Aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis.

BACKGROUND: Stentless porcine prosthetic valves offer several advantages over traditional valves. Among these are superior hemodynamics, laminar flow patterns, lack of need for anticoagulation and perhaps improved durability. METHODS: One hundred and twelve patients were operated on from September 17, 1992 to April 13, 1998 as part of a multi-center worldwide investigation. All patients received a total aortic root replacement. Patients were evaluated postoperatively at discharge, 3 to 6 months, and yearly by clinical exam and color flow Doppler echocardiography. RESULTS: There were 4 deaths either in the hospital or within 30 days after surgery for an operative mortality of 3.6%. No patients experienced structural valve deterioration, non-structural valve deterioration, paravalvular leak, unacceptable hemodynamic performance, or postoperative endocarditis. The linearized rates for survival and thromboembolic complications at 5 years were 82.8% and 90.5% respectively. Excellent hemodynamic function is demonstrated by very low gradients, large EOA, and an exceedingly low incidence of any aortic regurgitation. CONCLUSIONS: The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root for aortic valve and aortic root pathology. Root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Early and intermediate results are encouraging, but further follow-up is needed to determine valve durability.

Stentless aortic valve replacement with Freestyle or Toronto SPV: an early comparison.

BACKGROUND: Stentless aortic xenograft valves have been developed to overcome the disadvantages of conventional stented prostheses. We have implanted two new aortic bioprostheses: the Medtronic Freestyle and the St. Jude Toronto SPV. Early results are compared. METHODS: Forty-four Freestyle valves were implanted using a freestanding total root technique. Fourteen subcoronary Toronto SPV bioprostheses were implanted. Sixty-four percent of both groups (28 of 44 Freestyle and 9 of 14 Toronto SPV) underwent concurrent procedures. RESULTS: Ischemic time was 117 +/- 21 minutes for Freestyle and 124 +/- 19 minutes for Toronto SPV. There were no operative deaths or valve-related reoperations. Aortic valve area was 1.83 +/- 0.51 cm2 for Freestyle and 1.80 +/- 0.51 cm2 (p = 0.89) for Toronto SPV. Transvalvular gradient was 8.03 +/- 4.09 mm Hg for Freestyle and 12.4 +/- 1.82 mm Hg (p = 0.002) for the Toronto SPV. Aortic regurgitation was not experienced in any Freestyle patients, while Toronto SPV patients were graded as none to trace 79% (11 of 14), mild 14% (2 of 14), and moderate 7% (1 of 14). CONCLUSIONS: Aortic valve replacement with the Freestyle and Toronto SPV required equal time for implantation and had equal effective orifice areas. Freestyle had lower transvalvular gradient and less aortic insufficiency without increasing morbidity or mortality.

Caries risk assessment in a longitudinal discrimination study.

Our objective was to develop and perfect a model for the assessment of risk of dental caries onset in children. Even though dental caries prevalence in children is continuing to decline, there is still a significant minority for whom it is a problem. In this study, we sought to ascertain whether a set of variables selected in a previous cross-sectional study could be used to differentiate between caries-free six-year-olds who would or would not subsequently present with clinically-detectable caries. A total of 472 caries-free six-year-olds--286 from a fluoridated community and 186 from a fluoride-deficient community--was selected. Clinical examinations for DMFS, dental fluorosis, and plaque were conducted. Stimulated whole saliva was collected for analysis of mutants streptococci, lactobacilli, total viable flora, and fluoride, calcium, and phosphate concentrations. A questionnaire was used for collection of demographic data as well as information on prior fluoride exposure, dietary habits, and oral hygiene practices. By means of linear discriminant analyses, it was possible to predict correctly which children would develop caries within six to 12 months (sensitivity) in 82.8% of cases and which children would not develop caries during that period (specificity) in 82.4% of cases.

Caries risk assessment by a cross-sectional discrimination model.

