Patient satisfaction with root canal treatment and outcomes in the Swedish public dental health service. A prospective cohort study.

AIM: To document satisfaction with root canal treatment procedures and outcomes among patients treated at Swedish public dental clinics. METHOD: The original material comprised 243 patients who began root canal treatment (RCT) at 20 public dental clinics in the county of Västra Götaland, Sweden. One to three years later, 236 (97.1%) were posted a questionnaire of eight items, rating patient perceptions of RCT-completion, present pain intensity and satisfaction with the RCT. To evaluate the reliability of the original responses, the first 50 respondents were mailed a follow-up questionnaire. Both descriptive and analytical statistics were used to compare respondents and non-respondents and tooth groups. RESULTS: One hundred and fifty-nine patients (67.4%) responded: 86 (54.1%) women and 73 (45.9%) men. The mean age 52.5 years, was higher than for non-respondents (P<0.001). A completed root filling was registered for the majority of the teeth (n = 112, 70.9%), but significantly fewer molars had been completed (n = 46, 59.7%, P = 0.02). Fifty percent (n = 59) of the patients reported current pain, mostly mild in intensity (n = 45, 38.1%). One hundred and twenty-three patients (80.9%) recalled experiencing pain during RCT. The highest satisfaction was registered for the item 'chewing ability' (mean = 1.6, SD = 1.9). The majority of patients (n = 114, 75.0%) stated that in retrospect they would still have chosen RCT. However, these patients belonged to the group which either registered the tooth as still present, or had not experienced much discomfort during or after RCT. Forty-four patients (88.0%) responded to the second questionnaire. The reliability of the responses was good. In summary, one to 3 years after beginning RCT at a public dental clinic, patient satisfaction was high, even though every fourth molar had been extracted or treatment had not been completed and half the patients reported persistent pain. The reliability of the patients' responses was considered to be good. CONCLUSIONS: The results indicate a need for further clinical observational studies of RCTs undertaken in general dental practice, with special reference to patient-centred outcomes.

Indications for root canal treatment in a Swedish county dental service: patient- and tooth-specific characteristics.

AIM: To study patient- and tooth-specific characteristics of teeth indicated for root canal treatment, in the public dental service of the county of Västra Götaland, Sweden. METHODOLOGY: During a designated 8-week period, general dental practitioners working at 20 different public dental clinics consecutively registered indications for undertaking root canal treatment. The patients' subjective level of pain was also registered (visual analogue scale) at the very first appointment. The following information was retrieved from computerized dental records and radiographs: gender, age, number of remaining teeth, tooth group, previous restoration, number of restored surfaces, dental caries and tooth substance loss. Gender and age were compared using both descriptive and analytical statistics. RESULTS: The material comprised 243 teeth in 243 patients: 128 (52.7%) women and 115 (47.3%) men, mean age 48.3 years. Molar teeth predominated (47.7%). Most of the teeth (83.5%) had previously been restored and exhibited significant loss of tooth substance, more than a third of the crown (71.3%). Dental caries was present in 127 teeth (62.9%). Dental trauma was implicated in only seven cases (2.9%). Initial treatment was frequently undertaken at an emergency visit, for relief of symptoms (64.9%). The most commonly registered indication was pulpal necrosis with apical periodontitis (38.1%), followed by pulpitis (37.7%). Retreatment of a root filled tooth was reported in 18 teeth (7.4%). CONCLUSIONS: In the general Public Dental Service of Sweden, root canal treatment is most frequently undertaken in molars. The primary indication is relief of symptoms. Retreatment of root filled teeth is uncommon.

European Society of Endodontology position statement: the use of antibiotics in endodontics.

