Investigating femoral growth disruption in subadults from the 10th-13th century St. Étienne cemetery of Toulouse, France.

OBJECTIVES: The skeleton embodies an individual's environment and lived experiences. Studying childhood growth disruption can, therefore, aid in understanding the experiences of children in the past. This study evaluates growth disruption in a medieval Toulousian subadult sample to explore factors that may have influenced childhood growth and mortality at this site and to assess the utility of Harris line (HL) interpretations in bioarchaeology. MATERIALS AND METHODS: Femoral growth disruption was assessed in n = 71 subadults (0.125-12.42 years) from the 10th-13th century St. Étienne cemetery of Toulouse, France, using femoral length, total area, cortical area, and relative cortical area. Femoral radiographs were assessed for HLs. To determine the prevalence of growth disruption, z-scores were calculated using data from the Denver growth study. RESULTS: The majority of subadults in this sample suffered from femoral growth disruption. Young children (1.0-3.99 years) were the most affected, with >65% experiencing reduced appositional growth and linear growth stunting at time-of-death. Additionally, while many individuals presented with observable HLs, linear and appositional growth did not significantly differ between individuals with and without HLs. DISCUSSION: Maternal malnutrition and inadequate complementary feeding practices likely contributed to the high prevalence of growth disruption among the youngest individuals in the study. The older children and adolescents buried at St. Étienne experienced an amelioration in growth deficits, indicating an improvement in nutrition and/or disease load. The results of this study suggest that more consideration is required when interpreting the presence/absence of HLs, and that studies assessing HLs may benefit from using a more individualistic approach.

Precarious adolescence: Adolescent rickets and anterior sacral angulation in two Dutch skeletal collections from the 18th-19th centuries.

OBJECTIVE: This project aims to provide an objective approach to suggesting cases of adolescent rickets using the presence of anterior sacral angulation and interglobular dentine. MATERIALS: Sacra from 49 individuals from Hattem and 150 individuals from Middenbeemster, and second and third molars from five individuals from Hattem were analyzed. Both sites date to the 17th to 19th centuries. METHODS: The sacra were visually assessed for sacral angulation and measured to quantify anterior sacral angulation. The sampled molars were thin sectioned to look for the presence of interglobular dentine. RESULTS: Metric analysis determined that seven individuals had significantly anteriorly angled sacra. Three of the five individuals with sampled molars had interglobular dentine formed during adolescence. CONCLUSIONS: Adolescent rickets may be associated with anterior sacral angulation. SIGNIFICANCE: Anterior sacral angulation may help identify possible cases of adolescent rickets in archaeological human remains. LIMITATIONS: The small sample size for the molars prevented the identification of more individuals with interglobular dentine present during adolescence. Several individuals with visibly angled sacra were unmeasurable due to post-mortem damage and lacked molars. SUGGESTIONS FOR FURTHER RESEARCH: Research on a larger sample would allow us to understand better the association between anterior sacral angulation and adolescent rickets.

Is dietary deficiency of calcium a factor in rickets? Use of current evidence for our understanding of the disease in the past.

OBJECTIVE: Rickets is considered an indicator of vitamin D deficiency in palaeopathology, but a strand of biomedical thought maintains that dietary calcium deficiency may sometimes play a part in its causation. Our aim is to evaluate the extent to which low calcium intake should be considered as a factor in biocultural interpretations of rickets. METHODS: We assess published modern epidemiological studies that provide primary data to support claims for a role for dietary calcium deficiency in rickets. We also consider how we might identify, via indicators of calcium intake, populations at risk of calcium deficiency in the past. RESULTS: Support for dietary calcium deficiency as a cause of rickets is equivocal. Direct measurement of dietary calcium in the past is not possible, but exposure to risk factors for low calcium intake can to some extent be identified. CONCLUSION: Whilst there is little evidence to alter the view that rickets is essentially an indicator of a population's vitamin D status, occasionally, in very low calcium intake groups, dietary calcium deficiency may play a synergistic role by accentuating the need for vitamin D. SIGNIFICANCE: The notion that dietary calcium deficiency may be a cause of rickets appears to be gaining currency in bioarchaeological studies. This paper shows that it is unusual for this to be the case, and even then the role of vitamin D remains crucial. LIMITATIONS: This paper attempts to summarise the current state of biomedical study in an area that is subject to continuing investigation.