Although the prevalence of dental caries is continuing to decline, it still affects a majority of the US population and can be a serious problem for those afflicted. The objective of this project was to develop and perfect a model for assessment of risk of dental caries onset in children. In the first study, reported herein, a set of clinical, microbiological, biochemical, and socio-demographic variables was identified that distinguished, with an acceptable level of sensitivity and specificity, between children who had no previous caries experience and children who had high caries levels. A total of 313 children--age 12-15 years, 140 from a fluoridated community and 173 from a fluoride-deficient community--was selected on the basis of previous caries experience, either zero DMFS or high DMFS (> or = 6 in the fluoridated or > or = 8 in the fluoride-deficient community). Clinical exams for DMFS, dental fluorosis, and plaque were conducted. Stimulated whole saliva was collected for analysis of mutans streptococci, lactobacilli, total viable flora, and fluoride concentration. A questionnaire was used for collection of demographic data as well as information on prior fluoride exposure, dietary habits, and oral hygiene practices. By means of discriminant analyses, with use of seven key clinical and laboratory variables, it was possible for zero-DMFS subjects to e classified correctly (specificity) in 77.6% of cases in the fluoridated community and in 86.1% of cases in the fluoride-deficient community. High-caries subjects were classified as such (sensitivity) in 79.3% and 88.1% of cases, respectively.

Comparison of results using "freestyle" stentless porcine aortic root bioprosthesis with cryopreserved aortic allograft.

Aortic valve replacement with natural heart valves offer the advantages of superior hemodynamics, laminar flow patterns, lack of need for anticoagulation, and perhaps improved durability. This study compares 5-year results for two stentless aortic valves. In 1992, two prospective clinical trials using two different stentless aortic valves were initiated at our center. The Freestyle stentless porcine aortic root bioprosthesis (SPB) was placed in 106 patients, and cryopreserved aortic allografts (CAA) were placed in 174 patients using a freestanding total root replacement technique in each series. The mean systolic gradient for the SPB was 7.5+/-4.4 mm Hg at discharge and 5.9+/-3.1 mm Hg at 5 years. The mean systolic gradient for the CAA was 6.4+/-3.3 mm Hg at discharge and 5.0+/-2.2 mm Hg at 5 years. At discharge 92.2% of SPB patients had no aortic insufficiency (AI) and 7.8% had trivial AI. In all, 92.9% of CAA patients had no AI at discharge, and 7.1% had mild AI. At 5-year follow-up, 100% of the SPB had no AI, and only 20% of the allograft patients had no AI. The remainder, 80%, had mild AI. Excellent hemodynamic function was seen with both SPB and CAA. A lower incidence of nonhemodynamically significant AI was observed in the SPB group. Preoperative factors such as chronic renal failure and endocarditis may have adversely affected durability in the allograft group, but long-term follow-up is still required to determine durability.

Resolution of early lesions of juvenile periodontitis with tetracycline therapy alone: long-term observations of 4 cases.

Our previous studies have demonstrated that early-identified lesions of localized juvenile periodontitis (LJP) can be treated by the use of systemically administered tetracycline alone (1 gm/day for 6 weeks). This therapy results in arrest of disease progression, decreased pocket depths, gains in clinical attachment, and significant repair of alveolar defects. This paper reports on the long-term clinical and radiographic improvement in 4 subjects followed for 1 to 4 years after the completion of tetracycline therapy. Four patients (mean age 14 years) were examined 1 to 4 years following the completion of a single 6 week course of tetracycline. Mean pocket depth was reduced from the initial level of 7.1 mm to 3.6 mm. Mean attachment loss was reduced from 3.8 mm to 0.9 mm and angular bone defects had filled by an average of 72%. Pocket depths and attachment loss continued to decrease during the entire study period, while alveolar bone repair continued to increase. The findings support those of our previous investigation and confirm that: 1) early identified lesions of LJP can be effectively treated with 6 weeks of tetracycline therapy alone; 2) decreases in pocket depth, gains in clinical attachment, and repair of alveolar defects remain stable up to 4 years following antibiotic therapy; 3) clinical and radiographic improvement continues over time and may lead to complete resolution of some lesions; and 4) the reparative/regenerative potential of the periodontium in early onset disease in young individuals may exceed that observed in chronic adult periodontitis.

Tetracycline therapy in patients with early juvenile periodontitis.