This position statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on Antibiotics in Endodontics. The statement is based on current scientific evidence as well as the expertise of the committee. The goal is to provide dentists and other healthcare workers with evidence-based criteria for when to use antibiotics in the treatment of endodontic infections, traumatic injuries of the teeth, revascularization procedures in immature teeth with pulp necrosis, and in prophylaxis for medically compromised patients. It also highlights the role that dentists and others can play in preventing the overuse of antibiotics. A recent review article provides the basis for this position statement and more detailed background information (International Endodontic Journal, 2017, https://doi.org/10.1111/iej.12741). Given the dynamic nature of research in this area, this position statement will be updated at appropriate intervals.

Outcome after hip arthroscopy for femoroacetabular impingement in 289 patients with minimum 2-year follow-up.

Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction. The purpose of this study was to report outcome 2 years after the arthroscopic treatment of FAI using validated outcome measurements. Two hundred and eighty-nine patients (males = 190, females = 99) with a mean age of 37 years underwent arthroscopic surgery for FAI. Patients were included consecutively in a hip arthroscopy registry. The cohort was evaluated using online web-based validated health-related patient-reported outcomes measurements, including the iHOT-12, HAGOS, EQ-5D, HSAS for physical activity level, VAS for overall hip function and overall satisfaction. The mean follow-up time was 25.4 months. Pre-operative scores compared with those obtained at follow-up revealed statistically and clinically significant improvements (P < 0.05) for all measured outcomes; iHOT-12 (43 vs 66), VAS for global hip function (50 vs 71), HSAS (2.9 vs 3.6), EQ-5D index (0.58 vs 0.75), EQ-VAS (67 vs 75) and HAGOS different subscales (56 vs 76, 51 vs 69, 60 vs 78, 40 vs 65, 29 vs 57, 33 vs 58). At the 2-year follow-up, 236 patients (82%) reported they were satisfied with the outcome of surgery. We conclude that arthroscopic treatment for FAI resulted in statistically and clinically significant improvements in outcome parameters.

Retrograde root canal treatment: a prospective case series.

AIM: Root canal treatment of teeth with necrotic pulps and apical periodontitis may be complicated by limited access to the root canals due to restorations and dystrophic calcifications. The objective of this study was to evaluate retrograde root canal as a primary treatment using a surgical approach as an alternative to conventional orthograde treatment. METHODOLOGY: Patients with apical periodontitis in the anterior region of the maxilla were consecutively recruited to the study over a period of 4 years. Fifty-seven patients met the inclusion criteria and received retrograde root canal treatment. A clinical and radiographic evaluation was made after 1 and 2 years postoperatively. RESULTS: Clinical and radiographically evaluation after 2 years revealed a successful outcome (as defined in this study) in 90% of the cases. CONCLUSION: Retrograde root canal as a primary treatment was a reliable alternative to treat apical periodontitis on single- and two-rooted teeth with limited orthograde access to the root canals in the maxilla.

Antibiotics in Endodontics: a review.

The overuse of antibiotics and the emergence of antibiotic-resistant bacterial strains is a global concern. This concern is also of importance in terms of the oral microbiota and the use of antibiotics to deal with oral and dental infections. The aim of this paper was to review the current literature on the indications and use of antibiotics and to make recommendations for their prescription in endodontic patients. Odontogenic infections, including endodontic infections, are polymicrobial, and in most cases, the prescription of antibiotics is empirical. This has led to the increasing use of broad-spectrum antibiotics even in cases where antibiotics are not indicated, such as symptomatic irreversible pulpitis, necrotic pulps and localized acute apical abscesses. In case of discrete and localized swelling, the primary aim is to achieve drainage without additional antibiotics. Adjunctive antibiotic treatment may be necessary in the prevention of the spread of infection, in acute apical abscesses with systemic involvement and in progressive and persistent infections. Medically compromised patients are more susceptible to complication arising from odontogenic infections and antimicrobials have a more specific role in their treatment. Therefore, antibiotics should be considered in patients having systemic diseases with compromised immunity or in patients with a localized congenital or acquired altered defence capacity, such as patients with infective endocarditis, prosthetic cardiac valves or recent prosthetic joint replacement. Penicillin VK, possibly combined with metronidazole to cover anaerobic strains, is still effective in most cases. However, amoxicillin (alone or together with clavulanic acid) is recommended because of better absorption and lower risk of side effects. In case of confirmed penicillin allergy, lincosamides such as clindamycin are the drug of choice.

