Tooth formation and eruption - lessons learnt from cleidocranial dysplasia.

The principles of formation, renewal, and eruption of teeth are discussed. Numerous genetic aberrations may affect the formation and eruption of teeth. Cleidocranial dysplasia (CCD), caused by mutations in the runt-related transcription factor 2 (RUNX2) gene, is such a condition. The dental phenotype includes problems in both tooth formation (multiple supernumerary permanent teeth) and tooth eruption (lack of shedding of primary teeth and delayed or arrested eruption of permanent teeth). Clinical studies, animal models, and molecular biology studies have documented that RUNX2 is of paramount importance for osteoblast differentiation, for regression of the dental lamina, and for osteoclastogenesis in the dental follicle and the periodontal ligament. Jensen & Kreiborg, 25 yr ago, proposed a treatment strategy to be applied to patients with CCD, focussing on the importance of early treatment to promote spontaneous eruption of permanent teeth through extraction of primary teeth, surgical removal of supernumerary teeth, and removal of bone covering the first formed permanent teeth at the time when root formation of the permanent teeth has reached half or two-thirds of their final length. This strategy still seems valid and seems to lead to reduction in the burden of care for patients compared with the treatment protocols otherwise recommended.

Quantitative sensory tests before and 1(1/2) years after orthognathic surgery: a cross-sectional study.

Quality control is very important in relation to invasive and lengthy treatments, such as integrated orthodontic and surgical correction of dentofacial deformities. The aim of this cross-sectional study was to compare self-reported somatosensory disturbances and quantitative sensory testing (QST) findings between two groups of patients and a healthy control group (n = 24); one group (n = 21) scheduled for bimaxillary orthognathic surgery (BOS) (pre-op) and one group (n = 24) examined 1(1/2) years after BOS (post-op). Self-reported data on pain and somatosensory disturbances were collected, and QST was performed at six trigeminal and one extratrigeminal site. Sensitivity to brush stroke, tactile stimuli, pinprick, two-point-discrimination threshold (2P-DT), pinch pain threshold (PiPT) and pressure pain threshold (PPT) was evaluated. Results were analysed with anovas, Spearman's Correlation, and chi square tests. Eight per cent of post-op patients reported intra-oral, 46% extra-oral, and 46% no somatosensory disturbances. Sensitivity to brush stroke, pinprick and 2P-DT was significantly increased at all examination sites in the post-op patients compared with healthy controls (P < 0.002). Tactile thresholds and PPT did not differ between groups (P > 0.071). Pinch pain threshold were decreased in pre-op patients compared with controls (P < 0.040). Self-reported somatosensory disturbances were not correlated with QST findings. In conclusion; 1(1/2) years after BOS, a large proportion of patients reported somatosensory disturbances and was hypersensitive to mechanical stimuli when compared with pre-op patients and healthy controls. Pre-op patients showed minor somatosensory changes. In addition to patients serving as their own control in prospective studies, a healthy control group and extratrigeminal control sites should be included in future studies.

Treatment of severe hypodontia-oligodontia--an interdisciplinary concept.

The authors' experience with oral rehabilitation of patients suffering from oligodontia (i.e. six or more congenitally missing permanent teeth, third molars excluded) is reported. The concept is based on an interdisciplinary team approach involving pedodontists, orthodontists, maxillofacial surgeons and prosthodontists. A series of 112 consecutive patients suffering from oligodontia were referred from 1997 to 2001. Ten of the patients (8.9%) suffered from ectodermal dysplasia. The total number of missing teeth was 1126, with an average of 10 per patient. Ninety-two patients had either finished treatment or were on an active treatment schedule. Of these, 97% underwent some kind of orthodontic treatment. Of the 112 patients, 51 had finished treatment at the end of the follow-up period (mean 28 months, range 1-68). Of these, fixed implant-supported prosthetic restoration was used in 90% to replace missing teeth, often combined with alveolar ridge augmentations (73%), sinus floor augmentation (43%), inferior alveolar nerve transposition (18%) and orthognathic surgery (27%). Early diagnosis, and comprehensive treatment planning with good coordination and timing of the individual treatment phases are decisive for a successful treatment outcome. The therapeutic concept is presented with special emphasis on surgical aspects.

A new method for the estimation of mutans streptococci in human saliva.