Tetracycline therapy, when used in conjunction with surgery or root planing, has been shown to be effective in controlling the progression of juvenile periodontitis. However, the ability of tetracycline alone to control the disease has not been assessed. The present study evaluated the effects of tetracycline therapy, with supragingival plaque control, on clinical attachment levels and radiographic bone height in patients with clinical and radiographic evidence of juvenile periodontitis. The four patients (mean age 15.2 +/- 0.3 yrs) each demonstrated loss of attachment of greater than or equal to 2 mm at one or more probing sites and had accompanying radiographic evidence of early localized bone loss. Following an initial clinical evaluation consisting of pocket depths, attachment levels and standardized radiographs, the patients received systemic tetracycline therapy (1 gm/day for three to six weeks) and oral hygiene instruction. At the completion of antibiotic therapy, patients received a supragingival professional prophylaxis every two weeks for three months, whereupon the initial evaluation was repeated. On comparing the initial and three-month clinical and radiographic data, there were significant decreases in clinical and radiographic measurements. For a total of 85 affected probing sites around 26 teeth, 79% decreased in pocket depth by greater than or equal to 2 mm (with no sites increasing in pocket depth) and 69% gained clinical attachment (with only one site losing attachment of 1 mm). Radiographic measurements revealed an increase in both the height and area of coronal alveolar bone. The findings indicated that six weeks of systemic tetracycline therapy combined with supragingival plaque control was effective in the initial control of early juvenile periodontitis.

Prevention of dental disease. The role of the pediatrician.

Evidence increasingly suggests that to be successful in preventing dental disease, we must begin preventive interventions within the first year of life. Pediatricians are well positioned to begin this process with early assessment of oral health and provision of anticipatory guidance, including ensuring that patients establish a dental home in addition to their medical home. This article provides information that will enable pediatricians to assess caries risk and provide practical and effective advice to parents about preventing dental disease, including oral hygiene, diet, and fluoride recommendations.

Fluoride in whole saliva, parotid ductal saliva and plasma in children.

The purpose was to investigate the relation between fluoride concentrations in whole saliva, parotid ductal saliva, and plasma in 5- to 10-year-old children (n = 17). Two stimulated whole-saliva samples were obtained from each child. Before the second sample was obtained, each child rinsed several times with a total of 100 ml of deionized water. Parotid saliva samples were obtained by use of a Lashley cup. Fluoride concentrations were determined by fluoride ion-specific electrode after diffusion with hexamethyldisiloxane. Rinsing with deionized water did not significantly reduce the fluoride concentration in whole saliva. The whole-saliva fluoride concentrations were not significantly related to those in plasma or parotid ductal saliva. Parotid fluoride concentrations, however, were significantly related to plasma fluoride concentrations (p < 0.0001) by a proportionality constant of 0.80. It was concluded that parotid salivary fluoride concentrations can be used to estimate plasma fluoride concentrations in 5- to 10-year-old children.

Overview of the history and current status of fluoride supplementation schedules.

Clinical trials of dietary fluoride supplements began in the 1940s in an effort to bring the benefits of fluoride to those who did not receive it through their drinking water. Following the early success of these trials, the Council on Dental Therapeutics of the American Dental Association (ADA) published its first recommendations for fluoride supplementation in 1958. The American Academy of Pediatrics (AAP) followed with its own recommendations in 1972. During the 1970s a variety of alternative schedules appeared in the literature, most in reaction to the findings of unexpectedly high levels of enamel fluorosis in children being supplemented with the AAP schedule. In 1979 the ADA and AAP agreed on essentially identical schedules. During the 1980s, however, the prevalence of enamel fluorosis continued to increase, and fluoride supplements were found in some studies to be a risk factor for fluorosis. This finding prompted another round of dosage schedule recommendations in the early 1990s. This paper presents a history of fluoride dosage recommendations and reviews the recent proposals for reducing supplement dosage.

Ultraconservative and cariostatic sealed restorations: results at year 10.

Changes in restorative techniques and the development of newer restorative materials have allowed for the use of more conservative cavity preparations. This 10-year study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations. The results indicate that both types of sealed restorations exhibited superior clinical performance and longevity compared with unsealed amalgam restorations. Also, the bonded and sealed composite restorations placed over the frank cavitated lesions arrested the clinical progress of these lesions for 10 years.

Practical clinical applications of sports dentistry in private practice.