An Investigation of Micro-CT Analysis of Bone as a New Diagnostic Method for Paleopathological Cases of Osteomalacia.

OBJECTIVE: This paper looks to broaden the methodological possibilities for diagnosing osteomalacia in archaeological bone using micro-CT analysis. Increasing the identification of osteomalacia in paleopathology will provide support for important interpretive frameworks. MATERIALS: Nine embedded and two unembedded rib fragments were sourced from St. Martin's Birmingham and Ancaster, UK, and Lisieux Michelet, France. Of the 11 samples, nine were previously confirmed as osteomalacic, and presented with varying levels of diagenesis and two were non-osteomalacic controls, one of which exhibits diagenetic change. METHODS: Micro-CT, backscattered scanning electron microscopy, and light microscopy were employed. Micro-CT images were evaluated for osteomalacic features using corresponding microscopic images. RESULTS: Micro-CT images from osteomalacic samples demonstrated the presence of defective mineralization adjacent to cement lines, areas of incomplete mineralization, and resorptive bays/borders, three key diagnostic features of osteomalacia. Diagenetic change was also detectable in micro-CT images, but did not prevent the diagnosis of osteomalacia. CONCLUSIONS: Micro-CT analysis is a non-destructive method capable of providing microstructural images of osteomalacic features in embedded and unembedded samples. When enough of these features are present, micro-CT images are capable of confirming a diagnosis of osteomalacia. SIGNIFICANCE: Vitamin D deficiency has important health consequences which operate throughout the life course. Increasing the ability to detect cases of vitamin D deficiency provides researchers with a greater understanding of health and disease in past communities. LIMITATIONS: Only adult rib samples were used. SUGGESTIONS FOR FURTHER RESEARCH: Paleopathologists should look to test the utility of micro-CT analysis in diagnosing active rickets in subadult individuals.

Latitude, urbanization, age, and sex as risk factors for vitamin D deficiency disease in the Roman Empire.

OBJECTIVES: The aims of the study are to investigate the effects of latitude, settlement type, age, and sex on the prevalence of vitamin D deficiency disease in the Roman Empire using human skeletal remains from cemetery sites (1st to 6th cent. AD). MATERIALS AND METHODS: Data from 2,787 individuals (1,143 subadults, 1,644 adults) from 18 cemeteries associated with 15 different settlements in the Mediterranean and north-western Europe were analyzed. Vitamin D deficiency disease (rickets, osteomalacia) was identified using standard paleopathological criteria. Multivariate statistical analysis was used analyze the effects of the variables of interest on the prevalence of vitamin D deficiency. RESULTS: The overall prevalence of rickets in subadults (<20 years) was 5.7%, and 3.2% of adults showed osteomalacia and/or residual rickets. There was a positive association between rickets in subadults and latitude, with numerous cases of rickets among infants. There was no general association with sex or settlement type, although an elevated prevalence of rickets was observed at a cemetery associated with a settlement (Ostia, Italy), which had multi-storey buildings. DISCUSSION: The association of rickets with latitude may reflect care practices that, in more northerly locations where solar radiation is less intense, placed infants at increased risk of insufficient sunlight exposure to permit adequate vitamin D biosynthesis. The elevated level of vitamin D deficiency at Ostia may reflect, at least in part, the lack of sunlight due to dense occupation of multi-storey blocks that prevented direct sunlight from reaching living quarters and the streets between these closely spaced buildings.

Growth in an English population from the Industrial Revolution.

The rapid urbanization of the Industrial Revolution in 18th-19th century England presented new health challenges. Our aim is to investigate using English skeletal remains whether the living conditions for an urban working class group in the Industrial Revolution negatively impacted upon their skeletal growth compared with a population from a rural agrarian parish. The Industrial Revolution skeletal material is from St Martin's Churchyard, Birmingham (SMB), West Midlands. It dates primarily from the first half of the nineteenth century when Birmingham was a major manufacturing center. The rural group is from Wharram Percy (WP), North Yorkshire, and dates from 10th-19th century AD. The methodology involves plotting diaphyseal bone lengths versus dental age for subadults. No overall difference was found between the two populations in bone length-for-age among the 2- to 18-year cohort. However the younger parts of the SMB cohort were smaller than at WP; the opposite was true of the older parts of the cohort. Growth rate, as inferred from crosssectional data, appeared greater at SMB than at WP. The only result consistent with expectations is the larger bone dimensions in young children from WP, but this likely reflects prolonged breastfeeding at WP not differences in urban and rural environments. That the deleterious health effects that we know accompanied the major transition in human society from a rural agrarian to an urban industrialized living environment should be little manifest in skeletal endochondral growth data is discouraging for those who would use such methodology to monitor health in earlier populations.

