[Improvement of a removable complete denture by relining or rebasing]. / Verbetering van een gebitsprothese door middel van relining of rebasing.

When the fit of a removable complete denture is diminished as a result of progressive alveolar bone reduction, relining or rebasing might be indicated. In clinical practice, a degree of confusion exists concerning the concepts relining, and rebasing. Relining is resurfacing the tissue side of a denture with a new material to fill the space which exists between the original denture contour and the altered tissue contour. Rebasing is resurfacing the fitting surface of a denture by replacing the entire denture base with new material, also to fill the space which exists between the original denture contour and the altered tissue contour. In particular, attention is given to 3 specific forms ofrelining and rebasing which serve to restore the maxillomandibular relationship, to extend effectively the palatal denture surface of the maxillary denture and to reline or rebase an implant-supported overdenture.

[Influence of a maxillary complete denture on taste perception Patients regularly report an alteration in taste perception after the insertion]. / De invloed van een gebitsprothese op de smaakgewaarwording.

Patients regularly report an alteration in taste perception after the insertion of a maxillary complete denture. It is generally accepted that changes in temperature and texture perception of the food induced by covering the hard palate are the principalfactors contributing to this alteration. Besides temperature and texture, other factors contributing to taste perception are smell, age and saliva composition.

[The quality of oral healthcare for edentulous individuals]. / De kwaliteit van de zorgverlening voor edentaten.

Fabricating removable complete dentures is a rather complicated treatment. The quality of the care delivered is broadly determined by 2 factors: the technical result and the way in which the individual patient experiences and evaluates the treatment. Healthcare professionals who carry out this treatment are subject, with respect to their capability, to the Dutch Individual Healthcare Professions Act. In cases of persisting complaints or problems, edentulous individuals are often treated with an overdenture on oral implants. Several oral healthcare providers are then involved in the treatment. In order to clarify procedures, a trajectory of care is presented in which all of these oral healthcare providers are located. It is expected that the number of edentulous individuals will decline and that the degree of treatment complexity will increase. To guarantee future efficiency and quality of care delivery, a number of regionally distributed national centres of expertise should be established.

[An immediate removable complete denture for the transition from a natural to a prosthetic occlusal system]. / Een immediate volledige gebitsprothese voor de overgang van een natuurlijk naar een prothetisch occlusiesysteem.

During the process of losing teeth, the fabrication of an immediate removable complete denture usually plays an important role. The path from a natural to a prosthetic occlusal system separates itself into a phased and a non-phased treatment. Various patient-related factors are of importance in the decision-making process for a phased or a non-phased treatment, such as the patient's time available, the medical indication, the complexity of the natural occlusal system, and the motivation for treatment. A positive result can be more confidently predicted in the case of a phased treatment than a non-phased treatment. Placement of an immediate removable complete denture requires immediate aftercare. Particularly in the case of non-phased treatment, the fabrication of a new complete removable denture will be required within 1 year.

[Treatment planning in patients with a severe reduced dentition]. / Behandeling van een sterk gemutileerde dentitie.

Because loss of teeth many people have a reduced maxillary and mandibular dentition. The appropriate prosthetic rehabilitation is dependent on whether or not a standard mutilation of the dentition can be achieved. In this article, the focus is on treatment of a remaining mandibular dentition combined with an edentulous maxilla, whether or not with a reduced residual alveolar ridge. In the literature, there is no consensus on the appropriate prosthetic treatment if implant-supported overdentures are not applicable. The amount of bone loss in already during some time edentulous maxillary and mandibular alveolar ridge segments as well as the available vertical space for the removable (partial) denture are important decision-making factors.

Differences in coronary heart disease prevalence and risk factors in African and White patients with type 2 diabetes.