A new method for quantitating the numbers of mutans streptococci in saliva--the "Strip mutans" test--was developed. It includes the following steps: A prepared plastic spatula is contaminated with saliva, transferred to a selective broth, incubated for two days, and dried. A predetermined area is counted or evaluated for CFUs of mutans streptococci. The medium contains sucrose to promote adhesion of mutans streptococci to the strip. Bacitracin, added just before use, is the basis for the selectivity. Results with the new medium were compared with those from the "spatula technique" and with those from conventional saliva sampling with dilution. The studies involved 302 and 60 schoolchildren, respectively. There was a highly significant correlation between the results from the new method and those from conventional methods. The strip mutans test is easy to used and has long shelf-life, and the spatulas with adherent colonies can be saved for future comparisons.

Antipolymer antibodies in Danish fibromyalgia patients.

OBJECTIVE: To use a new immunologic assay to investigate antipolymer antibody (APA) levels in women with fibromyalgia (FM). METHODS: The study population consisted of 35 patients with FM and 129 controls. The controls were selected based on a prior history of breast surgery and the presence or absence of a prior hospital diagnosis of soft tissue rheumatism. Study subjects underwent blood sampling, including tests for antinuclear antibodies (ANA) and APA, a clinical examination, and an interview focusing on rheumatic complaints and self-reported disability. The severity of rheumatic symptoms/signs was scored from 1 (= none) to 5 (= severe) based on the clinical examination and the interview. RESULTS: FM patients in this study represented a broad spectrum of disease severity, with the majority having mild symptoms. FM patients had a higher symptom severity and myalgic scores than controls (p < 0.001 for both variables). Adjusting for symptom severity, a weak positive association between APA levels and FM was observed (p = 0.08). The APA level was inversely associated with age, i.e., decreasing APA levels were seen with increasing age (p = 0.008). CONCLUSION: FM patients tended to have slightly higher APA levels than controls when adjusted for symptom severity. APA levels declined with age, a finding that has not been reported previously. The APA test and its clinical relevance should be evaluated in future studies.

Rheumatic manifestations in danish women with silicone breast implants.

The aim of this study was to investigate whether women with silicone breast implants (SBI) present with a unique rheumatic symptomatology. We assessed the profile of rheumatic disease in six groups of women identified through Danish hospital and population registers, three groups of women with a prior hospital diagnosis of muscular rheumatism (a non-specific diagnostic code) who had previously undergone SBI surgery (n = 28), breast reduction surgery (n = 29) or no breast surgery (n = 27); and three groups of women without a diagnosis of muscular rheumatism who had undergone SBI surgery (n = 21), breast reduction surgery (n = 27) or no breast sugery (n = 56). All women in the study population (n = 188) underwent a thorough clinical examination, blood tests and a personal interview. In all study groups soft-tissue rheumatism and degenerative diseases were the most frequent diagnoses. Women with a prior diagnosis of muscular rheumatism but no prior breast surgery had a significantly higher prevalence of soft-tissue rheumatism than those with breast implant or reduction surgery. No significant differences in the frequencies of rheumatic diseases were observed among the three groups of women without previous muscular rheumatism. No specific pattern of inflammatory rheumatic disorders or soft-tissue complaints was identified among the women with SBI, and blood tests for autoimmunity revealed no unique pattern. Overall, women with earlier rheumatism had significantly increased frequencies of rheumatic conditions than did those without. We found no evidence of a rheumatic symptomatology unique to women with silicone breast implants. Our study emphasises the need for consideration of prior rheumatic disease when evaluating rheumatic manifestations in women with SBI.

Alveolar bone loss and crowding in adult periodontal patients.

The present study aimed to examine whether local crowding and tooth angulation in the mandibular incisor region led to alveolar bone loss in patients with moderate periodontal disease. The sample comprised 27 patients from the Department of Periodontology aged 29-57 yr. Mesiodistal tooth angulation and crowding, defined as an overlap of 2 mm or more, were assessed from dental casts. Alveolar bone loss was assessed from intraoral standardized paralleling radiographs by two methods, the absolute bone level (ABL), recorded from the cementoenamel junction, and the relative bone level (RBL), a new measure, expressing the bone level relative to the two adjacent interradicular crests. Contralateral sites were used as controls. A significant difference in bone level was found between crowded and non-crowded sites by both methods (-1.7 mm, P less than 0.001). This indicates that in periodontal patients local crowding and tooth angulation predisposes to increased bone loss. Analysis of the correlations between tooth angulations and the two measures of bone loss indicated that the RBL value is a more sensitive measure of localized bone loss.

Orofacial pain, jaw function, and temporomandibular disorders in women with a history of juvenile chronic arthritis or persistent juvenile chronic arthritis.

