The treatment of black stain associated with of iron metabolism disorders with lactoferrin: a litterature search and two case studies.

Among the various pathologies of the oral cavity, the formation of "unsightly black spots" on the surface of the tooth, universally known as Black Stain (BS) has recently been acquiring more interest. Usually BS is typically found in individuals in prepubertal age, even though it has been identified in adults associated with microbial exchange and / or with iron metabolism disorders. Microbial exchange concerns the possible exchange of bacteria between family members which can take place directly, through effusions, or indirectly, through brushes, cutlery or glasses. For this reason, it is recommended that toothbrushes of family members not be left damp and in contact with each other. The bathroom, being a warm-humid environment, is in fact an optimal habitat for microbial proliferation. Of specific importance in BS is the accumulation of iron in tissues and secretions which, together with chromogenic bacteria, are the primary cause of this pathology. In fact, among the metabolic products synthesized by bacteria in the oral cavity, hydrogen sulfide is of considerable interest, since upon reacting with iron available in saliva, in pathological conditions (iron metabolism disorders), it forms black precipitates consisting of ferric sulfide. These precipitates bind to the surface of the teeth, tending to form a stria that usually follows the contour of the gingiva, with an unsightly and variable chromatic intensity. In physiological situations, iron homeostasis is defined as the state of equilibrium between iron present in tissues and in secretions and that which is present in the circulation. Instead, in pathological conditions, defined as iron metabolism disorders, there is an accumulation of iron in tissues and secretions and a lack of it in the circulation. It is also important to remember that subjects affected by BS are more protected from carious processes than healthy subjects, probably due to a significant predominance of chromogenic bacteria compared to those responsible for caries. It should also be remembered that in young subjects BS tends to regress with pubertal development and the transition to adult life. In any case, using common professional hygiene procedures, it is possible to remove BS as well as plaque and tartar deposits. In particular, with ultrasonic scalers, polishing pastes and powders carried by air and water jets, the surfaces of the teeth can be restored to their natural healthy state. All the techniques for removing the precipitates, are not enough however, to fix and permanently eradicate their appearance, as these precipitates last only for short periods and recur very frequently. Due to the frequent recurrences, new oral microbiota control therapies are emerging; among these the use of lactoferrin (Lf) in the dental field and particularly in the treatment of BS appears to be very promising. Taken togheter, here the effect of Lf in subjects affected by BS has been investigated.

Staffing patterns and team composition.

The authors describe the work of a Veterans Administration task force in developing guidelines for staffing patterns and team composition on a hospital inpatient ward. The task force first defined the objectives of treatment, and then proceeded to define the needs of patients and their families, the types of professionals constituting the mental health team, and the functions they performed. It also identified the specific activities required in providing patient care, the staff involved in them, and those who could be involved, in some cases with more training.

A clinical psychogeriatric unit: organization and function.

A psychogeriatric unit in Brentwood VA hospital is described with regard to function and organization. Its clinical task is to evaluate the elderly veterans in several dimensions. Then a comprehensive plan emerges for continuing care, to which each professional staff member contributes his own experience. The presenting problems are given priorities, and needed services are coordinated. This process involves staff roles and training, the needs of the population served, diagnostic and treatment procedures, and aftercare programs. Liaison with other agencies addressing the problems of aging provides support in policy-making, consultation and education for the proprietors of homes accepting placement of elderly veterans. It is hoped that the findings of this report (including a clinical study of 47 patients) may serve as a stimulus to others who contribute to the care of the aged.

Important factors in rehabilitating the psychiatric patient.

Family conflicts, retirement, bereavement, and isolation often precipitate emotional and physical decompensation in the elderly. Such stresses can cause a precipitous regression, and as the ego tries to master the intense anxiety, massive denial, hypochondriasis, projection, introjection, and helplessness can take over. Evaluation of an emotionally distraught patient with behavioral changes should include comprehensive assessment of medical, psychologic, and social problems. The physician should not be concerned only with physical disorders and ignore psychosocial data; neither should the psychiatrist focus on the psyche and disregard obvious somatic disorders. Treatment must be realistic, prompt, and energetic. Undertreatment for fear of drug toxicity, overtreatment by plying the patient with multiple drugs, and delay in treatment are equally destructive. Appropriate medication and group psycho-therapy are extremely useful, but the most important element of treatment is a doctor-patient relationship that supports and sustains hope in the distressed patient.

The Vietnam veteran: the task is re-integration.

The Vietnam veteran is re-integrating into the Community. Some veterans are experiencing special difficulties, and tend to cluster inot groups which are cemented by common needs, common symptoms or ideologies. At Brentwood V.A.H., the Vietnam veterans show serious psychiatric illness. The contributing factors are often complex, and include personality and social maladjustments, traumatic experiences and an impoverished family and social structure. The full range of psychiatric therapies may be appropriate, depending upon the individual problem constellation. In addition to empathic professional treatment, there is a need for community support and for a continuing open-minded clinical inquiry about both the defined and as yet unmet needs of the Vietnam veteran. Some veterans are in need of help but reject V.A. facilities. Answers to this problem are not easy. As the adolescent veteran ages, some maturation may spark a greater flexibility in attitudes and viewpoints. The V.A. as an institution is obligated to exercise its own strugles to attain a broader community base for its services. Other non-V.A. agencies have this responsibility as well. Veterans are also citizens in a wider sense. Everywhere, helping professionals have many tasks. One of these is to recognize the dangers of blurring the boundary between advocacy and therapy. The failure to attend to this confusion risks sacrificing the patient in advancing the cause.

Current medico-legal issues -- a psychiatrist's view.

The present challenges in medicine indicate clearly that a fuller partnership between patient and doctor is being evolved, without secret or unshared clauses. When a satisfactory relationship develops, it not only satisfies medico-legal requirements, but also fulfills the basic needs of excellent practice. The education of the patient and his family is an important part of the treatment process. The physician must consider and evaluate symptom, disease, and the patient as a person. It is the failure to establish a balanced equilibrium of these elements in any program of patient care, which give rise to crisis in patient-physician relationships, from which legal actions originate.

Comprehensive history taking for the non-psychiatrist.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient's personality "style" influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient's personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.SEVEN MAJOR PERSONALITY TYPES AND APPROPRIATE PHYSICIAN RESPONSES ARE OUTLINED: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.