Preparing a practice to become "trauma-ready" involves more than educating the dentist and the staff in the proper management of dentofacial trauma. All members of the office should understand their roles in preventing and treating trauma. They must be willing to provide care after hours when called upon to do so. Dentists who want to be more involved might wish to volunteer their services as sports dentists for local school or recreational league teams. The dentist who is conscious of his or her patients who are at risk for sports-related trauma will also find others in the practice who might benefit from many of the same protective devices that are being constructed for athletes. These include children involved in higher-risk activities, developmentally disabled patients, patients undergoing general anesthesia, and others. Being trauma-ready may open up several rewarding activities for the practice because of the many spin-off applications. The trauma-ready practice must also be cognizant of the some-times perplexing legal and insurance issues with regard to preventing and treating sport-related injuries. In addition to lowering the risk exposure to the practice, the dentist can help ensure the maximum third-party benefits for the patient.

Pit and fissure sealant application using a drying agent.

This clinical investigation assessed the retention of pit and fissure sealants with and without the use of a post-etching drying agent in pediatric dental patients. Twenty eight healthy patients with four fully erupted, non-carious first permanent molars participated. Sixteen males and 12 females, 5-12 years of age, each received four sealants, two with and two without a drying agent. Sealants were placed by three dental operators. Assignment for sealant application (with and without drying agent) was based on a computer-generated randomization table. Sealant application involved cleansing of the teeth with a non-fluoridated prophylaxis paste followed by rinsing 60 seconds with air/water spray, enamel conditioning with 40% phosphoric acid for 60 seconds, rinsing with air/water spray for 60 seconds, application of drying agent for 5 seconds, application of sealant material, and light curing for 60 seconds. Modified USPHS (Ryge) criteria were used to evaluate interfacial staining, secondary caries, marginal integrity, and surface texture. Sealant retention was evaluated as fully retained or lost (failed). All 28 participants returned for the 12-month recall visit. Four evaluators reported a 91% overall retention rate. Of the 56 teeth sealed without a drying agent, there was a 13% (n = 7) failure rate compared to 5% (n = 3) failure rate for the 56 teeth sealed with a drying agent. These results were not statistically significant (P > 0.05) based on the log-rank test.

The role of fluoride mouthrinses in the control of dental caries: a brief review.

Fluoride mouthrinses have generally proved to be effective in controlling caries in clinical studies. Caries reductions in North American studies have averaged about 30%. Large-scale school-based mouthrinse programs conducted during the 1970s, however, used historical controls at a time when caries rates were now known to be declining. Post-hoc analysis of the absolute (not relative) caries reductions in these studies showed that school-based fluoride mouthrinse programs were of questionable benefit from a cost standpoint. Fluoride mouthrinses have been shown to reduce demineralization and enhance remineralization of enamel adjacent to orthodontic bands and brackets. Benefits in adults have been less well documented. Use of fluoride mouthrinses by young children is discouraged until they have mastery of their swallowing reflexes. This paper recommends the use of fluoride mouthrinses for patients at increased or high risk for dental caries, but cautions that school-based programs be undertaken only in communities with a high population caries rate.

The Ace Bandage approach to digit-sucking habits.

This article describes an at-home program to assist children with nocturnal digit-sucking habits. Children with such habits are candidates for this program if they wish to discontinue their habits and have no psychological contraindications for habit cessation. The program involves nightly use of an elastic bandage wrapped across the elbow. Pressure exerted by the bandage removes the digit from the mouth as the child tires and falls asleep. Careful patient selection and parent education can lead to a success rate that makes the program worth attempting prior to instituting appliance therapy.

Association of generalized joint hypermobility with history, signs, and symptoms of temporomandibular joint dysfunction in children.

This study determined the prevalence of signs and symptoms of temporomandibular joint dysfunction (TMD) in children with and without generalized joint hypermobility (GJH). Twenty children with GJH, ages 4-19, and 20 age- and sex-matched control children completed a TMD signs/symptoms history and underwent an examination consisting of palpation of the joints and associated musculature for tenderness, clicking, or crepitation. Children with historical or clinical findings were designated positive for TMD signs/symptoms. Maximum vertical opening, expressed as a percentage of lower facial height, and maximum mandibular lateral excursion (in mm) were recorded. Fifteen (75%) of the GJH participants and ten (50%) of the controls were positive for TMD findings. There were statistically significant differences between the groups for the presence of total positive findings (P < 0.001) and for responses to palpation of muscle or joint (P = 0.03). There were no significant differences in positive responses to the history alone, joint palpation alone, or muscle palpation alone. There were no significant differences between the groups in jaw excursions. This study suggests that children with GJH may be more likely to demonstrate some signs and symptoms of TMD than children with normal joint mobility.

