Dental status in nursing home residents with domiciliary dental care in Sweden.

OBJECTIVE: To describe the dental health status of elderly people in nursing homes receiving domiciliary dental care. DESIGN: Case note review. CLINICAL SETTING: Nursing homes in 8 Swedish counties. PARTICIPANTS: Care dependent elderly people (≥65 years). METHODS: Clinical data, including the number of remaining natural teeth, missing and decayed teeth (manifest dental caries) and root remnants, recorded by dentists according to standard practices. Medical and dental risk assessments were performed. RESULTS: Data were available for 20,664 patients. Most were women (69.1%), with a mean age of 87.1 years (SD 7.42, range 65-109). The mean age for men was 83.5 years (SD 8.12, range 65-105). Two or more medical conditions were present in most of the population. A total of 16,210 individuals had existing teeth of whom 10,974 (67.7%) had manifest caries. The mean number of teeth with caries was 5.0 (SD 5.93) corresponding to 22.8% of existing teeth. One in four individuals were considered to have a very high risk in at least one professional dental risk assessment category. CONCLUSIONS: Care dependent elderly in nursing homes have very poor oral health. There is a need to focus on the oral health-related quality of life for this group of frail elderly during their final period of life.

Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers-Cadavers versus Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion.

BACKGROUND: The aims of this study are to characterize (1) the cadaver intubation biomechanics, including the effect of repeated intubations, and (2) the relation between intubation force and the motion of an injured cervical segment. METHODS: Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations. RESULTS: Cadaver intubation biomechanics were comparable with those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (set 2/set 1 force ratio = 0.61; 95% CI, 0.46 to 0.81; P = 0.002) and Oc-C5 extension (set 2 - set 1 difference = -6.1 degrees; 95% CI, -11.4 to -0.9; P = 0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ (1) between intact and injured states; or (2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm; 95% CI, 0.7 to 4.9 mm; P = 0.004). CONCLUSIONS: With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or the Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression.

Patient safety in domiciliary dental care for elderly nursing home residents in Sweden.

OBJECTIVE: To analyse patient safety in domiciliary dental care, with data from a quality registry. DESIGN: Retrospective analysis. CLINICAL SETTING: Domiciliary dental care, private caregiver, Sweden, 2012-2014. METHODS: All reported events in the quality registry at a provider of domiciliary dental care, (2012-05-01 to 2014-06-30) were categorized into 14 domains, and for severity as 'minor', 'moderate', or 'serious' events. The reported events were also independently assessed by an experienced reviewer for national requirements of reporting patient safety related events. RESULTS: The quality registry covered 724 (0.03%) reported events during 218,586 consecutive treatment sessions in domiciliary dental care, including 628,070 registered dental procedures. Fifty (6.9%) of the reported events were patient safety related, of which 11 (1.5%) events were reportedly of minor severity, 20 (2.8%) as moderate, and 19 (2.6%) as serious. For all degrees of severity, the most frequently reported events were related to problems with patient identity control (3.3%). None of the events required reporting to national authorities. CONCLUSIONS: Domiciliary dental care has a low frequency of patient safety related events (0.03% of all treatments). Identity controls need to be emphasised in nursing homes or where individuals are dependent on the care of others.

Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden.

OBJECTIVES: Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. METHODS: A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. RESULTS: The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. CONCLUSIONS: Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Factors affecting eyelid crease formation before and after silicone frontalis suspension for adult-onset myogenic ptosis.

