Osteonecrosis and osteomyelitis of the jaw associated with tumour necrosis factor-alpha (TNF-α) inhibitors: a systematic review.

Tumour necrosis factor-α (TNF-α) inhibitors are increasingly being used as immunomodulators to manage inflammatory conditions such as rheumatoid arthritis and Crohn's disease. Reported serious side effects include an increased incidence of lymphoma and greater susceptibility to infections such as tuberculosis. The aim of this systematic review was to find out whether there is an associated risk of medication-related osteonecrosis of the jaw (MRONJ). Three authors independently searched PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials for published reports of oral osteonecrosis (ONJ) or osteomyelitis (OM) in patients who took anti TNF-α drugs and had no history of antiangiogenic agents or antiresorptive treatment. All types of studies on humans treated with TNF-α inhibitors were considered. Only six were eligible for analysis, and all were independently assessed for risk of bias. They included six patients with ONJ or OM that was attributed solely to TNF-α inhibitors. The most common site of ONJ was the posterior mandible (n=5). The mean (SD) duration of anti-TNF-α treatment before the development of bony lesions was 62.5 (47.4) months. Invasive surgery was reported as a precipitating factor in five cases, and the ONJ/OM resolved with conservative management in five. Although all the studies were judged to be at high risk of bias, the limited data suggest that some patients will potentially develop ONJ/OM as a result of treatment with TNF-α inhibitors. Studies of higher quality are now needed to establish the relative risk of MRONJ in patients who take them.

A national follow-up survey of UK graduates opinion of undergraduate oral surgery teaching.

INTRODUCTION: A national follow-up survey was undertaken to determine whether dental graduates from 2009 perceived that their undergraduate oral surgery education had equipped them for general dental practice 4 years after graduating. MATERIALS AND METHODS: Graduates from the same 13 United Kingdom dental schools who had taken part in the original survey were invited to take part in this follow-up online survey. Their contact details were identified via the general dental council register, social media and alumni groups. RESULTS: In total, 161 responded (2009b) which represents 16% of the graduates of the original survey in 2009a. A similar percentage of these respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practice (83% and 79% in 2009a and 2009b, respectively). Most respondents (99% in both years) reported confidence in undertaking simple forceps exodontia. Confidence in surgical exodontia was poor in both surveys, but one area that appeared improved in the follow-up related to the sectioning of teeth (84% in 2009b compared with 49% in 2009a). Areas of weakness identified in 2009 were reported to be improved in the follow-up. CONCLUSION: This follow-up survey supports the findings of the original survey. Future longitudinal studies would allow institutions to identify possible weaknesses in their curriculum and to track the career development of their graduates and facilitate robust data collection.

Assessment of pain in temporomandibular disorders: the bio-psychosocial complexity.

Temporomandibular joint disorders (TMD) affect the joint, the masticatory muscles, or are expressed as a clinical combination of these two factors. The aims of this study were to: (i) identify the clinical and psychosocial factors that aid in the diagnosis and classification of acute and chronic TMD, (ii) determine specific initiating and perpetuating factors which may act as a guide to differentiate between acute and chronic TMD, (iii) identify factors which might predispose to conversion from acute to chronic TMD. Twenty-two patients were examined in the pain clinics at the Eastman Dental Institute. The assessment technique incorporated questionnaires, clinical history and examination including dental panoramic tomography. The results of this pilot study show a significant correlation between mood and enjoyment of life in both groups, mood and relationships in the chronic group, average pain and sleep in the chronic group, average pain and eating-chewing in the chronic group, and phobia for physical disease with trust in clinicians in the chronic group. The bio-psychosocial model of pain is an important appraisal tool. The newly designed TMD Pain Assessment is described with good results.

The influence of self-deception and impression management upon self-assessment in oral surgery.

OBJECTIVE: To see if poor self-assessment of surgical performance during removal of mandibular third molars is influenced by self-deception (lack of insight) and impression management (trying to convey a favourable impression). DESIGN: A prospective study of 50 surgeons, surgically removing a lower third molar tooth. SETTING: One UK dental school over a two year period. METHODS: The surgeons' surgical skills were assessed (by two assessors) and self-assessed using check-list and global rating scales. Post-operatively, surgeons completed validated deception questionnaires which measured both self-deception enhancement (lack of insight), and impression management (the tendency to deliberately convey a favourable impression). MAIN OUTCOME MEASURES: Reliability between assessors, and between assessors' and surgeons' self-assessments were calculated. Discrepancies between assessors' and surgeons' scores were correlated with surgeons' deception scores. RESULTS: Reliability between assessors was excellent for checklist (0.96) and global rating scales (0.89) and better than the reliability between assessors and surgeons (0.51 and 0.49). There was a statistically significant correlation (r=0.45 p=0.001 checklist, r= 0.48 p<0.001 global) between over/ under-rating of their surgical performance by surgeons and their impression management scores. No statistically significant correlation was found between this inaccuracy in self-assessment and surgeons' individual self-deception scores. CONCLUSION: The majority of surgeons scored themselves higher than their assessors did for surgical skill in removing a single mandibular third molar tooth. Impression management (the tendency to deliberately convey a favourable impression) may contribute to a surgeon's inaccurate self-reporting of performance. Lack of insight appears to be much less important as a contributing factor. The authors speculate that pressure to provide evidence of good performance may be encouraging surgeons to manage their image and over-score themselves.

