Effect of massage on the efficacy of the mental and incisive nerve block.

The purpose of this trial was to assess the effect of soft tissue massage on the efficacy of the mental and incisive nerve block (MINB). Thirty-eight volunteers received MINB of 2.2 mL of 2% lidocaine with 1 : 80,000 epinephrine on 2 occasions. At one visit the soft tissue overlying the injection site was massaged for 60 seconds (active treatment). At the other visit the crowns of the mandibular premolar teeth were massaged (control treatment). Order of treatments was randomized. An electronic pulp tester was used to measure pulpal anesthesia in the ipsilateral mandibular first molar, a premolar, and lateral incisor teeth up to 45 minutes following the injection. The efficacy of pulp anesthesia was determined by 2 methods: (a) by quantifying the number of episodes with no response to maximal electronic pulp stimulation after each treatment, and (b) by quantifying the number of volunteers with no response to maximal pulp stimulation (80 reading) on 2 or more consecutive tests, termed anesthetic success. Data were analyzed by McNemar, Mann-Whitney, and paired-samples t tests. Anesthetic success was 52.6% for active and 42.1% for control treatment for lateral incisors, 89.5 and 86.8% respectively for premolars, and 50.0 and 42.1% respectively for first molars (P = .344, 1.0, and .508 respectively). There were no significant differences in the number of episodes of negative response to maximum pulp tester stimulation between active and control massage. A total of 131 episodes were recorded after both active and control massage in lateral incisors (McNemar test, P = 1.0), 329 (active) versus 316 (control) episodes in the premolars (McNemar test, P = .344), and 119 (active) versus 109 (control) episodes respectively for first molars (McNemar test, P = .444). Speed of anesthetic onset and discomfort did not differ between treatments. We concluded that soft tissue massage after MINB does not influence anesthetic efficacy.

Buccal versus lingual articaine infiltration for mandibular tooth anaesthesia: a randomized controlled trial.

AIM: To compare the effectiveness of buccal and lingual local anaesthetic injections in the mandibular first molar region in obtaining pulpal anaesthesia in mandibular teeth. METHODOLOGY: Twenty healthy volunteers received 1.8 mL of 4% articaine with 1 : 100,000 epinephrine as a buccal or lingual infiltration in the mandibular first molar region in a randomized double-blind cross-over design. The responses of the first molar, a premolar and the lateral incisor teeth were assessed using an electronic pulp tester over a 47-min period. Successful anaesthesia was defined as no response to maximum stimulus from the pulp tester on two or more consecutive tests. Success between techniques was analysed using the McNemar test and variations between teeth were compared with Chi-square. RESULTS: The number of no responses to maximum stimulation from an electronic pulp tester was significantly greater for all test teeth after the buccal injection compared with the lingual approach (P < 0.001). Successful anaesthesia was more likely following the buccal infiltration compared with the lingual method for molar (65% and 10%, respectively) and premolar (90% and 15%, respectively) teeth. There was no difference in anaesthetic success for the lateral incisor. CONCLUSION: Buccal infiltration at the first mandibular molar is more effective than lingual infiltration in the same region in obtaining anaesthesia of the mandibular first molar and premolar teeth.

The efficacy of infiltration anaesthesia for adult mandibular incisors: a randomised double-blind cross-over trial comparing articaine and lidocaine buccal and buccal plus lingual infiltrations.

AIM: To compare the efficacy of 2% lidocaine and 4% articaine both with 1:100,000 adrenaline in anaesthetising the pulps of mandibular incisors. METHODS: Thirty-one healthy adult volunteers received the following local anaesthetic regimens adjacent to a mandibular central incisor: 1) buccal infiltration of 1.8 mL lidocaine plus dummy lingual injection (LB), 2) buccal plus lingual infiltrations of 0.9 mL lidocaine (LBL), 3) buccal infiltration of 1.8 mL articaine plus dummy lingual injection (AB), 4) buccal plus lingual infiltrations of 0.9 mL articaine (ABL). Pulp sensitivities of the central incisor and contralateral lateral incisor were assessed electronically. Anaesthetic efficacy was determined by two methods: 1) Recording the number of episodes with no responses to maximal electronic pulp tester stimulation during the course of the study period, 2) recording the number of volunteers with no response to maximal pulp tester stimulation within 15 min and maintained for 45 min (defined as sustained anaesthesia). Data were analysed by McNemar, chi-square, Mann-Whitney and paired t-tests. RESULTS: For both test teeth, the number of episodes of no sensation on maximal stimulation was significantly greater after articaine than lidocaine for both techniques. The split buccal plus lingual dose was more effective than the buccal injection alone for both solutions (p <0.001). 4% articaine was more effective than 2% lidocaine when comparing sustained anaesthesia in both teeth for each technique (p <0.001), however, there was no difference in sustained anaesthesia between techniques for either tooth or solution. CONCLUSIONS: 4% articaine was more effective than 2% lidocaine (both with 1:100,000 adrenaline) in anaesthetising the pulps of lower incisor teeth after buccal or buccal plus lingual infiltrations.

Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block.

AIM: To compare mandibular tooth pulpal anaesthesia and reported discomfort following lidocaine inferior alveolar nerve block (IANB) with and without supplementary articaine buccal infiltration. METHODOLOGY: In this prospective randomized double-blind cross-over study, thirty-six healthy adult volunteers received two IANB injections of 2 mL lidocaine 2% with epinephrine 1 : 80,000 over two visits. At one visit, an infiltration of 2 mL of articaine 4% with epinephrine 1 : 100,000 was administered in the mucobuccal fold opposite a mandibular first molar. At the other visit, a dummy injection was performed. Injection discomfort was recorded on 100 mm visual analogue scales. Pulpal anaesthesia of first molar, premolar, and lateral incisor teeth was assessed with an electronic pulp tester until 45 min post-injection. A successful outcome was recorded in the absence of sensation on two or more consecutive maximal pulp tester stimulations. Data were analysed using McNemar and Student's t-tests. RESULTS: The IANB with supplementary articaine infiltration produced more success than IANB alone in first molars (33 volunteers vs. 20 volunteers respectively, P < 0.001), premolars (32 volunteers vs. 24 volunteers respectively, P = 0.021) and lateral incisors (28 volunteers vs. 7 volunteers respectively, P < 0.001). Buccal infiltration with articaine or dummy injection produced less discomfort than IANB injection (t = 4.1, P < 0.001; t = 3.0, P = 0.005 respectively). CONCLUSIONS: The IANB injection supplemented with articaine buccal infiltration was more successful than IANB alone for pulpal anaesthesia in mandibular teeth. Articaine buccal infiltration or dummy buccal infiltration was more comfortable than IANB.

Assessing competency in dentoalveolar surgery: a 3-year study of cumulative experience in the undergraduate curriculum.

AIM: To assess and observe the development of competence in oral surgical skills during a 3-year undergraduate programme. METHOD: Over a 3-year period 75 students were followed through from the beginning of their clinical course to their Bachelor of Dental Surgery graduation and their surgical experience monitored by the use of logbooks. Their development of competence was assessed objectively through structured assessments and subjectively by a single tutor responsible for each year. Assessments were made of their ability in exodontia, pre-surgical assessment and the surgical extraction of teeth/roots. RESULTS: Seventy-three students completed the course (97%). Successful completion rates for the objective testing were 100% for both exodontia and pre-surgical assessment. The surgical assessment, (surgical extraction of a tooth or root) had a successful completion rate of only 23% and the caseload for students was low with a mean of four teeth removed surgically upon graduation. Relationships were examined between total numbers of teeth extracted, total number of minor oral surgical procedures completed and the successful completion of the surgical competence assessment, but no significant relationships were found. CONCLUSIONS: This study demonstrates that it is possible to achieve objectively measurable levels of competence in undergraduates undertaking oral surgery procedures. It is however, a labour and time intensive process and appropriate clinical and teaching resources are required. National co-operation towards agreed standardised competencies should be encouraged to allow data to be pooled and more powerful analyses to occur.

Pulpal anaesthesia for mandibular permanent first molar teeth: a double-blind randomized cross-over trial comparing buccal and buccal plus lingual infiltration injections in volunteers.

AIM: To compare the efficacy of buccal and buccal plus lingual infiltration anaesthesia for permanent mandibular first molars. METHODOLOGY: Thirty one healthy adult volunteers received each of the following methods of anaesthesia for a mandibular first molar tooth in a randomised order, 1) Buccal infiltration of 1.8 mL and needle penetration lingually. 2) Buccal infiltration of 0.9 mL, plus lingual infiltration of 0.9 mL. Two percent lidocaine with 1:100,000 epinephrine was used. Electrical pulp testing was performed before, and every 2 minutes for 30 minutes after injection. A successful outcome was recorded as the absence of pulp sensation on two or more consecutive maximal pulp tester stimulations (80 microA). Injection discomfort was assessed using visual analogue scales. Data were compared with McNemar and Wilcoxon Signed Ranks tests. RESULTS: Buccal infiltration was successful in 38.7% of cases compared to 32.3% after combined infiltrations; the difference was not significant (P = 0.63). Buccal infiltration produced more episodes of no response to maximum stimulation than buccal and lingual infiltrations (129 and 114 respectively), this difference was not significant (P = 0.11). Peak anaesthetic effect occurred around 10-14 minutes after injection. There was no difference in injection discomfort between buccal injections of 0.9 mL and 1.8 mL of solution (P = 0.90). Lingual injection was more uncomfortable than lingual penetration (P = O.O02). CONCLUSIONS: Buccal and buccal plus lingual infiltrations did not differ in their efficacy in producing anaesthesia of permanent first molar teeth.