Coronary heart disease (CHD) is rare in sub-Saharan Africans; there are few data in African diabetic populations. We therefore evaluated the prevalence of CHD and conventional risk factors in 744 consecutive African (A, n=448) and White European (W, n=296) subjects with type 2 diabetes. CHD was present in 4% of A and in 23% of W (p<0.001). Compared with W, the A groups had lower total cholesterol (TC) and triglyceride (TG) levels: men: TC-W, 5.76 (S.D., 1.36) and A, 4.98 (1.29)mmol/l; TG-W, 2.10 (IQR,1.40-3.00) and A, 1.60 (1.10-2.55)mmol/l; women: TC-W, 5.85 (1.31) and A, 5.20 (1.24); TG-2.00 (1.40-2.90) and A, 1.40 (1.00-2.03)mmol/l (p< or =0.0022 for each comparison). The A had significantly lower TG:HDL-C ratios (an index of insulin resistance) (p=0.004) and were less likely to have (estimated) small dense LDL-C particles (p< or =0.038). In subjects with established CHD traditional risk factors were similar in A and W. Regression analysis revealed that CHD associated in A with serum creatinine (p=0.0015) and TC (p=0.038) and with TG in W (p=0.0072). We conclude that the rarity of CHD in diabetic Africans can be explained by contributions of low TC levels and probably lesser insulin resistance and its consequences; renal disease may be an important additional risk factor.

[A schizophrenic patient with loss of teeth]. / Een schizofrene patiënte met verlies van gebitselementen.

A 53-year-old woman, known with a schizophrenic disorder and a history of drug addiction, was referred because of progressive hematomas of the lower extremities and fatigue. Her medical history included hyperplastic gums, tooth hypermobility and anaemia. Scurvy was diagnosed as a result of an insufficient diet due to drug addiction and a paranoid psychosis. After suppletion of vitamin C and starting highly nutritious food a rapid amelioration of the scurvy related complaints was observed. While dreaded and often fatal in earlier eras, in the 21st century scurvy is easily treatable if this diagnosis is recognised.

Immunoreactive glucagon responses to intravenous tolbutamide in chronic pancreatitis.

The effects of tolbutamide infusion (1 gm. over forty minutes) on plasma pancreatic glucagon-like immunoreactivity (PGLI), serum insulin, and blood glucose were studied in six patients with chronic pancreatitis and six matched controls.asal PGLI levels were significantly higher in the patients, despite higher fasting glucose concentrations. Tolbutamide infusion had no significant effect on mean PGLI levels in controls but was associated with significant elevation in pancreatitis patients, despite higher circulating glucose levels in the latter. The data suggest that chronic calcific pancreatitis patients hypersecrete immunoreactive glucagon, possibly from a nonpancreatic source and that this immunocreactive material may be stimulated by sulfonylureas.

The inexhaustible beta cell.

Repeated intensive pancreatic beta-cell stimulation was carried out in 42 subjects, comprising 22 normal controls, 10 mild to "severe" maturity-onset diabetics, and 10 chronic pancreatitis patients. Each subject received 75 gm. oral glucose twice and 1 mg. glucagon plus 0.5 gm. tolbutamide intravenously three times at short intervals. Each of the three combined stimuli caused almost equivalent marked spikes of insulin release in all experimental groups. The total calculated output of insulin was equivalent to the total daily insulin output in normal subjects. Pancreatitics and those with severe diabetes (fasting blood sugar greater than 120 mg./100 ml.) had qualitatively similar but a quantitatively smaller response. Those with mild diabetes were similar to the normal subjects but had an exaggerated response to the second oral glucose dose, suggesting overactivity of the enteroinsular axis. Despite the inordinate insulin levels, hypoglycemia did not occur.

Parathyroid hypertension. A reversible disorder.

A retrospective study of 75 patients who were surgically cured of primary hyperparathyroidism from 1976 to 1984 was performed to evaluate the blood pressure and metabolic responses to parathyroid surgery. Published data on the population prevalence of hypertension (HT) in South Africa were used for comparison. The overall prevalence of HT before surgery was 47%, compared with 23% in the general population. Hypertension was most frequent in patients older than 60 years (62% vs 39% expected). Renal insufficiency was found in 13 of 35 hypertensive patients and in two of 40 normotensive patients. However, the prevalence of HT in patients with normal creatinine levels (37%) exceeded that expected. The frequency of urolithiasis and mean levels of serum and urine calcium and phosphate were similar in normotensive and hypertensive patients. Parathyroidectomy resulted in a substantial fall in both mean systolic and mean diastolic blood pressures in 54% of the hypertensive subjects, unrelated to improvement in renal function.

[Bruises, loose teeth and fatigue in a patient with schizophrenia]. / Blauwe plekken, uitvallende tanden en vermoeidheid bij een patiënte met schizofrenie.