PURPOSE: To evaluate factors that affect eyelid crease formation before and after frontalis suspension. DESIGN: Nonrandomized, comparative, interventional case series. METHODS: Sixty-three patients (125 eyes) with myogenic ptosis were included. Data collected included age, gender, previous surgeries, follow up, as well as pre- and postoperative margin reflex distance, palpebral fissure height, and levator function. Intraoperative maneuvers of incorporation of the levator aponeurosis into the skin closure, conservative fat excision, and conservative skin excision were recorded. Pre- and postoperative eyelid creases were graded by 2 masked, independent observers as "good," "fair," or "poor." RESULTS: The weighted κ coefficient between the graders was 0.68 (95% CI, 0.58-0.79) preoperatively and 0.70 (95% CI, 0.61-0.79) postoperatively. Evaluating preoperative eyelid crease grades, there was no significant difference with regard to age or gender (p = 0.83 or 0.69, respectively). Eyelid crease grade correlated with margin reflex distance (p = 0.0004) and palpebral fissure height (p = 0.002). There was no significant correlation of eyelid crease with levator function (p = 0.104). After frontalis sling, intraoperative maneuvers of incorporation of the levator aponeurosis into the incision, skin preservation, and fat preservation correlated with postoperative eyelid crease (p = 0.0004, 0.059, and 0.033, respectively). CONCLUSIONS: Preoperative levator function in patients with adult onset myogenic ptosis may be an inaccurate measure of true levator palpebrae strength. Reliance on levator function alone in decision making for surgical intervention in these patients may be misguided. The inclusion of the intraoperative maneuvers of incorporation of the levator aponeurosis into the skin incision and preservation of fat and skin results in a stronger eyelid crease after frontalis sling surgery.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial.

BACKGROUND: Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training. OBJECTIVE: The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress. METHODS: Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress. RESULTS: A total of 574 children, ages 4-10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels. DISCUSSION: Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.

Salivary cortisol responsivity to an intravenous catheter insertion in children with attention-deficit/hyperactivity disorder.

OBJECTIVE: To compare salivary cortisol baseline levels and responsivity as well as behavioral distress to intravenous (IV) catheter insertions in 4- to 10-year-old children with (n = 29) and without (n = 339) attention-deficit/hyperactivity disorder (ADHD). METHODS: This is a secondary data analysis from a sample of 542 children who participated in a multisite study on distraction. Data included were demographic variables, Pediatric Behavior Scale-30, Observational Scale of Behavioral Distress-Revised, and four salivary cortisol samples. RESULTS: Home samples from the ADHD group revealed nonsignificant but higher cortisol levels than the non-ADHD group. However, on the clinic day, the ADHD group had significantly lower cortisol levels before (0.184 vs. 0.261, p = .040) and 20-30 min after IV insertion (0.186 vs. 0.299, p = .014) compared with the non-ADHD group. CONCLUSIONS: Cortisol levels in children with and without ADHD differ in response to the stress of an IV insertion.

Efficacy of Alveolar Ridge Preservation: A Randomized Controlled Trial.

Alveolar ridge preservation (ARP) therapy is indicated to attenuate the physiologic resorptive events that occur as a consequence of tooth extraction with the purpose of facilitating tooth replacement therapy. This randomized controlled trial was primarily aimed at testing the efficacy of ARP as compared with unassisted socket healing. A secondary objective was to evaluate the effect that local phenotypic factors play in the volumetric reduction of the alveolar bone. A total of 53 subjects completed the study. Subjects were randomized into either the control group, which involved only tooth extraction (EXT n = 27), or the experimental group, which received ARP using a combination of socket grafting with a particulate bone allograft and socket sealing with a nonabsorbable membrane (dPTFE) following tooth extraction (ARP n = 26). A set of clinical, linear, volumetric, implant-related, and patient-reported outcomes were assessed during a 14-wk healing period. All linear bone assessments (horizontal, midbuccal, and midlingual reduction) revealed that ARP is superior to EXT. Likewise, volumetric bone resorption was significantly higher in the control group (mean ± SD: EXT = -15.83% ± 4.48%, ARP = -8.36% ± 3.81%, P < 0.0001). Linear regression analyses revealed that baseline buccal bone thickness is a strong predictor of alveolar bone resorption in both groups. Interestingly, no significant differences in terms of soft tissue contour change were observed between groups. Additional bone augmentation to facilitate implant placement in a prosthetically acceptable position was deemed necessary in 48.1% of the EXT sites and only 11.5% of the ARP sites (P < 0.004). Assessment of perceived postoperative discomfort at each follow-up visit revealed a progressive decrease over time, which was comparable between groups. Although some extent of alveolar ridge remodeling occurred in both groups, ARP therapy was superior to EXT as it was more efficacious in the maintenance of alveolar bone and reduced the estimated need for additional bone augmentation at the time of implant placement (ClinicalTrials.gov NCT01794806).