Skeletal manifestations of rickets in infants and young children in a historic population from England.

Gross and radiographic changes characteristic of inadequate bone mineralization due to rickets are described in 21 immature skeletons from a 19th century urban population from Birmingham, England. The aims of the study are as follows: to evaluate and if possible augment existing dry-bone criteria for the recognition of rickets in immature skeletal remains; to investigate the value of radiography for the paleopathological diagnosis of rickets; and to compare and contrast the expression of rickets in this group with that previously documented for a rural agrarian population from Wharram Percy, England. Some gross skeletal signs of rickets which were not previously well-documented in paleopathological studies are noted. The worth of radiography for evaluating structural changes to both cortical and trabecular bone in the disease is demonstrated, and features useful for the interpretation of vitamin D deficiency are discussed. The pattern of skeletal elements affected and the severity of changes differs in the Birmingham group from that seen in the comparative rural population. It is emphasized that a variety of factors may influence the expression of rickets in paleopathological material, including rate of skeletal growth, age cohort affected, and intensity of vitamin D deficiency. Nevertheless, careful analysis, not only of the frequency of rickets but also of the degree of severity of lesions and the patterning with respect to skeletal elements affected, may enable more nuanced understanding of the biocultural context of the disease in earlier populations.

Third molar treatment outcome: a comparison of patients' preferences in Sweden and Wales.

AIM: To elucidate and compare patients' outcome preferences for removal and retention of mandibular third molars in Sweden and Wales. SUBJECTS AND METHOD: The subjects comprised patients referred and scheduled for removal of one or both mandibular third molars in Sweden and Wales. The multi-attribute utility (MAU) methodology was applied to study patients' preferences for outcomes of removal and retention of the mandibular third molar. RESULTS: Relative weighting of domains was similar in the two countries. "Home and social life" received the highest relative weighting in Sweden and "general health and wellbeing" in Wales. "Your appearance" received the lowest relative weighting in both countries. In both Sweden and Wales operative jaw fracture was considered to be the outcome with most impact, and dentigerous cyst and imbricated incisors the least impact. Outcome ranking was similar in both countries and operative outcomes were considered by patients to be more detrimental to health than retention outcomes. CONCLUSIONS: This comparison showed that patients' preferences in Sweden and Wales were similar and that the outcomes of surgery were considered worse after third molar removal than retention. Patient-orientated treatment decisions were less subject to variation than clinician-orientated decisions.

Comparison of decisions regarding prophylactic removal of mandibular third molars in Sweden and Wales.

OBJECTIVE: To test the hypothesis that Swedish dentists schedule more mandibular third molars for prophylactic removal compared with UK dentists and oral surgeons. DESIGN: Clinical and radiographic information relating to a stratified sample of 36 disease-free mandibular third molars (equal distribution of males and females, patients' age, angular position and degree of impaction) was presented to 26 general dental practitioners (GDPs) and 10 oral surgeons in Sweden and 18 GDPs and 10 oral surgeons in Wales who were asked to decide whether or not the third molars should be removed. RESULTS: There was no evidence of any difference in mean number of molars scheduled for removal by the GDPs, but the Swedish oral surgeons scheduled significantly more third molars for removal than oral surgeons in Wales. CONCLUSION: The less interventionist approach among oral surgeons in the UK may reflect the development and application of authoritative guidelines in the UK and an extensive debate concerning appropriateness of prophylactic removal there.

A controlled trial of three referral methods for patients with third molars.

AIM: To evaluate the accuracy, sensitivity and specificity of three primary to secondary care referral strategies. METHOD: Thirty two primary care dental practitioners (GDPs) were randomly allocated one of three referral strategies: current practice (control strategy); a neural network embedded within a computer program and a paper-based clinical algorithm. One hundred and seven patients were assessed for lower third molar treatment: 47, 30 and 30 in each group, respectively. Clinical details were assessed by a panel of experts against a gold standard for third molar removal (the National Institutes of Health criteria). The accuracy, sensitivity, specificity, positive and negative predictive values were calculated for each strategy. RESULTS: The referral decisions made by the GDPs in the control group displayed greater accuracy and sensitivity but poorer specificity (0.83; 0.97; 0.22) compared with the neural network (0.67; 0.56; 0.79) and clinical algorithm (0.73; 0.56; 0.93). CONCLUSIONS: It was concluded that incorporation of the clinical algorithm into primary care was the most appropriate option. The computer neural network performed less well than either current practice or the clinical algorithm.