A preliminary study on the technical feasibility and outcome of retrograde root canal treatment.

AIM: To investigate the technical feasibility and outcome of retrograde root canal treatment. SUMMARY: Endodontic access cavity preparation in abutment teeth may jeopardize the retention of the coronal restoration leading to prosthodontic failure. In such cases leaving the crown intact and performing retrograde root canal treatment might be an alternative approach. The potential to promote healing with retrograde endodontic treatment, and the technical feasibility to shape, clean and fill the canal was evaluated retrospectively. The study consisted of 21 incisors, canines and premolar teeth followed-up clinically and radiographically from 6 to 48 months. In 14 teeth the canals were completely negotiated. These cases were all judged as completely healed. In five cases no canal could be explored by files and a conventional ultrasonic root-end preparation and filling was performed. Two of these were classified as completely healed and three as 'uncertain'. In 2 two-rooted premolars a combination was performed with complete instrumentation of the buccal canal and the ultrasonic root-end preparation of the palatal root. One case was judged as a failure and the other was classified as completely healed. The results from this preliminary evaluation of retrograde root canal treatment are promising and merit a randomized clinical trial. KEY LEARNING POINTS: Abutment teeth with vital pulps may develop pulp necrosis and apical periodontitis in 10% of cases. Endodontic access preparation through an artificial crown may weaken its retention and jeopardize the longevity of a bridgework. Retrograde root canal treatment is often feasible in maxillary teeth. Results from this preliminary study suggest that treatment outcome for retrograde and orthograde root canal treatment is similar.

Affinity-assisted in vivo folding of a secreted human peptide hormone in Escherichia coli.

We show that coexpression of a specific binding protein in Escherichia coli can significantly improve the relative yields of correctly folded human insulin-like growth factor I (IGF-I). A glutathione redox buffer was used during growth to allow formation and breakage of disulfide bonds in the periplasm of the bacterial host. Both the binding protein and the peptide hormone were produced as affinity fusions, which allowed purification of the in vivo formed heterodimer by alternative affinity purification methods. The use of affinity-assisted in vivo folding has general implications for expression, folding, and purification of recombinant proteins.

Basilar and bilateral carotid dolichoectasia with spontaneous dissection of C2 segment of the internal carotid artery.

We describe a previously unreported case of cranial arterial dolichoectasia associated with spontaneous dissection of the petrous (C2) segment of the internal carotid artery (ICA) with 2 patent lumena. Dolichoectasia of the cranial arteries and different types of double lumen of ICA are discussed. A review of previously reported cases is included.

Gene fragment polymerization gives increased yields of recombinant human proinsulin C-peptide.

A multimerization strategy to improve yields upon recombinant production of the 31-aa human proinsulin C-peptide is presented. Gene fragments encoding the C-peptide were assembled using specific head-to-tail multimerization. DNA constructs encoding one, three or seven copies of the C-peptide gene, fused to a serum albumin binding affinity tag, were expressed intracellularly in Escherichia coli. The three fusion proteins were produced at similar levels (approximately 50 mg/l) and were proteolytically stable during production. Enzymatic digestion by trypsin-carboxypeptidase B treatment of the fusion proteins was shown to efficiently release native C-peptide, as determined by mass spectrometry, reverse-phase chromatography and a radioimmunoassay. The quantitative yields of C-peptide obtained from the three different fusion proteins suggest that this multimerization strategy could provide a cost-efficient production scheme for the C-peptide, and that this strategy could be useful also for production of other recombinant peptides.

Denatured states of human carbonic anhydrase II: an NMR study of hydrogen/deuterium exchange at tryptophan-indole-H(N) sites.