OBJECTIVES: We sought to study the long-term outcome of juvenile chronic arthritis (JCA) in the temporomandibular joint (TMJ). STUDY DESIGN: Temporomandibular disorders, including TMJ involvement, were assessed in 42 women with pauciarticular or polyarticular JCA--on average 25.8 years from disease onset--and compared with those found in matched control subjects. Disease-related parameters associated with temporomandibular disorders were identified. RESULTS: The TMJ was involved in 66.7% of the patients, most severely in extended pauciarticular JCA. Temporomandibular disorders were more frequent in the patients than in the control subjects, especially in those with persistent disease. The TMJ involvement was positively correlated with disease duration and negatively correlated with jaw opening and occlusal support. Duration of active JCA and history of functional pain were identified as predictors of present TMJ involvement. CONCLUSION: In a long-term follow-up, TMJ involvement proved frequent in the studied patients and was associated with long disease duration and previous pain on jaw opening. The findings suggest that patients with JCA should undergo orofacial evaluation on a regular basis.

Dental treatment strategies in cleidocranial dysplasia.

Based on the findings of our recent longitudinal study on the abnormalities of the dentition in cleidocranial dysplasia (CCD), a hypothesis has been proposed, which makes it possible to predict time of onset of formation of supernumerary teeth and their location in the jaws. It was found that a diagnosis should be made early so that formation of supernumerary teeth can be diagnosed and early intervention undertaken. It should be possible to diagnose supernumerary incisors at about 5-7 years of age and supernumerary canines and premolars a few years later. When root length of the normal permanent teeth has reached about one third of its final length, the overlying supernumerary teeth should be removed, together with overlying bone and primary teeth. In regions where no supernumerary teeth are formed, eruption may also be improved by removal of the primary teeth and surgical exposure of the underlying permanent teeth. Conventional orthodontic treatment and eventually autotransplantation of teeth may still be necessary in the future, but it can be anticipated that the new strategy, with much earlier intervention, will materially reduce the extent of surgical and orthodontic interventions, which have previously been of extremely long duration, tedious to the patients and often of limited success.

Oral manifestations of Schimmelpenning syndrome: case report and review of literature.

Schimmelpenning syndrome (SS) is characterised by specific skin manifestations, skeletal defects, and central nervous system abnormalities. Here, the SS is briefly reviewed, and the oral and dental manifestations are described in a patient whose medical findings were previously published and included severe hypophosphatemic rickets. Significant oral and dental features included papillomatous lesions of the gingiva, hemihyperplasia (hemihypertrophy) of the tongue, bone cysts, aplasia of teeth, enlarged pulp chambers, hypoplastic or absent enamel, and an odontodysplasia-like permanent tooth.

Benzodiazepines in child dental care: a survey of its use among general practitioners and paediatric dentists in Sweden.

Dental treatment in children too young or too apprehensive to co-operate is often performed under sedation. The aim of this study was to survey the use of rectal and oral liquid and tablet benzodiazepine sedation in Swedish child dentistry, and estimation of treatment success. A questionnaire was sent to 500 randomly selected dentists (GPs) working in the Public Dental Health Service and all (77) specialists (PDs) working at paediatric dentistry clinics. Benzodiazepine sedation was used by 73% of the GPs and 97% of the PDs. Seven per cent of the GPs and 87% of the PDs had sedation sessions at least once a month. Of the GPs, 60% administered the sedation rectally, 7% orally in liquid form, and 39% orally in tablet form. For PDs, the corresponding figures were 97%, 78%, and 68%. Sixteen per cent of the GPs and 84% of the PDs used midazolam for rectal sedation. PDs rated rectal sedation better than the GPs (p < 0.001). GPs rated their experiences of rectal sedation as better the more frequent the use (p = 0.03), as did PDs concerning oral liquid sedation (p = 0.03). Thus, it seems that a more regular use of sedation is advantageous in achieving better treatment outcome.

[Surgical treatment of temporomandibular joint ankylosis]. / Kirurgisk behandling af kaebeledsankylose.

Surgical treatment of temporo-mandibular joint (TMJ) ankylosis may be a particularly difficult procedure due to unfavourable anatomic configurations and the proximity of vital structures. Postoperatively, it is followed by an often long and painful period of physiotherapy. The results of treatment of eight patients with TMJ ankylosis are reported. Different methods were used according to age of the patient and the extent of the ankylotic changes. The importance of early treatment is emphasized. This results in less extensive surgery and reduces secondary growth anomalies of the jaws.