Age determination of an Alaskan mummy: morphological and biochemical correlation.

Aspartic acid racemization analysis of a tooth from an Alaskan mummy yielded an age at death of 53 (+/- 5) years, which correlates well with earlier estimates based on morphological features. This study illustrates the value of integrative approaches to paleopathologic problems and the importance of preserving rare specimens for the application of new techniques.

Normative salivary cortisol values and responsivity in children.

This was a descriptive study on normative salivary cortisol values and responsivity to a hospital clinic visit and an intravenous (IV) procedure in children. The study presented was a subproject of a primary research study that examined parents coaching their children requiring an IV placement in the use of distraction. One measure of child response in the primary study, salivary cortisol, was included to further our understanding of children's physiologic response to stressful and painful stimuli. Salivary cortisol samples were obtained from 384 children aged between 4 and 10 years upon arrival to the clinic and 20 minutes after their IV insertion. Baseline samples were collected at home on a typical day for the children. Data from baseline samples were used to establish normative values between 8:00 a.m. and 3:00 p.m. on a nonprocedural day. Results demonstrate that normative cortisol levels in children follow a pattern similar to the circadian pattern in adults, decreasing from early morning to mid afternoon. Matched samples from control group children were used to evaluate group responsivity. Salivary cortisol levels on the baseline day were lower than those obtained during the day of the procedure and tapered over time as expected (-8.7% +/- 6.7%, p = .431). Cortisol levels on the clinic day increased from baseline and increased further in response to IV placement (15.7% +/- 6.7%, p = .023). A Location x Time interaction was significant (p = .019). Findings demonstrate that salivary cortisol is a useful measure of stress response that can be used to evaluate intervention effectiveness.

Relationship between community-level variables and number of general dentists.

BACKGROUND: In this study, the authors used observational data from 2014 to evaluate the association between the number of general dentists and several community characteristics. METHODS: The authors collected community-level characteristics from secondary sources for all 947 Iowa incorporated communities to study their relationships with the mean number of general dentists per 1,000 population per square mile (population density), the dependent variable. The authors used zero-inflated negative binomial models to examine the association between the dependent and predictor variables. RESULTS: Only 22.8% of communities had a dentist. Urban, young, well-educated, fluoridated communities with at least 1 elementary school had the highest estimated mean concentration of dentists. Isolated communities with older, less educated adults and lacking fluoridation and an elementary school had the fewest dentists. CONCLUSIONS: Although population is an important determinant for where a dentist practices, other variables such as urbanization, demographic characteristics, fluoridation status, and presence of at least 1 elementary school are also predictors of the number of dentists in a community. PRACTICAL IMPLICATIONS: These findings provide dental students and young practitioners useful information by highlighting community characteristics that are associated with office locations.

The Relationship between Methamphetamine Use and Dental Caries and Missing Teeth.

PURPOSE: This study examined the relationship between methamphetamine use and oral health status. METHODS: Using a cross-sectional design, data were collected in 1998 from 174 newly admitted prisoners in Iowa. Oral examinations identified dental caries and missing teeth, and personal interviews identified methamphetamine use and covariates. Descriptive statistics were used to summarize the data, and bivariate and multivariate linear regression analyses, including testing for interaction effects, were used to examine the effects of methamphetamine use on oral health status. RESULTS: Multivariate regression analyses for carious teeth and surfaces showed significant interaction effects: methamphetamine*race/ethnicity (carious teeth: p=0.039; surfaces: p=0.023) and methamphetamine*tooth brushing when on drugs (carious teeth: p=0.044; surfaces: p=0.035). Methamphetamine use had a significant effect on dental caries among Non-Whites and among those who brushed their teeth less than once a day when on drugs. Soda consumption (carious teeth: p=0.026; surfaces: p=0.030) and reason for last dental visit (carious teeth: p=0.025; surfaces: p=0.011) were also associated with caries. For missing teeth there was a significant methamphetamine*race/ethnicity interaction (p=0.028) among Whites who used methamphetamine compared to Whites who did not use methamphetamine. Age (p=0.0001) and reason for last dental visit (p=0.0001) were also associated with missing teeth. CONCLUSION: The effect of methamphetamine use on missing teeth was moderated by race/ethnicity,; while its effect on dental caries was moderated by race/ethnicity and tooth brushing when on drugs.

