were treated surgically for spinal epidural hematoma (SEH). Twelve of these cases resulted from spinal surgery, seven from epidural catheters, four from vascular lesions, three from anticoagulation medications, two from trauma, and two from spontaneous causes. Pain was the predominant initial symptom, and all patients developed neurological deficits. Eight patients had complete motor and sensory loss (Frankel Grade A); six had complete motor loss but some sensation preserved (Frankel Grade B); and 16 had incomplete loss of motor function (10 patients Frankel Grade C and six patients Frankel Grade D). The average interval from onset of initial symptom to maximum neurological deficit was 13 hours, and the average interval from onset of symptom to surgery was 23 hours. Surgical evacuation of the hematoma was performed in all patients; 26 of these improved; four remained unchanged, and no patients worsened (mean follow up 11 months). Complete recovery (Frankel Grade E) was observed in 43% of the patients and functional recovery (Frankel Grades D or E) was observed in 87%. One postoperative death occurred from a pulmonary embolus (surgical mortality 3%). Preoperative neurological status correlated with outcome; 83% of Frankel Grade D patients recovered completely compared to 25% of Frankel Grade A patients. The rapidity of surgical intervention also correlated with outcome; greater neurological recovery occurred as the interval from symptom onset to surgery decreased. Patients taken to surgery within 12 hours had better neurological outcomes than patients with identical preoperative Frankel grades whose surgery was delayed beyond 12 hours. This large series of SEH demonstrates that rapid diagnosis and emergency surgical treatment maximize neurological recovery. However, patients with complete neurological lesions or long-standing compression can improve substantially with surgery.

Sporadic unifocal infantile myofibromatosis involving the skull. Case report.

Infantile myofibromatosis involving the skull is a benign disease if there is a solitary lesion. However, the multifocal form with skull involvement may portend a lethal course in the 1st year of life if there is involvement of the heart, lungs, or gastrointestinal tract. The authors report the case of a 3-year-old boy with an enlarging left parietal skull lesion that had been present since infancy. Increasing pain and the need to obtain tissue for diagnosis led to resection of the lesion by means of a small craniectomy. Further evaluation revealed no other lesions. A distinctly rare disease is presented, and the need for staging in children younger than 2 years of age is suggested to rule out cardiac, pulmonary, or gastrointestinal involvement.

Subdural hematoma from a Type I spinal arteriovenous malformation. Case report.

The authors report a patient in whom a subdural hematoma developed from a Type I spinal arteriovenous malformation (AVM). The patient became symptomatic with back pain, and magnetic resonance imaging revealed a spinal subdural hematoma. Selective spinal angiography, however, failed to demonstrate a pathological process. The patient underwent exploratory laminoplasty that revealed a subdural extraarachnoid hematoma with an underlying Type I spinal AVM, which was surgically obliterated. The patient recovered completely. Subdural hematomas that affect the spine are rare. Although a negative result was obtained using selective spinal angiography, exploratory surgery should be considered for the evacuation of a subdural hematoma and possibly for the definitive treatment of a spinal AVM.