Hydrogen/deuterium (H/D) exchange measurements in low and moderate concentrations of GuHCI were conducted on the side chain H(N) atoms of the seven tryptophans of pseudo wild-type human carbonic anhydrase II. Tryptophans 5, 16 and 245, situated in or close to the N-terminal domain were found to have little protection against exchange. The H/D exchange results for Trp-123, Trp-192 and Trp-209 showed that a previously identified molten globule and the native state gave a similar protection against exchange. Global unfolding of the protein is necessary for the efficient exchange at Trp-97, which is located in the central part of the beta-sheet.

The serum albumin-binding domain of streptococcal protein G is a three-helical bundle: a heteronuclear NMR study.

Streptococcal protein G (SPG) is a cell surface receptor protein with a multiple domain structure containing tandem repeats of serum albumin-binding domains (ABD) and immunoglobulin-binding domains (IgBD). In this paper, we have analysed the fold of ABD. Far-UV circular dichroism analysis of ABD indicates high helical content (56%). Based on an analysis of nuclear magnetic resonance 13C secondary chemical shifts, sequential and short-range NOEs, and a few key nuclear Overhauser effects, we conclude that the ABD is a three-helix bundle. The structure of the ABD is, thus, quite different from the IgBD of protein G [Gronenborn, A.M. et al. (1991) Science 253, 657-661]. This strongly suggests that the ABD and the IgBD of SPG have evolved independently from each other. However, the fold of ABD is similar to that of the IgBD of staphylococcal protein A, possibly indicating a common evolutionary ancestor, despite the lack of sequence homology.

Cis-trans isomerization is rate-determining in the reactivation of denatured human carbonic anhydrase II as evidenced by proline isomerase.

The refolding of human carbonic anhydrase II is a sequential process. The slowest step involved is the recovery of enzymic activity (t1/2 = 9 min). Kinetic data from 'double-jump' measurements indicate that proline isomerization might be rate determining in the reactivation of the denatured enzyme. Proof of this is provided by the effect of proline isomerase on the reactivation kinetics: the presence of isomerase during reactivation lowers the half-time of the reaction to 4 min, and inhibition of proline isomerase completely abolishes this kinetic effect. A similar acceleration of the refolding process by proline isomerase is also observed for bovine carbonic anhydrase II, in contrast to what has previously been reported. In human carbonic anhydrase II there are two cis-peptidyl-Pro bonds at Pro30 and Pro202. Two asparagine single mutants (P30N and P202N) and a glycine double mutant (P30G/P202G) were constructed to investigate the role of these prolines in the rate limitation of the reactivation process. Both in the presence and absence of PPIase the P202N mutant behaved exactly like the unmutated enzyme. Thus, cis-trans isomerization of the Pro202 cis-peptidyl bond is not rate determining in the reactivation process. The mutations at position 30 led to such extensive destabilization of the protein that the refolding reaction could not be studied.

Integrated production of human insulin and its C-peptide.

The potential for the development of an integrated process for production of human insulin and its C-peptide in Escherichia coli has been investigated. Human proinsulin was produced intracellularly in E. coli fused to two synthetic IgG-binding domains (ZZ) derived from staphylococcal protein A. High expression levels (3 g/l culture) of the gene product, which accumulated as inclusion bodies, was obtained. Solubilization of inclusion bodies by oxidative sulfitolysis and subsequent renaturation was performed directly after cell lysis and pellet wash. IgG affinity chromatography was used for efficient recovery of pure proinsulin fusion protein in a single step. Monomers of the proinsulin fusion protein constituted approximately 70%. A single step conversion of the fusion protein into insulin and C-peptide by trypsin and carboxypeptidase B treatment was achieved by engineering the junction between proinsulin and its affinity handle, ZZ. Characterization of the cleavage products by reversed phase chromatography (RPC) verified that human insulin and C-peptide were generated and that the ZZ affinity handle was resistant to cleavage. Human insulin and C-peptide were recovered with high yields by preparative reversed-phase high performance liquid chromatography (RP-HPLC). The potential use of the presented scheme for large-scale production of recombinant insulin and/or its C-peptide is discussed.

