Disease control in chronic rhinosinusitis: a qualitative study of patient perspectives.

BACKGROUND: The definition of disease control in chronic rhinosinusitis (CRS) is an active area of study. However, investigations have not engaged CRS patients in how they think about disease control. This study seeks to understand the patient perspective on CRS disease control. METHODS: Qualitative phenomenological study using constant comparative methodology was applied. The research team conducted 10, one-on-one interviews with CRS patients ranging from 22 to 55 minutes in length. The content of the interview protocol was determined through iterative discussion amongst all authors. Two authors served as coders to identify recurrent themes. Themes were analyzed for meaning and conclusions were summarized. RESULTS: Three recurring themes determined from patients were that (1) use of the terminology control adequately represents this phenomenon, (2) components of control could be classified into four main themes relating to CRS symptomatology, exacerbation of comorbid disease, quality of life and acute exacerbations of CRS, and (3) when patients deem their CRS is uncontrolled they are more willing to escalate their treatment to include escalating their daily maintenance regimen, seeking otolaryngology referral, taking rescue medication or undergoing endoscopic sinus surgery. CONCLUSIONS: CRS patients consider their daily symptoms, the severity and frequency of CRS exacerbations, impact on quality of life as well as exacerbation of comorbid disease when thinking about their disease control. Disease control is a goal of treatment for patients and uncontrolled disease motivates patients to seek further treatment. Physicians should explore all components of CRS control when considering disease status and need for further treatment.

The role of automatic computer-aided surgical trajectory planning in improving the expected safety of stereotactic neurosurgery.

PURPOSE: Minimal invasion computer-assisted neurosurgical procedures with various tool insertions into the brain may carry hemorrhagic risks and neurological deficits. The goal of this study is to investigate the role of computer-based surgical trajectory planning tools in improving the potential safety of image-based stereotactic neurosurgery. METHODS: Multi-sequence MRI studies of eight patients who underwent image-guided neurosurgery were retrospectively processed to extract anatomical structures-head surface, ventricles, blood vessels, white matter fibers tractography, and fMRI data of motor, sensory, speech, and visual areas. An experienced neurosurgeon selected one target for each patient. Five neurosurgeons planned a surgical trajectory for each patient using three planning methods: (1) conventional; (2) visualization, in which scans are augmented with overlays of anatomical structures and functional areas; and (3) automatic, in which three surgical trajectories with the lowest expected risk score are automatically computed. For each surgeon, target, and method, we recorded the entry point and its surgical trajectory and computed its expected risk score and its minimum distance from the key structures. RESULTS: A total of 120 surgical trajectories were collected (5 surgeons, 8 targets, 3 methods). The surgical trajectories expected risk scores improved by 76% ([Formula: see text], two-sample student's t test); the average distance of a trajectory from nearby blood vessels increased by 1.6 mm ([Formula: see text]) from 0.6 to 2.2 mm (243%). The initial surgical trajectories were changed in 85% of the cases based on the expected risk score and the trajectory distance from blood vessels. CONCLUSIONS: Computer-based patient-specific preoperative planning of surgical trajectories that minimize the expected risk of vascular and neurological damage due to incorrect tool placement is a promising technique that yields consistent improvements.

Evaluation of success rate of endodontic treatment performed by students with stainless-steel K-files and nickel-titanium hand files.

A previous study by our group found nickel-titanium (NiTi) 0.02 hand files maintained the original canal shape better than similar stainless-steel K-files (SS-K). Inexperienced dental students used both file types on molar teeth. The purpose of this study was to compare the 1-yr success rate of endodontic treatment of the same teeth used in our previous study. Twelve-month follow-up radiographs were compared with the immediate follow-up radiographs. Both sets of radiographs were taken with the same customized stent. Quantification of osseous changes using digital imaging was used. Thus, a reliable numerical estimation (densitometric ratio) of disease and healing processes could be established. Sixty-seven percent of the patients returned for the 12-month radiographs (19 NiTi vs. 21 SS-K). Immediate postoperative periapical status was found to be similar (p > 0.05). Teeth instrumented with the NiTi files demonstrated a higher mean change in densitometric ratio, compared with SS-K files (p < 0.05). Further tests of success (values: > or =0) and failure (value: < or =0) with the Fisher exact test showed more success (decreasing radiographic density) with NiTi files and more failures (increasing radiographic density) with SS-K type files (p < or = 0.03). This study indicates that maintaining the original canal shape after instrumentation leads to a better prognosis of endodontic treatment.