Effects of environmental exposure on carbon polysulphone composites.

In vivo and in vitro studies were designed to characterize the material degradation associated with implantation of carbon fibre-reinforced polysulphone (C/PS). Composite plates were compression moulded for both studies, and a fibre orientation of 0 degrees with the long axis and a fibre volume fraction of approximately 55% were used. The in vitro experiment involved soaking three groups of four plates each at 4, 12 and 26 wk in 0.9% saline solution at 37 degrees C. The plates were measured for weight gain after each time period and mechanically tested non-destructively in four-point bending to determine modulus. The in vivo experiment involved implanting three groups of eight composite plates (24 total) subcutaneously in the abdomens of 12 rabbits (two implants/animal). Implants were harvested at 4, 12 and 26 wk after implantation and evaluated for changes in weight or modulus of elasticity. In vitro results showed a statistically significant (P less than 0.05 paired t-test) increase in weight for all time periods: 0.41, 1.25 and 0.93% weight gain for the 4, 12 and 26 wk periods respectively. In vivo results were similar to those in vitro: 0.66, 1.06 and 1.15% weight gain for the 4, 12 and 26 wk periods respectively (P less than 0.05 paired t-test). There was no statistically significant difference between the pre- and post-implantation modulus of elasticity for any time period in vivo or in vitro. However, in both studies, on average, the modulus tended to increase with environmental exposure.

Development of a three-dimensional transmigration assay for testing cell--polymer interactions for tissue engineering applications.

The ability of synthetic or natural scaffolds to support invasion of cells from surrounding tissue is a key parameter for tissue engineering (TE). In this study, the migration of fibroblasts, chondrocytes, and osteoblasts into biodegradable polymer scaffolds was evaluated using a novel, three-dimensional (3-D) transmigration assay. This assay is based on a cell-populated contracted collagen lattice with a biodegradable polymer scaffold implanted at the center of the collagen gel. Cell migration into the scaffolds was assessed both quantitatively and qualitatively following various time lengths in culture using image analysis. Chondrocytes, incorporated within the collagen lattice, migrated into polymer scaffolds, when cultured both statically or in a rotating bioreactor. However, the bioreactor cultures resulted in a significantly greater cell invasion as compared to static cultures. There was a cell density-dependent osteoblast migration from collagen lattice into polymer scaffold, when tested in the transmigration assay. In addition, polymer scaffolds, treated with or without recombinant human platelet-derived growth factor (rh-PDGF-BB) were evaluated for fibroblast migration. The presence of rh-PDGF-BB resulted in significantly greater fibroblast invasion as compared to untreated scaffolds. Our studies suggest that the transmigration model provides a rapid system for testing cell invasion of potential scaffolds for tissue engineering applications.

A new abrasive applicator for human enamel biopsy procedures.

Experiments were performed that demonstrated that the felt cylinder usually used to obtain abrasive biopsy specimens did not uniformly remove enamel from rounded or irregular enamel surfaces in the window area. A foam-silicone rubber laminate was developed to replace the felt cylinder. This resulted in greater uniformity of abrasion over the enamel surface within the biopsy window area and better operator handling characteristics.

Extranodal American Burkitt's lymphoma of the head and neck.

Burkitt's lymphoma was first described in 1958 as a mandibular malignancy found in African children. The American, or nonendemic, form of the disease differs from the African form in that the tumor most often presents with abdominal or bone marrow involvement. Head and neck manifestations of American Burkitt's lymphoma are encountered in less than a quarter of the reported cases and usually present as cervical adenopathy. A review of all cases of American Burkitt's lymphoma treated at the UCLA Medical Center, Los Angeles, Calif, from 1971 to 1989 revealed an unusual subset of seven patients with American Burkitt's lymphoma of the head and neck who presented with extranodal disease of the soft tissues or bones of the face. The medical literature was reviewed to compile similar cases of extranodal American Burkitt's lymphoma. The clinical and pathologic features of these cases, their radiographic findings, and treatment are described.