Integrated bioprocess for production of human proinsulin C-peptide via heat release of an intracellular heptameric fusion protein.

An integrated bioprocess has been developed suitable for production of recombinant peptides using a gene multimerization strategy and site-specific cleavage of the resulting gene product. The process has been used for production in E. coli of the human proinsulin C-peptide via a fusion protein BB-C7 containing seven copies of the 31-residues C-peptide monomer. The fusion protein BB-C7 was expressed at high level, 1.8 g l(-1), as a soluble gene product in the cytoplasm. A heat treatment procedure efficiently released the BB-C7 fusion protein into the culture medium. This step also served as an initial purification step by precipitating the majority of the host cell proteins, resulting in a 70% purity of the BB-C7 fusion protein. Following cationic polyelectrolyte precipitation of the nucleic acids and anion exchange chromatography, native C-peptide monomers were obtained by enzymatic cleavage at flanking arginine residues. The released C-peptide material was further purified by reversed-phase chromatography and size exclusion chromatography. The overall yield of native C-peptide at a purity exceeding 99% was 400 mg l(-1) culture, corresponding to an overall recovery of 56%. The suitability of this process also for the production of other recombinant proteins is discussed.

Acute in vivo toxicity of heat-sterilized glucose peritoneal dialysis fluids to rat peritoneal macrophages.

OBJECTIVE: To evaluate the in vivo effects of heat-sterilized peritoneal dialysis (PD) fluids on the respiratory burst response of rat peritoneal leukocytes. DESIGN: Rats were exposed to intraperitoneal injections of a laboratory-made PD fluid that was either heat-sterilized (H-PD) or filtered (F-PD). Control groups of animals were given Hank's buffer (HBSS) or saline (NaCl). Leukocytes were harvested by intraperitoneal lavage at different times in different animals and analyzed with respect to cell numbers, differential counts, and production of superoxide (chemiluminescence) in response to opsonized zymosan. The chemiluminescence responses of the macrophage and the neutrophil populations, respectively, were obtained by curve-fitting techniques from the responses of the mixed populations. RESULTS: All fluids induced a recruitment of neutrophils, the PD fluids causing a cell number increase that was more transient than that caused by NaCl and HBSS. Macrophage numbers were only slightly influenced, but were generally higher after NaCl and HBSS injections than after PD fluid injections. The H-PD exposure induced a significant inhibition of the macrophage chemiluminescence response after 2 and 12 hours, compared with the exposure to F-PD. The neutrophil chemiluminescence response was not significantly affected. CONCLUSION: The toxins produced by heat-sterilization of glucose-containing PD fluids inhibit in vivo the respiratory burst response of peritoneal macrophages.

Heat-sterilized PD fluid blocks leukocyte adhesion and increases flow velocity in rat peritoneal venules.

Data from cell culture experiments indicate that heat sterilization of peritoneal dialysis (PD) fluids produces cytotoxic glucose degradation products. The present vital microscopic study investigated the effects of different sterilization methods on the biocompatibility of PD fluids. Thus, heat-sterilized (commercially obtained and experimentally produced) and filter-sterilized PD fluids (pH = 5.30-5.40; 1.5% glucose) were compared with Tyrode buffer, with respect to the effects on microvascular blood flow velocity and leukocyte adhesion in the rat mesentery. Exteriorization of the mesentery produced a mild inflammation, known from the literature and characterized by the adhesive rolling of leukocytes along venular walls. Superfusion of the mesentery with filter-sterilized PD fluid had no significant effects on leukocyte rolling or flow velocity in venules 25-40 microns in diameter compared with buffer superfusion. Heat-sterilized PD fluid decreased the concentration of rolling leukocytes and increased flow velocity significantly, as compared with buffer and filter-sterilized PD fluid. The results indicate that heat sterilization of PD fluids produces substances that interact with microvascular tone and leukocyte-endothelial adhesion, which hypothetically could impair the acute, granulocyte-mediated defense against bacterial infections.