Evaluation of the effects of orthodontic pacifiers on the primary dentitions of 24- to 59-month-old children: preliminary study.

This study was designed to compare the occlusions of 24- to 59-month-old children who used orthodontic or conventional pacifiers to the occlusions of a group of controls who had no sucking habits. Information on the habits was collected by parental questionnaires. Ninety-five children were examined for malocclusions involving overbite, overjet, canine, and molar relationships, and posterior crossbites. Users of orthodontic pacifiers had statistically significantly greater overjets, and there was a significantly higher proportion of subjects with open bite in the conventional pacifier group. There was a trend toward a greater number of subjects in the control and orthodontic pacifier group with overbites less than or equal to 50%. These differences were not clinically significant, however. There appeared to be only minor differences between the occlusions of the two pacifier groups.

Comparison of the use of a child and an adult dentifrice by a sample of preschool children.

The purpose of this study was to compare the use of a child dentifrice (CD) and an adult dentifrice (AD) by a convenience sample of preschool-aged children. Fifty participants, ages 31 to 60 months, were recruited from a dental school clinic and an area day care center. All were healthy, free of developmental delays, and capable of applying dentifrice to a toothbrush. The study employed a crossover design in which the children each brushed their teeth twice, once with each type of dentifrice. The order of dentifrice use was assigned randomly, and the two brushings were separated by at least 1 week. The following were recorded: 1) the amount of dentifrice applied, 2) the time spent brushing, and 3) whether the child expectorated and/or rinsed after brushing. The mean weight of CD the children used (0.689 g, 0.43 SD) was significantly greater than that of AD (0.509 g, 0.41 SD, P = 0.02, Wilcoxon's signed rank test). The mean time spent brushing with CD (83.56 sec, 85.4 SD) was significantly greater than for AD (57.48 sec, 39.0 SD, P = 0.01). A "risk factor" (dentifrice weight x usage time) was derived to estimate the relative fluoride exposure of each child. The mean risk factor for CD (58.54, 64.8 SD) was significantly greater than that for AD (27.43, 25.0 SD, P < 0.001). Most children did not expectorate or rinse after brushing. Most parents selected drawings on a questionnaire that indicated that their child routinely used 0.25-0.5 g of dentifrice per brushing, which underestimated the amount they used in the study. The results of this study indicated that young children may be exposed to more fluoride for a longer period of time with CD.

Effects of current and former pacifier use on the dentition of 24- to 59-month-old children.

Two hundred eighteen children ages 24-59 months participated in a study to examine the effect of pacifier use on the occlusion of the primary dentition. A questionnaire was used to gain information on habit history. Eighty-two children were current or former users of functional exercisers, 38 had a history of conventional pacifier use, and 98 had no history of oral habits. Compared to children with no habit, those with a history of pacifier use had a significantly larger mean overjet (P < 0.001), as well as significantly higher occurrences of Class II primary canines (P = 0.015), distal step molars (P = 0.014), openbite (P = 0.001), and posterior crossbite (P = 0.025). Compared to users of conventional pacifiers, users of functional exercisers had a significantly higher occurrence of Class II primary canines (P = 0.013) and distal step molars (P = 0.037). Pacifier use time in months was significantly higher for children with openbite (P = 0.02) and posterior crossbite (P = 0.019). Compared to former pacifier users, those with current habits had a significantly higher prevalence of openbite (P = 0.002) and posterior crossbite (P = 0.001), and a greater mean openbite (P = 0.19). The reported number of hours use per day was not related to any aspect of the occlusion of pacifier users. African-American and European-American children began their habits at about the same age and used their pacifiers for an equivalent number of hours per day. Among those who had discontinued their habits, African-American children had maintained theirs for a significantly shorter period (P < 0.001), leading to a longer elapsed time between habit discontinuation and the examination.