[Arteriovenous shunts used in hemodialysis. A retrospective study of the results in 86 patients treated during a 5-year period]. / Arteriovenøse shunter til haemodialysebrug. En retrospektiv opgørelse af resultater hos 86 patienter behandlet over en periode på 5 år.

During a period of five years, 104 arterio-venous fistulas and 14 PTFE-grafts were used in the construction of vascular access for long term hemodialysis in 86 patients with end-stage renal disease. The overall cumulative patency rate is 71% at one year, 64% at two years and 47% at five years. Sex and age cannot be shown to influence the patency rates. The vascular access sites in patients with chronic glomerulonephritis have significantly higher patency rates than the vascular access sites in patients with chronic pyelonephritis. We are unable to show any difference in the patency rates of vascular access sites salvaged by revision compared with patency rate of the remaining access sites. The following conclusions are drawn: 1) In the majority of patients undergoing the first vascular access operations, an arterio-venous fistula is the procedure of choice. 2) Advanced age does not itself contraindicate the construction of an arterio-venous fistula. 3) Reoperation should be considered, if dialysis is no longer possible.

[Should electronic mouth thermometers be used in routine everyday hospital practice? Usefulness of mouth thermometers]. / Bør elektroniske mundhuletermometre anvendes i dagligt rutinemaessigt afdelingsarbejde?

An oral electronic thermometer was compared with Hg-thermometer used rectally in the daily clinical routine. The rectal temperatures were, on an average, 0.7 degrees C higher than the oral temperatures. In 27% of the cases, the difference between rectal and oral measurement was more than 1 degree C. The variations between the differences of oral and rectal temperature measurement were unacceptable. It is concluded that the precision of oral electronic thermometers was not found to be satisfactory, and employment of this apparatus can not be recommended in daily clinical work.

Post-operative pain and pain management in children after dental extractions under general anaesthesia.

AIM: To evaluate post-operative pain in children and compare self-ratings of pain with those of a parent, and to study analgesic use after dental extractions under general anaesthesia (GA). STUDY DESIGN: Prospective observational study. METHODS: One hundred children, aged 3-12 years, who had extractions performed under GA participated. After treatment, the child and one parent assessed post-operative pain on 5 occasions: before discharge, the evening of the treatment day, and the following three evenings. The parent rated the child's level of pain on a visual analogue scale (VAS), and the child made two ratings, one on a facial analogue scale (FAS) and one on a coloured analogue scale (CAS). Analgesics were recommended 3-4 times daily, and the parent recorded the intake. RESULTS: Seventy-eight children only had primary teeth extracted, 8 children had both primary and permanent teeth extracted, and 14 children only had permanent teeth extracted. The median number of extracted primary teeth was 5 (range 1-12) and of permanent teeth 3 (range 1-4). The median pain ratings were highest in the post-operative ward, VAS=1.0 (max 9.2), FAS=2 (max 10), and CAS=1.4 (max 10). The second highest median values were in the evening following treatment. No significant differences were found between pain ratings of the parent and the child or between the two ratings of the child. 60% took analgesics on day 1. On day 2, 45% took analgesics, of which 29% more than once. STATISTICS: Spearman's rank correlation coefficient was used to test concordance between ratings. CONCLUSIONS: Most children had mild or no pain, and parent and child pain ratings agreed well. The dentist's analgesic recommendations were often poorly followed.

Surface modification of chromatography adsorbents by low temperature low pressure plasma.