Correlation between a patient-centred outcome score and surgical skill in oral surgery.

Our aim was to find out whether scores derived from a patient-centred outcome questionnaire correlated with the skill of the surgeon as assessed by a trainer. We found a relatively poor correlation after removal of a third mandibular molar, probably because outcome scores incorporate other measures, including patients' perceptions, anaesthesia, clarity of explanations and instructions, apart from surgical skill. The experience of the surgeon and the length of operation also influenced the results. The correlation was closest (i.e. higher levels of skill produced milder symptoms) when the operation was under local anaesthesia, probably because the surgeon's skill, behaviour, and attitude were visible to the patient throughout, and other team members had a less prominent role. In future, it may be more appropriate to assess the performance of the whole surgical team, rather than the surgeon alone.

Assessment of surgeon competency to remove mandibular third molar teeth.

There is an increasing demand for methods to objectively assess a surgeon's competence. The purpose of this study is to test two evaluation methods that assess a surgeon's skills in the removal of mandibular third molar teeth. One method uses an objective checklist scale by which twenty components of the operation are judged as correct or incorrect. The second method is a global rating scale, that scores different aspects of performance, such as respect for tissue, number of manoeuvres, knowledge of procedure and instrument handling. Using these two methods, assessors judged the removal of 22 mandibular third molar teeth by 17 different surgeons. Good inter-rater reliability was achieved using both scales. A greater preference was expressed for the global rating scale for assessment and for the objective checklist scale for guiding feedback in training. Scales such as these need to be developed for, and tested on, different surgical procedures in order that credible assessment of surgical skills can be obtained.

Are we really as good as we think we are?

Differences are examined in assessment and self-assessment scores, in oral and maxillofacial surgery trainees and MSc postgraduates, following the surgical removal of lower third molar teeth. This study found evidence of a surprising and worrying over-rating of their own surgical skills by many trainees and postgraduates.

A randomized controlled clinical trial of increased dietary iron in breast-fed infants.

Six-month-old breast-fed infants were randomly allocated to a high iron (8.2 +/- 2.9 mg/day, n = 36) weaning diet or a control group (5.2 +/- 3.4 mg/day, n = 26). We could detect no effect of increased iron intake from weaning foods on iron status of these iron-sufficient infants at 12 months.

The development of patient information leaflets. Care of the mouth after radiotherapy.

OBJECTIVES: Describe the methodology used to produce a patient leaflet on care of the mouth after radiotherapy. DESIGN: Prospective study to design a patient information leaflet. SETTING AND SUBJECTS: Patients undergoing radiotherapy for oral cancer. INTERVENTION: After a review of the relevant literature, a patient questionnaire was produced. This was then completed by patients undergoing radiotherapy treatment and gave an indication of the problems being encountered. Healthcare professionals were surveyed for their views. A leaflet was then produced according to published guidelines. It was taken back to another group of patients and a further version produced after input from a health promotion group. RESULTS: A leaflet was produced after wide consultation and survey. CONCLUSIONS: Considerable effort must to be put into the production to patient information leaflet. It must be discussed with patients in the target group if it is to be sensitive, understood and find acceptance among its users.

Close association of centroacinar/ductular and insular cells in the rat pancreas.

Close contacts between endocrine insular cells and exocrine acinar, centroacinar and ductular cells occur frequently in the rat pancreas as seen by both light and electron microscopy. Islets of Langerhans are surrounded incompletely by a thin connective tissue capsule or mantle but numerous exocrine-endocrine cell contacts occur at the periphery, which is irregular with considerable "intermingling" of the two cell types. Centroacinar and ductular cells are seen to be in contact with all endocrine cell types but most commonly insulin-secreting B-cells. The basal surface of centroacinar cells in the region of contact may be extensive, sometimes with overlap of basal processes of these cells and their lateral extension between acinar and insular cells. The areas of contact contain no connective tissue or basal lamina and show no surface specializations. The presence of both the "open" and "closed" type of enteroendocrine cells within acini is confirmed, some also being in contact with centroacinar cells. The functional significance of these exo-endocrine cell contacts is discussed in terms of the endocrine-acinar portal system, possible direct paracrine secretion, compartmentalization within the islet, and the known effects of islet hormones on exocrine secretion. Also relevant is the developmental origin of islets from ductal tissue and the cellular origin of some tumours, e.g., insulinomas, from duct cells.