Maxillary ameloblastoma. A potentially lethal neoplasm.

Ameloblastomas are benign tumors derived from the odontogenic apparatus. Of these tumors, 80% originate in the mandible, while 20% originate in the maxilla. Six cases of maxillary ameloblastoma treated at the UCLA hospitals are presented; four of these cases showed extensive and destructive tumor growth involving vital structures, including the orbit, base of skull, and parasellar structures. Two of four patients with extensive disease died of their tumors, one, with extensive involvement of the base of the skull, became unavailable for follow-up, and, one year after diagnosis, one is alive with middle cranial fossa disease. A review of the medical literature provides further evidence of the locally aggressive behavior and potentially lethal nature of this tumor. No effective treatment has evolved for extensive ameloblastomas of the maxilla that have invaded surrounding vital structures. When tumor-free surgical margins are not possible, radiation therapy may offer palliation of disease.

Mechanics of interbody spinal fusion. Analysis of critical bone graft area.

Bone graft subsidence is a serious complication of interbody spinal fusion. In this study, 66 mechanical tests were performed on 35 thoracic vertebral bodies to investigate the in situ mechanics of interbody spinal fusion. The relationships among trabecular bone density, bone strength, and size of bone graft area were analyzed. All vertebral bodies were scanned by quantitative computer tomography (QCT) to determine their bone density before mechanical testing. The decorticated trabecular beds of the vertebral bodies, void of all posterior elements, were loaded in a manner similar to that which occurs after surgical interbody fusion. That is, rectangular blocks of polymethylmethacrylate, representing bone grafts, were used to transfer controlled compressive loads to the decorticated vertebral trabecular surface. Both destructive and nondestructive tests were performed. The relationship between QCT bone density and trabecular bone strength was related by a power function, and, on average, the bone density and trabecular bone strength were 0.137 g/cm3 and 3.97 MPa, respectively. Eighty percent of the vertebral bodies with graft covering 25% of the total end plate area or less failed at loads less than 600 N, while 88% of the vertebral bodies with 30% or greater covered were able to carry a load greater than 600 N. The results suggest that the intrinsic behavior of trabecular bone loaded within the vertebral body is little different from the behavior of the whole body, that QCT bone density is indicative of bone strength, and that interbody graft area should be significantly greater than 30% of the total end plate area to provide a margin of safety.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a prosthetic intervertebral disc.

This article is a preliminary report of a 10-year investigation of the development of an intervertebral disc prosthesis. Spinal fusion is a method for the treatment of chronic, disabling low-back pain that does not respond to nonoperative treatments. Spinal fusion, however, has various adverse effects, and the results of spinal fusion are often unpredictable. The goal of this research project was to develop disc prostheses that have mechanical properties very similar to those of natural, normal discs. Two types of disc prosthesis, one with fiber-reinforced polyurethane and the other with multicomponent, non-fiber-reinforced polymers (C-Flex), have been designed and manufactured. The fiber-reinforced disc was made of polyurethane end-plates with A100 hardness, a homogenous nucleus with A40, and 12 layers of multidirectional (0, +45 degrees), fiber-reinforced anulus with A40 polyurethane. The design and modeling of the multicomponent polymers (non-fiber-reinforced) was made of C-Flex endplates with A90 hardness, a nucleus with A35 occupying 35% of the volume, and an anulus with 70A. Mechanical testing of these disc prostheses demonstrated similar mechanical properties to those of natural, normal discs.

The effect of smokeless-tobacco extracts on the growth of oral bacteria of the genus Streptococcus.

Aqueous tobacco extracts were used to supplement a basic salts solution (BSS) and a microbial medium. Thin-layer chromatography revealed sucrose in only one of four extracts. Discs saturated with extracts (0.1-50 mg/ml) failed to inhibit growth of any of the micro-organisms. Supplementation (10 mg/ml) of BSS with the tobaccos lacking sucrose resulted in augmented growth of Streptococcus mutans, Streptococcus salivarius and Streptococcus sanguis whereas the sucrose-containing brand augmented only Strep. sanguis growth. Thus extracts of these smokeless tobaccos would serve as a growth substrate for three species of oral streptococci which are frequently associated with human dental caries.