Observations on the exploration and external neurolysis of injured inferior alveolar nerves.

The inferior alveolar nerve is sometimes injured during mandibular surgery, resulting in altered sensibility. Incomplete recovery may be the result of nerve entrapment by scar tissue. Twelve patients underwent external neurolysis of the inferior alveolar nerve following prolonged sensory impairment secondary to mandibular surgery. The mean time to external neurolysis was 14 months (range 12-24 months). Five patients demonstrated improvement in sensibility, two patients returning to normal sensation. No patient had a worsening of symptoms. The results demonstrate that external neurolysis can be a useful step during surgical exploration in carefully selected patients.

A survey of local anaesthetic use among general dental practitioners in the UK attending postgraduate courses on pain control.

OBJECTIVE: The aim of this study was to identify which local anaesthetic solutions were used by general dental practitioners in the United Kingdom and to determine selection criteria. In addition, differences in anaesthetic choice between recent graduates (< or = 5 years) and more experienced practitioners were investigated. MATERIAL AND METHODS: Five hundred and six general dental practitioners attending postgraduate courses on pain control in dentistry completed a questionnaire. Participants were asked to indicate year and place of qualification, anaesthetic solutions available in their surgeries and criteria used in the choice of anaesthetic. In addition, the respondents were asked to indicate choice of local anaesthetic in a number of common medical conditions. Questionnaires were distributed and collected immediately prior to the start of the course presentation and participants were not asked to indicate whether the selection decisions were teaching, experience or evidence based. Data were analysed by using the Chi-square test. RESULTS: Lidocaine with epinephrine was the most widely available solution among this group of practitioners (94%), the second most common solution was prilocaine with felypressin (74%). The majority of practitioners had two or more solutions available. Practitioners who qualified within the last five years (14%) were more likely to have articaine available, the most recently introduced local anaesthetic into the UK (p = 0.04, one degree of freedom). Common medical conditions lead to a modification in anaesthetic selection: the use of prilocaine/felypressin increases in the majority of circumstances, although it is avoided in pregnant females by recent graduates. CONCLUSIONS: Lidocaine/epinephrine continues to be the most common anaesthetic solution used by this group of UK general practitioners. The primary criterion for selection of an anaesthetic agent was perceived efficacy. Prilocaine/felypressin is commonly selected as an alternative solution in the presence of common medical conditions.

Expression of c-erbB-2 proto-oncogene-encoded protein (p185erbB-2) in functional rat ameloblasts.

The c-erbB-2 proto-oncogene encodes a transmembrane glycoprotein with tyrosine kinase activity, p185erbB-2, that has been previously localized in some developing and mature epithelia. The possible occurrence of p185 in the inner enamel epithelium of rat tooth germ was here investigated immunocytochemically. Postmitotic functional ameloblasts displayed intense p185-immunoreactivity, thus suggesting that c-erbB-2 proto-oncogene is active during odontogenesis. The expression of this gene in differentiated and functional cells of the enamel organ suggests that its role is not restricted to mitotic events but may also be important in signalling pathways related to other cell activities.

Studies of c-jun oncogene expression in human breast using a new monoclonal antibody, NCL-DK4.

A new monoclonal antibody to human c-jun oncoprotein, designated NCL-DK4, has been produced. NCL-DK4 has been proved to be highly effective for use on formalin-fixed, paraffin-embedded tissues, enabling the study of c-jun expression at a cellular level in both normal and neoplastic human tissues. The expression of c-jun oncogene has been examined in normal, benign, and malignant breast tissues, and c-jun-specific immunoreactivity in carcinomas has been related to histological type, tumour grade, c-erbB-2, oestrogen receptor, progesterone receptor, and epidermal growth factor receptor expression. Normal and benign breast tissues showed c-jun-specific immunostaining, which was weaker and in fewer cells compared with the c-jun immunoreactivity observed in breast carcinomas. No relationship was found between the degree of immunostaining and the extent of proliferative changes in benign breast tissues. Ninety per cent of all breast carcinomas studied showed c-jun-specific nuclear staining. There were no statistically significant differences in the intensity of c-jun immunoreactivity among grade I, II, and III infiltrating ductal carcinomas. There was no significant relationship between c-jun oncoprotein expression and c-erbB-2, oestrogen, progesterone, and epidermal growth factor receptor immunoreactivity.