A 53-year-old woman was referred because of progressive haematomas of the lower extremities and fatigue. Her medical history included hyperplastic gums and tooth loss. Scurvy was diagnosed; this was the result of an insufficient diet due to a paranoid psychosis. There was a dramatic improvement within a few days after addition of vitamin C and starting highly nutritious food. Scurvy is easily treated, but is not a disease of the past.

Serum prolactin after chest wall surgery: elevated levels after mastectomy.

Galactorrhea is a recognized sequel of chest injury, but serum PRL levels in these patients have not been systematically documented. Therefore, we examined the PRL responses over 5 days in patients undergoing either mastectomy (10 patients) or thoracotomy (10) and in seven patients undergoing elective laparotomy (controls). Basal serum PRL levels were normal in every subject. There were no consistent or significant alterations in PRL levels after laparotomy or thoracotomy. After mastectomy, PRL levels rose from a mean preoperative level of 7.1 +/- 1.3 to 16.0 +/- 3.3 ng/ml (P < 0.01) on the first postoperative day. Mean levels continued to rise to 35.6 +/- 6.6 ng/ml (P < 0.005) on day 5; levels were supranormal in eight subjects. Hyperprolactinemia persisted in the four subjects evaluated 4 weeks postoperatively and in one of five patients evaluated at 6 months. In a retrospective study, serum PRL levels were measured months to years after thoracotomy (31 patients) and mastectomy (53 patients) and compared to levels in 41 normal female controls. Mean serum PRL levels were 8.4 +/- 1.3 ng/ml in the control group, 13.1 +/- 0.9 ng/ml in the thoracotomy group (P < 0.005), and 20.6 +/- 3.1 ng/ml in the mastectomy group (P < 0.001). One thoracotomy patient and 18 mastectomy patients (34%) had supranormal PRL levels. It is concluded that mastectomy acutely stimulates PRL secretion in most subjects, and levels may remain elevated for months, perhaps for years, in a proportion of patients. Both the acute and chronic hyperprolactinemic states are probably the result of neurogenic PRL release mediated via the suckling reflex.

Galactorrhea and hyperprolactinemia associated with chest wall injury.

A 48 year old premenopausal woman presented with galactorrhea and amenorrhea associated with chest wall burns. Basal serum prolactin levels were raised, and were further elevated by the administration of L-dopa, chlorpromazine and TRH. Intercostal nerve block and bromocryptine treatment reduced prolactin levels to normal, but did not noticably reduce milk secretion.

Pituitary and thyroid function before and after portacaval anastomosis in patients with normal livers.

Basal plasma thyroid hormone, testosterone and cortisol levels, TSH and PRL responses to TRH, and LH and FSH responses to LRH were assessed in six young subjects with normal liver function and anatomy before and after portacaval anastomosis. All tests were normal and unchanged by the operations. It is concluded that in patients with normal liver function, portal systemic shunting does not produce alterations in the pituitary-gonadal and pituitary-thyroid axes. The abnormalities of these endocrine functions in patients with cirrhosis are probably related to the severity of hepatocellular dysfunction rather than to the effects of portal systemic shunting.

Insulin responses to crude cholecystokinin-pancreozymin in normal subjects, in patients with chronic pancreatitis and patients with mild maturity onset diabetes.

The effects of repeated injections of 75 U crude cholecystolinin-pancreozymin (CCK-PZ) at increasing plateau glucose concentrations achieved by glucose infusion were studied in 15 controls, 8 chronic pancreatitics and 8 mild maturity onset diabetics. In control subjects CCK-PZ alone caused minor insulin release but proportinally greater secretion with increasing blood glucose concentrations. Chronic pancreatitis patients who had normal responses to intravenous glucose responded normally to the CCK-PZ but at significantly higher plateau glucose levels. Diabetics had no response to IV glucose boluses of 5 g or 10 g, but with glucose infusions of 250-500 mg/min had almost normal insulin responses to CCK-PZ. The responses to CCK-PZ plus glucose were greater than either stimulus alone, indicating an interaction between these and the beta cell. These studies suggest that the gut homone-receptor in the beta cell is intact in maturity onset diabetes and chronic pancreatitis, whether the glucose receptor is normal or defective. The peptide-responsible in the crude CCK-PZ is not secretin, glucagon or gut glucagon, but may be gastric inhibitory polypeptide (GIP) since pure CCK-PZ has no insuli releasing properties.