Comparison between PAI and quantitative digital radiographic assessment of apical healing after endodontic treatment.

OBJECTIVE: The purpose of this study was to compare both subjective (Periapical Index, PAI) and objective (densitometric) radiographic evaluation of healing after endodontic treatment for apical periodontitis. STUDY DESIGN: Standardized radiographs of 103 teeth taken at baseline (immediately after endodontic treatment) and at 1, 4, 12, 26, and 52 weeks were evaluated. Consensus PAI scores obtained from 7 calibrated observers served as "true scores." Densitometric estimates of periapical status were obtained from digitized radiographs as the ratio of mean gray value of an area of radiolucency (AR) to an adjacent and similar-sized normal (N) area (AR/N). The selected regions of interest on baseline images were automatically superimposed on postoperative images. All estimates of change were measured with respect to baseline. The subtraction estimate was expressed as AR(S)-N(S). Linear regression was used to analyze longitudinal changes against baseline and to assess the relationship of PAI and AR/N and of change in PAI with respect to baseline and AR(S)-N(S). RESULTS: Five hundred fifty-six PAI scores were generated, with 547 AR/N values and 444 subtraction estimates. PAI, AR/N, and AR(S)-N(S) demonstrated statistical significance for change (P < or = .05) starting at 12 weeks. PAI was significantly correlated with AR/N (P < .0001), as was CHPAI with AR(S)-N(S) (P < .024). CONCLUSION: The PAI and 2 densitometric estimates (AR/N and AR(S)-N(S)) detected healing of apical periodontitis at 12 weeks after treatment. No difference could be observed among the methods.

Bacteria isolated after unsuccessful endodontic treatment in a North American population.

OBJECTIVE: The purpose of this study was to determine the composition of the microbial flora present in teeth after the failure of root canal therapy in a North American population. These results were then compared with those of the previous Scandinavian studies. STUDY DESIGN: Fifty-four root-filled teeth with persistent periapical radiolucencies were selected for retreatment. After removal of the root-filling material, the canals were sampled with paper points, and by reaming of the apical dentin. Both samples were grown under aerobic and strict anaerobic conditions. Then the bacterial growth was analyzed. RESULTS: The microbial flora was mainly of 1 to 2 strains of predominantly gram-positive organisms. Enterococcus faecalis was the most commonly recovered bacterial species. CONCLUSIONS: Bacteria were cultivated in 34 of the 54 teeth examined in the study. E faecalis was identified in 30% of the teeth with a positive culture.

Pulp revascularization of replanted immature dog teeth after different treatment methods.

The purpose of the present study was to determine the effect of topical treatment with doxycycline and/or the application of unfilled resin to the anatomical crown on the occurrence of revascularization in reimplanted dog teeth. Ninety-six teeth in 4 young mongrel dogs were used. Eighty one teeth were atraumatically extracted and divided into four groups. Group 1, 17 teeth were kept dry for 5 min and then replanted. Group 2, 21 teeth were soaked with a freshly prepared solution of doxycycline (1 mg/20 mL saline) for 5 min before replantation. Group 3, 23 teeth were soaked with the doxycycline solution for 5 min, and then replanted. The crowns were coated with 2 layers of light cured unfilled resin. Group 4, 20 teeth were kept dry for 5 min, and then replanted. The crowns were treated as with the teeth in Group 3. Three months after surgery, radiographic evaluation revealed that 27 teeth had continued root development and 32 teeth showed arrested root development with periradicular pathosis. The remaining 17 teeth, which had arrested root development but no signs of periradicular pathosis, were all histologically evaluated for final assessment. The occurrence of revascularization according to treatment group was 29.4%, 60%, 60%, 36.8% in Group 1, 2, 3, and 4, respectively. A multiple logistic regression analysis in SAS indicated there was no significant association between vitality and dog (P = 0.7564). Soaking for 5 min in doxycycline significantly increased the revascularization rate (P = 0.024) while the addition of resin to the crown did not result in an increased incidence of pulp revascularization (P = 0.823).