Kinetics and dose response of the effects of heated glucose peritoneal dialysis fluids on the respiratory burst of rat peritoneal leukocytes.

Heat sterilization of glucose containing peritoneal dialysis (PD) fluids induces the production of cytotoxic glucose degradation products (GDPs), some of which are still unidentified. The present study was performed to characterize the kinetics and the dose-response of the respiratory burst inhibition of GDPs and to compare different fluids in this respect. The zymosan-induced respiratory burst of rat peritoneal neutrophils and macrophages was measured by chemiluminescence (CL) after incubation in vitro for 1, 2, and 4 hours in different homemade and commercially available PD fluids, followed by one hour of recovery in Hanks' buffer. Heat sterilized fluids were compared with their filter sterilized equivalents at two different pH levels. The results revealed that the inhibitory effect of heat sterilized fluids on the respiratory burst of peritoneal neutrophils is additive to that of low pH, but more fast-acting and, in contrast to the pH effect, similar in magnitude to its in vivo equivalent. The effect developed within 1 hour and had a linear dose response. The low GDP fluid Gambrosol-Bio was less toxic than the conventional fluid Gambrosol, but the difference was smaller than expected in relation to measured concentrations of known GDPs. Macrophages were less sensitive than neutrophils to the GDP effect.

Peritoneal leukocyte survival and respiratory burst responses in patients treated with a low glucose degradation and high pH peritoneal dialysis fluid.

The discovery of toxicity related to glucose degradation products (GDP) has initiated the development of new PD fluids with low GDP concentrations and higher, more physiological, pH levels. Cell numbers, differential counts and the respiratory burst responses of peritoneal leukocytes were compared between patients treated with the low GDP, high pH fluid Gambrosol-trio (n=10) and a conventional fluid (n=12). Effluents from over-night dwells were collected and leukocytes were evaluated morphologically and by luminol-amplified chemiluminescence (CL) after stimulation with opsonized zymosan. The frequency of necrosis and early apoptosis was quantified by means of annexin V binding and propidium iodide uptake. The Gambrosol-trio group produced significantly higher (p<5%) macrophage counts and stronger CL responses (p<10%) than did the conventional fluid group. The cell compositions did not differ significantly between the groups. Necrosis was significantly more common among the cells in the conventional fluid group. The occurrence of apoptosis did not differ between the fluids.

A commercially available PD fluid with high pH and low GDP induces different morphological changes of rat peritoneum in intermittent PD.

The aim of this study was to characterize the morphological changes in the peritoneum following experimental peritoneal dialysis of rats, and to compare the new high-pH and low glucose-derived degradation products (GDP)-level PD fluid PD-Bio with the conventional PD fluid Gambrosol at two different exposure frequencies. Rats were subjected to 10 mL intraperitoneal injections three times per day at 3-hour intervals daytime for 9 days (2 successive weeks, excluding weekends) or once daily for 4 weeks. Untreated animals and animals exposed to Gambrosol or PD-Bio were compared. Biopsy samples were taken from the diaphragm and prepared for light microscopy. Morphometric analysis was used to compare the thickness and the cell density of the sub-mesothelial connective tissue. Intraperitoneal leukocyte numbers were counted. Both fluids induced a significant thickening of the submesothelial connective tissue and an increase in intraperitoneal leukocyte numbers. After exposure three times per day, Gambrosol induced a significantly greater submesothelial thickening than PD-Bio. The submesothelial tissue was more cell-dense after exposure to PD-Bio than after exposure to Gambrosol. The present results indicate that the structural changes of the peritoneum that follow peritoneal dialysis may be dependent upon the chemical composition of the PD fluids.