Fasting blunts the TSH response to synthetic thyrotropin-releasing hormone (TRH).

Thyrotropin (TSH) responses to intravenous thyrotropin-releasing hormone (TRH) were studied in 9 men after 12 and 36-h fasts separated by more than a week and performed in random order. The TSH, basally and in response to TRH, was significantly lower after the 36-h fast compared to that after 12 h. The mechanism for this effect is not clear, but may be related to the altered hormonal or fuel status associated with prolonged fasting.

Influence of dietary protein on glomerular filtration and urinary albumin excretion in insulin-dependent diabetes.

We investigated the effects of dietary constituents on glomerular filtration (GFR) and albumin excretion rates (AERs) in a cross-sectional study in 39 young subjects with insulin-dependent diabetes. Dietary protein intake correlated significantly in patients with GFRs less than 150 mL/min per 1.73 m2 (r = 0.53, n = 23, P = 0.009), but not with AER. GFR also correlated with mean blood glucose at a concentration less than 12.0 mmol/L (r = 0.61, P = 0.0035). Protein and fat intakes were similar in patients with and without microalbuminuria (AER greater than 20 mg/L) but long-term glycemic control was worse in the former [HbA1 12.4 +/- 2.9% (mean +/- SD) and 10.6 +/- 2.1%, respectively, P = 0.043]. In seven patients, short-term reduction of dietary protein from 2.0 to 1.0 to 0.5 g.kg-1.d-1 produced a progressive fall in GFR by 11.6 +/- 6.0 and 9.6 +/- 5.9 mL/min, respectively (P less than 0.05), but did not consistently affect AER. We conclude that both dietary protein and glycemic control influence GFR but neither alone appears to explain glomerular hyperfiltration. Microalbuminuria was associated with poor glycemic control but not with dietary fat or protein consumption.

Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6-mo prospective study.

To assess whether moderate dietary protein restriction can delay the progression of overt diabetic nephropathy, 22 subjects with insulin-dependent diabetes mellitus were randomly assigned to an unrestricted protein diet (> 1.6 g.kg body wt-1.d-1) or a moderately protein-restricted diet (0.8 g.kg body wt-1.d-1) and followed prospectively for six mo. Direct isotope methods were used to assess renal function. Protein intake was assessed by measurement of urinary urea nitrogen. The two groups were well-matched for age, sex, duration of diabetes, glycemic control, blood pressure, and degree of renal insufficiency. Patients consuming the unrestricted protein diet (n = 11) showed a progressive decline in glomerular filtration rate of 1.3 mL.min-1.mo-1 with no change in proteinuria. Patients consuming the moderately protein-restricted diet showed a marked decrease in the degree of proteinuria (2.15-1.13 g/d, P = 0.036) and a stabilization of glomerular filtration rate. This occurred independently of changes in blood pressure or glycemic control. Moderate dietary protein restriction can ameliorate progression of overt diabetic nephropathy.

Thyroid hormone and carrier protein interrelationships in children recovering from kwashiorkor.

We have studied 15 infants with severe protein energy malnutrition (PEM) as a model of nutritional nonthyroidal illness. Changes in circulating thyroid hormones, binding proteins, and their interrelationships were assessed before and during recovery. Serum concentrations of total thyroxine and triiodothyronine and of thyroxine-binding proteins were extremely reduced, and increased progressively during 3 wk of refeeding. The T4:TBG molar ratio was initially 0.180 +/- 0.020, and increased progressively, parallel to the increases in TT4, to 0.344 +/- 0.038 after 21 days (p less than 0.025). The changes in free T4 estimates varied according to the methods used--FTI and analogue FT4 increased, dialysis FT4 fraction decreased. Serum TSH levels increased transiently during recovery. It is concluded 1) there is reduced binding of T4 and T3 to TBG in untreated PEM which takes 2-3 wk to recover; 2) there are methodological differences in evaluating free T4 levels in PEM; 3) increased TSH secretion appears to be an integral part of the recovery from PEM.