Reduction of intracanal bacteria using nickel-titanium rotary instrumentation and various medications.

The purpose of this study was to evaluate the extent of bacterial reduction with nickel-titanium rotary instrumentation and 1.25% NaOCl irrigation. Also, the additional antibacterial effect of calcium hydroxide for >1 wk was tested. Forty-two subjects with radiographic and clinical signs of chronic apical periodontitis were recruited. The canals were sampled before treatment, during and after instrumentation, and after treatment with calcium hydroxide and the samples incubated anaerobically for 7 days at 37 degrees C. The bacteria from each sample were quantified and the log10 values were used for calculations and comparisons. The initial sample confirmed infection of the canals. There was a significantly greater pattern of reduction of bacteria when NaOCl was used as an irrigant, compared with sterile saline (p < 0.05). After instrumentation with NaOCl irrigation, 61.9% of canals were rendered bacteria-free. The placement of calcium hydroxide for at least 1 wk rendered 92.5% of the canals bacteria free. This was a significant reduction, compared with NaOCl irrigation alone (p = 0.0001). The results of this study indicate that NaOCl irrigation with rotary instrumentation is an important step in the reduction of canal bacteria during endodontic treatment. However this method could not consistently render canals bacteria-free. The addition of calcium hydroxide intracanal medication should be used to more predictably attain this goal.

Endodontic complications of root canal therapy performed by dental students with stainless-steel K-files and nickel-titanium hand files.

Straightening of curved canals is one of the most common procedural errors in endodontic instrumentation. This problem is commonly encountered when dental students perform molar endodontics. The purpose of this study was to compare the effect of the type of instrument used by these students on the extent of straightening and on the incidence of other endodontic procedural errors. Nickel-titanium 0.02 taper hand files were compared with traditional stainless-steel 0.02 taper K-files. Sixty molar teeth comprised of maxillary and mandibular first and second molars were treated by senior dental students. Instrumentation was with either nickel-titanium hand files or stainless-steel K-files. Preoperative and postoperative radiographs of each tooth were taken using an XCP precision instrument with a customized bite block to ensure accurate reproduction of radiographic angulation. The radiographs were scanned and the images stored as TIFF files. By superimposing tracings from the preoperative over the postoperative radiographs, the degree of deviation of the apical third of the root canal filling from the original canal was measured. The presence of other errors, such as strip perforation and instrument breakage, was established by examining the radiographs. In curved canals instrumented by stainless-steel K-files, the average deviation of the apical third of the canals was 14.44 degrees (+/- 10.33 degrees). The deviation was significantly reduced when nickel-titanium hand files were used to an average of 4.39 degrees (+/- 4.53 degrees). The incidence of other procedural errors was also significantly reduced by the use of nickel-titanium hand files.

Subattachment inflammatory root resorption: treatment strategies.

Attempts have been made to classify root resorption according to its etiology in order to develop more efficient strategies for its treatment. This condition has been identified as resulting from damage to the protective attachment layer (predentin or precementum) of the root combined with inflammation adjacent to the root surface. This article demonstrates a series of treatment strategies focused on the reversal of each manifestation of subattachment root resorption, specifically emphasizing defects that extend apically and localized defects.

Local dexamethasone improves periodontal healing of replanted dogs' teeth.

The purpose of the present investigation was to evaluate histologically the effect of dexamethasone on root resorption in stored and replanted dogs' teeth. Twenty-nine roots from three beagle dogs were endodontically treated to prevent subsequent inflammatory root resorption of pulpal origin. The teeth were extracted and randomly assigned to three groups for 48-h storage. Group 1: control group teeth (n = 13) were stored in vials containing ViaSpan only; Group 2: topical treatment teeth (n = 10) were stored in vials containing ViaSpan and dexamethasone (16 micrograms/ml); and Group 3: systemic treatment teeth (n = 6) were stored in vials containing ViaSpan without any additives. Dexamethasone was administered intramuscularly (0.5 mg/kg body weight) 2 days prior to, on the day of, and every other day after extraction and replantation for two administrations. After 12 weeks, the dogs were sacrificed, and the teeth histologically prepared and evaluated according to the analysis of Andreasen. Significant differences were found for complete healing (P = 0.0583) and inflammatory root resorption (P = 0.0568) but not for replacement resorption (P = 0.1952). In addition, comparing local to systemic administration of dexamethasone (Group 2 vs. Group 3), statistically significant differences were found for healing, 85% (Group 2) vs. 67% (Group 3) (P = 0.0125) and inflammatory root resorption, 13% (Group 2) vs. 28% (Group 3) (P = 0.0126). This study indicated that topical use of dexamethasone enhances healing and results in fewer resorption complications.