Predicting outcome for patients with node negative breast cancer: a comparative study of the value of flow cytometry and cell image analysis for determination of DNA ploidy.

This study was aimed at determining whether tumour DNA content measured by cell image analysis could provide additional prognostic information when compared to that provided by flow cytometry. Sections cut from paraffin blocks of tumours from 101 patients with node negative breast cancer were analysed by both methods and the results related to other prognostic variables and to patient relapse and overall survival. DNA ploidy measured by flow cytometry classified 46 tumours as diploid and 55 as aneuploid, whereas by cell image analysis 30 were diploid and 71 aneuploid (P less than 0.002). There were 20 tumours with discrepancies between the two methods; 18 of these were tumours with only one peak in flow analysis, but determined to be aneuploid with image analysis. DNA content as measured by both methods was significant for predicting relapse and survival by log-rank test, as were tumour histological grade, c-erbB-2 expression and tumour size. Multivariate analysis showed DNA ploidy measured by flow cytometry to be the only variable of independent significance (P less than 0.02) for both relapse and overall survival. Compared with cell image analysis, flow cytometry demonstrated a significantly higher proportion of diploid tumours, which may be related to differences in the internal standards applied to each method. We suggest that cell image analysis techniques can provide more sensitive information on the DNA content of tumour cells by direct measurement of nuclear DNA density of both normal lymphocytes and tumour cells in the same section. However, although image analysis appears to be more sensitive than flow cytometry in detecting DNA aneuploidy, the image technique appears to lack the specificity of flow cytometry in correlation with clinical outcome.

c-erbB-2 oncogene expression in hepatocellular carcinoma and cholangiocarcinoma.

The c-erbB-2 proto-oncogene encodes a transmembrane protein which is homologous to the epidermal growth factor receptor. This protein can be localized immunohistochemically in formalin-fixed paraffin-embedded material using a monoclonal antibody NCL-CB11; positive membrane staining correlates with gene amplification and protein overexpression in breast cancer. Using this technique we have shown that only 2/26 (8%) of hepatocellular carcinomas, 0/10 (0%) of cholangiocarcinomas and 0/2 (0%) hepatoblastomas overexpressed c-erbB-2 as evidenced by membrane staining. Moreover c-erbB-2 mRNA was not detected in seven hepatocellular carcinomas examined by Northern blot analysis. c-erbB-2 overexpression is, therefore, unlikely to be contributing to the malignant phenotype in hepatocellular carcinoma and cholangiocarcinoma.

Immunohistochemical and other features of breast carcinomas presenting clinically compared with those detected by cancer screening.

Features of 111 mammary carcinomas derived from breast cancer screening were compared with those of 69 carcinomas presenting 'clinically'. Screen detected cancers were smaller, had less likelihood of nodal metastases, included a higher proportion of in situ tumours and if invasive, tended to be of lower grade. Using immunohistochemical methods, the expression of c-erbB-2 oncoprotein, epidermal growth factor receptor (EGFR) and cathepsin D were compared in the two groups. A similar proportion of screened and unscreened tumours expressed c-erbB-2 oncoprotein and EGFR but expression of the oestrogen regulated protein cathepsin D was significantly more frequent in the screened group (P less than 0.05). Although a relatively small series, the results suggest a biological difference between 'screened' and 'clinical' tumours.

Node negative breast cancer: the prognostic value of DNA ploidy for long-term survival.

The DNA content of breast tumours from 170 patients who presented between 1978 and 1980 was measured by flow cytometry. The relationship between tumour ploidy and disease outcome was assessed and its association with other prognostic factors evaluated. Compared with those with diploid tumours, patients with aneuploid tumours had significantly earlier relapse and shorter survival (P less than 0.0001). Tumour ploidy was strongly related to grade (P less than 0.001), but there was no significant association between DNA ploidy and c-erb-B-2 expression, lymph node status or tumour size. In lymph node negative and c-erb-B-2 negative patients, aneuploid tumours were associated with a poorer prognosis (P less than 0.001) than diploid tumours. Multivariate analysis showed that tumour ploidy gave independent information on disease free and overall survival. Tumour ploidy may be used as an independent prognostic variable in patients with breast cancer and it may be helpful in defining patients within the node negative or c-erb-B-2 negative groups likely to have a poor outcome who might benefit from adjuvant treatment.