The minor oral surgery outcome scale: a multi-attribute patient-derived outcome measure.

PURPOSE: The purpose of this study was to produce a clinically useful, patient-derived, minor oral surgery outcome scale. PATIENTS AND METHODS: Seventy-seven consecutive patients scheduled for minor oral surgery were interviewed using semistructured interview techniques to identify those areas of life (domains) that patients believed will be affected by minor oral surgery. These interviews were analyzed by a multidisciplinary panel and a scale based on 5 domains, each with 4 outcome statements was constructed. The domains and outcome statements were weighted in terms of importance by a further consecutive sample of 100 patients using resource allocation and visual analog tasks. An additive mathematical formula was applied to the mean weights for each domain and outcome states to produce the final weighted scale. RESULTS: Five domains were identified from the interviews and weighted according to their order of importance (0 to 100 scale; 0 = least important). These were general health and well-being (24.6); impact on home/social life (20.8); health and comfort of the mouth, teeth, and gums (20.0); appearance (18.8); and impact on job/studies (15.8). CONCLUSION: A clinically applicable, multi-attribute outcome scale has been produced that takes into account all determinants of health outcome as perceived by the patient in the context of minor oral surgery. It is completed by selecting a weighted statement from each domain, the sum of which constitutes the patient's health state utility score. The scale has potentially extensive application to both clinical care and research.

Perceived risk of future pathology associated with pathology-free third molars: a comparison of oral and maxillofacial surgeons and family dentists.

OBJECTIVE: To examine and compare practitioners' judgements of risk of future pathology associated with pathology-free disease asymptomatic third molars. SUBJECTS: 10 oral and maxillofacial surgeons and 18 family dentists (90% male) with experience ranging from 5-28 years. METHOD: Participants were presented with periapical radiographs of 36 asymptomatic, disease-free mandibular third molars and were informed of the age and sex of the patients and the degree of eruption of the third molars. Participants were asked to assess likelihood of future pathology in general, and more specifically, likelihood of root resorption, pericoronitis, periodontitis, cystic change and neoplasia if the third molar was left in situ. RESULTS: There was significant variation between the 28 raters but not between the two groups. Excepting assessment of future cystic change, there was no evidence that oral and maxillofacial surgeons and family dentists rated the 36 cases in consistently different ways. CONCLUSIONS: Practitioners varied very considerably in their judgment of the risks of pathology associated with asymptomatic disease-free third molars. Specialisation, did not account for this variation.

The outcomes of mandibular third molar removal and non-removal: a study of patients' preferences using a multi-attribute method.

The aim was to study patients' preferences about outcomes of mandibular third molar removal and non-removal using multi-attribute utility (MAU) methodology. The study comprised three stages. Stage 1: Elicitation of domains, i.e. main areas of patients' lives which could be affected by third molar removal and non-removal. Stage 2a: Interdomain weighting was obtained by relative weighting of the domains elicited in Stage 1. Stage 2b: Intradomain weighting obtained by patients' designation of values for different health states of each domain. Stage 3: Rating of outcomes. The patients were asked to imagine experiencing a variety of outcomes of mandibular third molar removal and non-removal, described in 19 short vignettes. The numbers of patients interviewed for the three stages were 30, 78, and 55, respectively. Five domains were identified. The mean relative weightings were approximately equal for the domains "Home and social life" and "General health and well-being", followed in order of importance by 'Job and studies" and "Health and comfort of mouth, teeth and gums". "Your appearance" received the lowest mean relative weighting. The vignette, which described the presence of a fluid-filled sac and suggested that this tooth must be removed, received the highest mean preference (least effect on patients' lives). The lowest mean preference (most effect on patients' lives) was generated by the vignette, which stated that the jaw was broken and that the teeth must be wired together for 6 weeks. We conclude that, from the patient's perspective, outcomes of non-removal were preferable to outcomes of mandibular third molar removal.