Bacterial reduction with nickel-titanium rotary instrumentation.

The purpose of this study was to compare intracanal bacterial reduction on teeth instrumented with 0.04 tapered nickel-titanium (NiTi) rotary instrumentation to bacterial reduction when using a stainless-steel K-file step-back technique using sterile saline irrigation. Forty-eight patients with apical periodontitis were randomly assigned treatment type. The canals were sampled before, during, and after instrumentation. The samples were incubated anaerobically for 7 days at 37 degrees C, colony-forming unit numbers calculated, and a log transformation performed to normalize the counts. Teeth exhibiting apical periodontitis were uniformly infected, whereas vital control teeth were not. A similar and uniform reduction occurred with progressive filing, regardless of technique (p < 0.0001). There was no detectable difference in colony-forming unit count after NiTi rotary or stainless-steel hand instrumentation (p = 0.42). Neither technique could predictably render canals free of bacteria. The results of this study indicate NiTi rotary and stainless-steel hand K-file step-back instrumentation techniques were not significantly different in their ability to reduce intracanal bacteria.

Dentinogenesis imperfecta: endodontic implications. Case report.

Dentinogenesis imperfecta is a hereditary disorder resulting in defective dentin in both the primary and secondary dentitions. The complications of dentinogenesis imperfecta are difficult to manage and provide a challenge to the dentist. This case report concerns treating an African American patient with dentinogenesis imperfecta who appeared for treatment with endodontic pathosis. It illustrates the need for appropriate and timely restorative treatment to prevent pulpal pathosis. Also demonstrated is the difficulty of endodontically treating dentinogenesis imperfecta teeth because of pulpal obliteration and abnormal dentin mineralization. Early and correct diagnosis of dentinogenesis imperfecta is imperative to enable appropriate preventive interventions and optimal dental treatment. Although pulpal pathosis is rarely reported with dentinogenesis imperfecta, endodontic treatment is occasionally necessary and has a guarded prognosis if initiated after pulp canal obliteration has occurred.

Nonsurgical root canal therapy treatment with apparent indications for root-end surgery.

The recent introduction of the surgical microscope to the practice of endodontics, especially for surgery, has allowed clearer visualization of the periapex during root-end resection and filling. However, despite this and other technologic advances, it has not been demonstrated that in the absence of thorough canal debridement the success rate of periapical surgery has improved over the 50% to 60% demonstrated in most long-term prognosis studies. Therefore it remains important to fully instrument and obturate the root canal system with conventional therapy before surgery is considered; this considerably improves the long-term prognosis. Each of the case reports in this article involves a situation in which conventional treatment was performed when a surgical approach might have been considered as the treatment of choice. Surgery should not be considered to be the primary treatment when root canal treatment or retreatment may be readily achieved. Indeed, the operating microscope and other technical aids will probably allow more cases to be treated and retreated conventionally that might otherwise have required surgical intervention.

Quantitative radiographic follow-up of apical surgery: a radiometric and histologic correlation.

The objective of this study was to establish an objective method for evaluating the treatment outcome of apical periodontitis (AP). AP was induced in the mandibular premolars of beagle dogs and apicoectomies were performed with retrofilling. Standardized periapical radiographs were taken immediately after completion of treatment and at 6 months. Ten pairs of standardized radiographs of 33 treated roots were analyzed. Radiographs were digitized and subtracted after warping and gamma correction. Areas of AP and adjacent normal areas (N) in digitized original and subtraction images were analyzed using eight radiometric computations. These computations were compared with subjective histologic evaluation and objective quantitative histomorphometry of the periapical condition at 6 months. The average gray value for AP on the subtraction images was found to have significant correlation with both objective (multiple regression p < 0.01) and subjective histology (logistic regression p < 0.01). Digital subtraction may be a useful tool in endodontic apical surgery assessment.