Long-term survival in breast cancer related to overexpression of the c-erbB-2 oncoprotein: an immunohistochemical study using monoclonal antibody NCL-CB11.

In a previous series we have shown poor short-term (3-5 years) survival for patients with tumours overexpressing the c-erbB-2 oncoprotein. In this study we employed archival paraffin-embedded tissue from patients who underwent mastectomy 10-12 years prior to assessment (n = 187). Immunohistochemical staining was carried out by an indirect immunoperoxidase technique using the novel monoclonal antibody NCL-CB11. Tumours were scored according to intensity of membrane staining. Patient and tumour information was obtained by scrutiny of clinical records. Survival analysis was carried out for both time to relapse and time to death, using the log rank test. Patients with tumours demonstrating intense membrane staining had a poor prognosis compared with the rest, with a steeply sloped survival curve over the first 4 years; the survival difference was still evident at 12 years follow-up (P less than 0.001). The survival advantage for c-erbB-2 negative patients was maintained in lymph node negative patients (P less than 0.001). However, c-erbB-2 status did not influence survival in the node positive group, where all patients had a uniformly poor outlook. These results applied to both time to relapse and time to death. In conclusion, c-erbB-2 status, determined using NCL-CB11, is a powerful prognostic indicator, defining in particular node negative patients with a particularly poor prognosis, and for whom alternative therapeutic strategies may be appropriate.

Expression of c-erbB-2 oncoprotein in salivary gland tumours: an immunohistochemical study.

Sections of formalin-fixed, paraffin-embedded primary salivary gland tumours were stained with a monoclonal antibody to the c-erbB-2 oncoprotein to determine the incidence and significance of expression of this protein. The series of 131 tumours comprised 33 cases of pleomorphic adenoma, 2 of malignant mixed tumour, 1 oxyphil adenoma, 31 Warthin's tumours, 4 basal cell adenomas, 6 mucoepidermoid carcinomas, 14 acinic cell carcinomas, 19 adenoid cystic carcinomas, 3 squamous carcinomas, and 18 poorly differentiated adenocarcinomas. Positive staining, as defined in previous studies, was present in five tumours (three cases of poorly differentiated adenocarcinoma, one mucoepidermoid carcinoma, and one adenoid cystic carcinoma). A review of the medical records of all patients did not disclose any clear difference between the clinical behaviour of positive and negative cases over a period of follow-up that ranged from 18 to 120 months. The findings of this study indicate that the protein product of the c-erbB-2 proto-oncogene is infrequently expressed in salivary gland tumours, and when it is localized on the tumour cell surface membrane, there is no clear evidence that this determines the biological behaviour of the tumour.

Human pituitary adenomas do not overexpress thec-erbB-2 oncoprotein.

Thec-erbB-2 proto-oncogene encodes a 190-kD putative membrane receptor that shows considerable homology to the epidermal growth factor (EGF) receptor.c-erbB-2 is overexpressed in many human tumors but has not previously been studied in pituitary tumors. In the normal pituitary gland, EGF is believed to play a regulatory role, but EGF receptors were found to be absent in a study of 22 pituitary adenomas. In the present study, 32 human pituitary adenomas and 7 samples of normal human pituitary were stained for thec-erbB-2 oncoprotein. All were negative for membrane staining, which suggests that amplification of thec-erbB-2 oncogene is not important in the etiology and progression of human pituitary adenomas.

c-erbB-2 oncoprotein expression in mammary and extramammary Paget's disease: an immunohistochemical study.

Over-expression of the c-erbB-2 oncogene occurs in a proportion of human adenocarcinomas and in breast carcinoma is associated with poorer prognosis. Sections of formalin-fixed, paraffin-embedded tumour tissue from 22 patients with mammary and extramammary Paget's disease have been stained immunohistochemically using a monoclonal antibody (NCL-CB11) raised against a synthetic peptide from the C-terminal end of the predicted sequence of the c-erbB-2 protein product. All 12 cases of mammary Paget's disease showed membrane staining of intra-epidermal cells, indicating c-erbB-2 over-expression. Sections of underlying ductal breast carcinoma were available in nine cases; all nine tumours were c-erbB-2 positive and in eight the in situ component was of comedo or solid type. There was membrane staining of tumour cells in four of the 10 cases of extramammary Paget's disease; staining intensity was generally weaker than that observed in the cases of mammary disease. The possible implications of these findings for the histogenesis of both mammary and extramammary Paget's disease are discussed.