The cost, effectiveness and cost effectiveness of removal and retention of asymptomatic, disease free third molars.

PURPOSE OF INVESTIGATION: The study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars. METHODS AND PATIENTS: A decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding back' the decision tree based on the probabilities. MAIN FINDINGS: Mandibular third molar retention was less costly (170 Pounds), more effective (69.5 effectiveness units on a 100 point scale) and more cost-effective (2.43 Pounds per unit of effectiveness) than removal (226 Pounds, 63.3 and 3.57 Pounds respectively). These findings were sensitive to changes in the probability of pericoronitis, periodontal disease and caries. PRINCIPAL CONCLUSIONS: Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy.

Impact of third molar removal on demands for postoperative care and job disruption: does anaesthetic choice make a difference?

A prospective cohort study was undertaken to investigate the influences of anaesthetic modality and surgical difficulty on social reintegration and demands on health services after third molar removal. The study was undertaken at the Oral and Maxillofacial Surgery Department, Cardiff Dental Hospital. Of 444 patients, 266 (60%) had their third molars removed. The main outcome measures included anaesthetic modality, surgical difficulty (WHARFE scores), utilisation of health services, effects on work, school and home life. In all, 101 (40%) patients were treated under local anaesthesia (LA) +/- intravenous (i.v.) sedation and 165 (60%) under general anaesthesia (GA); 81 (49%) as inpatients and 84 (51%) as day cases. Of these patients, 38 (14%) returned to the hospital and 74 (28%) utilised primary care services postoperatively in addition to a standard review appointment. Patients treated under GA made more demands on primary care services (chi 2 = 6.41, df = 2, P < 0.05) and took more time away from work (P < 0.05). Patients underestimated the time they needed to recover. There was similar disruption to job, college and home life. There were no links between disruption and particular anaesthetic modalities and surgical difficulty. Surgery under GA was linked to increased postoperative demands on primary care, but not secondary care, and to longer job disruption. This could not fully be attributed to surgical difficulty.

Factors influencing nerve damage during lower third molar surgery.

OBJECTIVE: To investigate relationships between pathology, eruption status, age, anaesthetic modality and nerve damage during lower third molar surgery. DESIGN: Single centre prospective study. SETTING: Oral surgery out-patient clinics. SUBJECTS: 367 patients unselected for age, gender or social class, scheduled for lower third molar removal. At 1 week, any evidence of iatrogenic nerve damage was recorded. Patients with altered lingual and/or labial sensation were followed up for 6 months. RESULTS: 718 lower third molars were removed from 250 males and 117 females. 96 removals (13.4%) were associated with altered lingual, labial or buccal sensation. There were no significant associations between nerve damage and eruption status, age and pre-operative pathology. There was a highly significant difference in the incidence of nerve damage between LA removal (3%) and GA removal (18%) (chi-squared = 17.18; f = 2; P < 0.01) but no significant associations between surgical difficulty and nerve damage within each of the two groups. CONCLUSIONS: Lingual and inferior alveolar nerve damage was five times more frequent when lower third molars were removed under general anaesthesia rather than local anaesthesia. This could not be explained in terms of surgical difficulty, pre-operative pathology, age or anatomical position.

Perceptions of women on the impact of menorrhagia on their health using multi-attribute utility assessment.

OBJECTIVE: To assess patient preferences regarding the treatment of menorrhagia using the multi-attribute utility methodologies, to produce a clinically applicable scale, and to assess health outcomes following treatment of menorrhagia. METHODS: Women referred to the gynaecology department for the treatment of menorrhagia were interviewed regarding the effects of menorrhagia on different aspects of their life. Their concerns were categorised into main components of health (domains). The relative importance of each domain was rated by the women using importance points which were distributed to represent the perceived importance of each domain. A series of statements (intra-domain statements) was developed for each domain, which described various possible conditions of that component of health. These were also rated using a one metre visual analogue scale with numerical anchor points at zero (worst) and 100 (best). RESULTS: The components of health considered most important were, in order of impact, family life, followed by physical health, work life, psychological health, practical difficulties and social life. The scores for the intra-domain statements were combined into a scale to allow the calculation of a final health state utility for a particular outcome based upon the statements the patient chooses within each domain. DISCUSSION: In planning treatment for menorrhagia clinicians can assess a woman's current perception of their health, using a simple to administer clinical scale.