The role of the socket in the periodontal healing of replanted dogs' teeth stored in ViaSpan for extended periods.

In a previous study on the extended storage of extracted dogs' teeth, it was hypothesized that changes in the socket environment might play a role in the periodontal healing of these teeth. The purpose of this study was to evaluate the role of the socket in the periodontal healing of replanted dogs' teeth. Extracted endodontically treated dogs' teeth were stored in ViaSpan for 6 hours and replanted into sockets after 6, 48 or 96 hours. Controls included teeth extracted and replanted immediately, 48-hour stored teeth replanted into 48-hour sockets and 96-hour stored teeth replanted into 96-hour sockets. After 6 months the dogs were killed and the teeth prepared for histologic evaluation according to Andreasen. Overall healing for the groups and healing for teeth within the groups were evaluated and compared. The best results were obtained when the teeth were replanted immediately. For the teeth stored in ViaSpan for 6 hours, complete healing decreased significantly as the age of the socket increased. In addition, the rate of replacement resorption increased significantly with increasing socket age for the 6-hour stored teeth. Forty-eight-hour stored teeth replanted into 48-hour sockets had the lowest healing rate with levels of inflammatory resorption not seen in the other groups. According to the results of this study, the socket environment plays an important role in the healing of replanted teeth in dogs.

Periodontal healing of extracted dogs' teeth air-dried for extended periods and soaked in various media.

The aim of this study was to determine the periodontal healing of replanted dogs' teeth which, after extended extra-oral dry times, had been soaked in various media before replantation. Incisors and premolars of beagle dogs were root canal treated, extracted and bench dried. The teeth were grouped according to dry times of 30, 45 and 60 minutes. Each group of teeth was soaked in one of three media, Hank's balanced salt solution, ViaSpan (Belzer UW-CSS, Dupont Pharmaceuticals), or Conditioned Medium (supernatant of confluent culture of human gingival fibroblasts) for 30 minutes before replantation. Controls consisted of teeth extracted and replanted without drying on soaking (negative control), and bench-dried teeth replanted without soaking in the media (positive control). The dogs were killed 6 months after replantation of the teeth, which were prepared for histologic evaluation. Five microns cross-sections (every 70 microns) of the root and surrounding tissue were evaluated for healing/resorption according to Andreasen's criteria. The best healing occurred for the roots which had been immediately replanted. Healing in the positive control groups decreased with increased dry time. For the 30-minute dry time groups, soaking in media had no beneficial effect on periodontal healing compared with the controls. Soaking in ViaSpan resulted in an increased healing incidence for both the 45- and 60-minute bench-dried groups while soaking in the other media had no consistent beneficial effect. It appears from this study that an avulsed tooth that has been left dry for 30 minutes should be replanted immediately without soaking. However, teeth that have been dry for 45 or 60 minutes would benefit from soaking for 30 minutes in ViaSpan.

TNF-alpha release in monocytes after exposure to calcium hydroxide treated Escherichia coli LPS.

Lipopolysaccharide (LPS), a cell wall component of Gram negative anaerobic bacteria, has been implicated in the pathogenesis of periapical disease resulting from infected root canals. Calcium hydroxide [Ca(OH)2] has been shown to be an effective medicament in such infections, reducing the microbial titre within the canal. It has been proposed that the therapeutic effect of Ca(OH)2 may also be the result of direct inactivation of LPS. The aim of this study was to investigate whether the toxic potential of an Escherichia coli LPS could be reduced or eliminated by Ca(OH)2. Four concentrations of E. coli LPS ranging from 1-1000 ng/ml sterile water were incubated in duplicate either with 25 mg Ca(OH)2 or sterile water alone. Controls consisted of Ca(OH)2 without LPS or sterile water only. Monocytes were collected from peripheral blood by centrifuging through a gradient and plated to a specific density. Adherent monocytes were incubated for 4 days at 37 degrees C with 5% CO2 in M199 medium with 10% autologous serum. The different LPS solutions were added to the wells on day 5. After 4 h the supernatants were collected and quantitatively assayed for TNF-alpha using a commercial ELISA kit. Statistical analysis was performed with ANOVA. Results indicated that Ca(OH)2 is able to eliminate the ability of an E. coli LPS to stimulate TNF-alpha production in peripheral blood monocytes (P < 0.0001).