In this study we show how low temperature glow discharge plasma can be used to prepare bi-layered chromatography adsorbents with non-adsorptive exteriors. The commercial strong anion exchange expanded bed chromatography matrix, Q HyperZ, was treated with plasmas in one of two general ways. Using a purpose-designed rotating reactor, plasmas were employed to either: (i) remove anion exchange ligands at or close to the exterior surface of Q HyperZ, and replace them with polar oxygen containing functions ('plasma etching and oxidation'); or (ii) bury the same surface exposed ligands beneath thin polymer coatings ('plasma polymerization coating') using appropriate monomers (vinyl acetate, vinyl pyrrolidone, safrole) and argon as the carrier gas. X-ray photoelectron spectroscopy analysis (first ∼10 nm depth) of Q HyperZ before and after the various plasma treatments confirmed that substantial changes to the elemental composition of Q HyperZ's exterior had been inflicted in all cases. The atomic percent changes in carbon, nitrogen, oxygen, yttrium and zirconium observed after being exposed to air plasma etching were entirely consistent with: the removal of pendant Q (trimethylammonium) functions; increased exposure of the underlying yttrium-stabilised zirconia shell; and introduction of hydroxyl and carbonyl functions. Following plasma polymerization treatments (with all three monomers tested), the increased atomic percent levels of carbon and parallel drops in nitrogen, yttrium and zirconium provided clear evidence that thin polymer coats had been created at the exteriors of Q HyperZ adsorbent particles. No changes in adsorbent size and surface morphology, nor any evidence of plasma-induced damage could be discerned from scanning electron micrographs, light micrographs and measurements of particle size distributions following 3 h exposure to air (220 V; 35.8 W L(-1)) or 'vinyl acetate/argon' (170 V; 16.5 W L(-1)) plasmas. Losses in bulk chloride exchange capacity before and after exposure to plasmas enabled effective modification depths within hydrated Q HyperZ adsorbent particles to be calculated as 0.2-1.2 µm, depending on the conditions applied. The depth of plasma induced alteration was strongly influenced by the power input and size of the treated batch, i.e. dropping the power or increasing the batch size resulted in reduced plasma penetration and therefore shallower modification. The selectivity of 'surface vs. core' modification imparted to Q HyperZ by the various plasma treatments was evaluated in static and dynamic binding studies employing appropriate probes, i.e. plasmid DNA, sonicated calf thymus DNA and bovine serum albumin. In static binding studies performed with adsorbents that had been exposed to plasmas at the 5 g scale (25 g L(-1) of plasma reactor), the highest 'surface/core' modification selectivity was observed for Q HyperZ that had been subjected to 3 h of air plasma etching at 220 V (35.8 W L(-1)). This treatment removed ∼53% of 'surface' DNA binding at the expense of a 9.3% loss in 'core' protein binding. Even more impressive results were obtained in dynamic expanded bed adsorption studies conducted with Q HyperZ adsorbents that had been treated with air (220 V, 3 h) and 'vinyl acetate/argon' (170 V, 3 h) plasmas at 10.5 g scale (52.5 g L(-1) of plasma reactor). Following both plasma treatments: the 10% breakthrough capacities of the modified Q HyperZ adsorbents towards 'surface' binding DNA probes dropped very significantly (30-85%); the DNA induced inter-particle cross-linking and contraction of expanded beds observed during application of sonicated DNA on native Q HyperZ was completely eradicated; but the 'core' protein binding performance remained unchanged cf. that of the native Q HyperZ starting material.

Dacron or PTFE for above-knee femoropopliteal bypass. a multicenter randomised study.

OBJECTIVES: To compare polytetrafluorethylene (PTFE) and polyester grafts (Dacron) for above knee femoropopliteal bypass. DESIGN: Multicenter randomised clinical trial. MATERIAL AND METHODS: 427 patients were randomised between 6mm Dacron (Uni-Graft, B. Braun Melsungen AG, 34212 Melsungen, Germany) and PTFE (Goretex, W. L. Gore & Ass. Inc., Newark DE 19711, USA) above-knee femoropopliteal bypass grafts within 13 centres in Denmark (n=261), Norway (n=113) & Finland (n=53) between 1993 and 1998. Fourteen (3%) patients were excluded, leaving 413 patients with 208 Dacron and 205 PTFE grafts for analysis. Age, gender, indication (claudication: 65%), run-off (2 or 3 vessels: 76%), diabetes (17%) and hypertension (31%) as well as cerebrovascular (9%) and cardiac (33%) risks were evenly distributed. Patients were followed postoperatively at 1, 12 and 24 months. Patency assessment was based on ankle-brachial pressures or imaging in case of doubt. RESULTS: The two-year primary patency rates for Dacron and PTFE were 70% and 57% (p=0.02), whereas the secondary patency rates were 76% and 65% (p=0.04), respectively. Primary patency at two years was significantly influenced by the number of patent crural vessels (two or three 67%, one 50%, p=0.01). Amputations at two years, major in 4% and minor in 3%, 30-days mortality and complications (wound infections: 3% and other wound complications: 13%) occurred equally frequent in both groups. At two years, patients treated for critical limb ischemia had a major amputation more often than patients operated on for intermittent claudication, 10 and 3 respectively (p=0.003), and had higher mortality rates, 20% and 8% respectively (p=0.001). CONCLUSION: This trial confirms that Dacron is at least as durable as PTFE for above-knee bypass procedures, and might even be superior.