Tritiated thymidine uptake in periodontal ligament cells of dogs' teeth stored in various media for extended time periods.

The purpose of this study was to evaluate a new storage solution, Conditioned Medium, vs Hank's balanced salt solution and ViaSpan with respect to the viability of periodontal ligament cells of exarticulated teeth. Teeth were stored for periods of 6, 48, and 96 hours in Hank's balanced salt solution, ViaSpan (Dupont Pharmaceuticals), or Conditioned Medium. Teeth were cultured for 24 hours in Dulbecco's medium supplemented with tritiated thymidine. The cultured teeth were sectioned and evaluated with autoradiography. Control teeth were extracted and immediately treated as above without storage. Mitotic activity was indicated by clusters of five or more grains over the nuclei of fibroblasts in the remaining periodontal membrane. The ratio of labeled to unlabeled cells (labeling index) was calculated for each treatment group. When storage time was compared across all groups, 96 hours was significantly different from 6 and 48 hours (P < 0.001 and P < 0.012 respectively). Storage time of 6 hours was not significantly different from 48 hours (P > 0.10). After comparison of the nine experimental groups with the control group, only Hank's balanced salt solution at 96 hours was significantly different (P < 0.004).

Healing of apical periodontitis in dogs after apicoectomy and retrofilling with various filling materials.

OBJECTIVE: To histologically assess the efficacy of various retrofilling materials in apical surgery. STUDY DESIGN: The pulps of mandibular premolars in seven beagle dogs were infected; this resulted in periapical lesions. Apical surgery was performed without disinfection of the root canals. Super EBA (Harry J. Bosworth Co., Skokie, III.), two formulations of glass ionomer cement, amalgam with varnish, IRM,(Caulk Co., Ltd., Densply International, Milford, Del.) and a light-cured composite resin were the retrofilling materials used. Roots infected and apicoectomized without retrofilling were positive controls. After 6 months the dogs were killed. The experimental roots and surrounding apical tissues were prepared and histologically examined and relative percentages of bone and inflammation were calculated. RESULTS: Super EBA was consistently the best. In overall periapical condition, Super EBA was statistically superior to all materials except IRM. IRM was superior to the glass ionomer cements but not the other materials. As to percentage of bone, Super EBA was the best overall; it was superior to glass ionomer, composite resin, and the positive control but not different from amalgam or IRM. When comparing remaining numbers of inflammatory cells, Super EBA was superior with the lowest number of inflammatory cells present. CONCLUSION: Although not statistically different from IRM, Super EBA was consistently the best retrofilling material tested when compared with all retrofilling materials studied.

Evaluation of success and failure after endodontic therapy using a glass ionomer cement sealer.

The purpose of this multicenter, prospective clinical study was to assess the treatment results following endodontic therapy using a glass ionomer cement sealer (Ketac-Endo) and to relate the results to various clinical factors. A total of 486 teeth were treated by three operators, using the "standardized technique" for canal preparation and either single cone or laterally condensed gutta-percha, in one or multiple treatment sessions. Six to 18 months postoperatively, the treatment results were assessed clinically and radiographically, and related to preoperative, intraoperative, and postoperative factors using a chi 2 analysis with 5% level of significance. Of 378 followed-up teeth, there was a 78.3% success, 15.6% incomplete healing, and 6.1% failure. Statistically, differences in the results were related to the number of canals (p < 0.04), primary treatment and retreatment (p < 0.02), pulp vitality (p < 0.001), periapical lesion (p < 0.001), preoperative symptoms (p < 0.003), operative complications (p < 0.001), and absence of restoration (p < 0.03). It was concluded that these treatment results were compatible with those reported in previous studies, and supported the clinical use of Ketac-Endo as an acceptable endodontic sealer.