Ecthyma gangrenosum: A case report in a child with acute lymphoblastic leukaemia.

Aim: We present a case of Ecthyma gangrenosum (EG) affecting left thigh in a child with acute lymphoblastic leukaemia (ALL) with an aim to raise awareness about this condition. Case presentation: A 7-year-old female child who presented with lethargy, pallor and lumps to inner lip was diagnosed with B-cell precursor ALL. She was started on treatment as per UKALL 2011 guidelines Regime B. On day 28, she developed neutropenic sepsis along with a new lesion in her left thigh. She was started on intravenous Meropenum, Gentamicin and Caspofungin. The clinical diagnosis of EG was made based on lesion progression, positive blood and wound swab & tissue cultures for Pseudomonas aeruginosa and patient's immunocompromised status. The wound healed with secondary intention following debridement. We present a series of photographs to demonstrate her remarkable improvement. Discussion: EG occurs in 1-30% of cases of Pseudomonas sepsis; other bacteria and fungi can be associated with this condition. It is identified more in oncology patients as seen in our patient. A multidisciplinary team approach should be provided in 3 stages with empirical antibiotics, followed by targeted antibiotics or antifungals & surgical debridement. Our patient was treated in similar fashion and made a good recovery. Conclusion: It is a rare skin condition associated with a high mortality. We suggest all clinicians to be vigilant about this condition to be able to provide accurate diagnosis and prompt treatment to improve the overall prognosis.

Routine four-quadrant cavity shaving at the time of wide local excision for breast cancer reduces re-excision rate.

INTRODUCTION: Breast conservation therapy (BCT) has been shown to have comparable long-term survival outcomes when compared with mastectomy. Clearance of excision margin is one of the mainstays of the surgical treatment, which if not achieved at the first operation of BCT results in the need for subsequent surgery. METHODS: This study evaluated the impact of routinely taken cavity shavings on re-excision rates. This retrospective two-centre study describes the use of routine four-quadrant cavity shaving in 449 patients with consecutively treated with wide local excision for invasive cancer or ductal carcinoma in situ. RESULTS: The overall incomplete excision rate was 10.6%. Routine cavity shaving prevented the need for re-excision in 84 patients (18.7%) and identified the need for further re-excision in 33 patients (7.3%). Median time from surgery to radiotherapy was 50 days (range 13-209) for non-re-excised patients versus 78 days (range 47-260) for re-excised patients (p<0.001). Median time to chemotherapy (n=75) was 44 days (range 14-106) for non-re-excised patients versus 56 days (range 35-116) for re-excised patients (p=0.017). CONCLUSIONS: This study demonstrates that routine cavity shaving decreases re-excision rate in patients treated with wide local excision and prevents delays to adjuvant treatment due to incomplete excision.

Osteogenic efficacy of bone marrow concentrate in rabbit maxillary sinus grafting.

Maxillary sinus grafting is required to increase bone volume in the atrophic posterior maxilla to facilitate dental implant placement. Grafting with autogenous bone (AB) is ideal, but additional bone harvesting surgery is unpleasant. Alternatively, bone substitutes have been used but they limit new bone formation. The strategy of single-visit clinical stem cell therapy using bone marrow aspirate concentrate (BMAC) to facilitate new bone formation has been proposed. This study aimed to assess bone regeneration capacity of autologous BMAC mixed with bovine bone mineral (BBM) in maxillary sinus grafting. Twenty-four white New Zealand rabbits were used and their maxillary sinuses were randomly assigned for grafting with 4 different materials. Rates of new bone apposition in augmented sinuses were measured and bone histomorphometry were examined. Significant increase in the quantity of nucleated cells and colony forming unit-fibroblasts were confirmed in BMAC. Mesenchymal stem cells in BMAC retained their in vitro multi-differentiation capability. Higher rates of mineral appositions in the early period were detected in BBM + BMAC and AB than BBM alone, though they are not significantly different. Graft volume/tissue volumes in BBM and BBM + BMAC were found to be higher than those in AB and sham.

Effect of different advancement positions on the maximum retrusive force of the mandible.

INTRODUCTION: Functional appliances lead, in different degrees, to loss of anchorage in the lower arch. By anchoring them to the mandibular bone, any dental side effects may be avoided and the skeletal effect enhanced. Stability of bone-borne fixation would be affected by forces created by the pull of the masticatory muscles. We aimed to identify mean maximum forces produced by mandibular retrusive muscles, at different degrees of advancement. SUBJECTS AND METHODS: Eighteen healthy adult volunteers participated in the study. Maximum retrusive force was measured using a splint/load cell system. Readings of the maximum forces of retrusion were taken from five mandibular positions: unstrained retruded position, and 4, 5, 6, and 7 mm anterior to the unstrained position. Data were presented as means ± SD and anova was performed to examine statistical significant differences between means of the maximum retrusion force. RESULTS: Mean maximum retrusion force ranged between 63.3 and 198.2 newtons at the unstrained and 7 mm positions, respectively. It increased as the distance of advancement increased, being statistically significantly (p < 0.05) less at unstrained position compared with all advancement distances, 4 mm of advancement than 6 and 7 mm advancement, 5 mm of advancement than at 7 mm advancement. CONCLUSION: Magnitude of the forces exerted by muscles during voluntary maximum retrusion movement from different advancement positions increased proportionately as the retrusion distance increased up to 7 mm. Such range of high forces might be important to consider when designing a bone-borne functional appliance.

Emergency management of dental trauma: knowledge of Hong Kong primary and secondary school teachers.

OBJECTIVES. To investigate the level of knowledge about emergency management of dental trauma among Hong Kong primary and secondary school teachers. DESIGN. Questionnaire survey. SETTING. A teachers' union that unites 90% of teachers in Hong Kong. PARTICIPANTS. Randomly selected primary and secondary school teachers. RESULTS. Only 32.8% of respondents correctly stated that a person sustaining dental trauma should go to dentists directly. In all, 73.1% of teachers correctly stated that a dental trauma patient should go for treatment immediately. Only 32.5% knew that a fractured tooth should be put in liquid. Even fewer (23.2%) realised that the displaced tooth should be repositioned back to the original position. Relatively more respondents (74.7%) understood that an avulsed baby tooth should not be put back. Disappointingly, only 16.3% of teachers knew that an avulsed permanent tooth should be replanted. Furthermore, only 29.6% of teachers thought that they were able to distinguish between deciduous teeth and permanent teeth, whilst 20.4% correctly identified at least one of the appropriate mediums: milk, physiological saline or saliva, for storing an avulsed tooth. Teachers who previously received first-aid training with dental content or acquired dental injury information from other sources, scored significantly higher than teachers without such training or acquired information. CONCLUSION. The knowledge on emergency management of dental trauma among primary and secondary school teachers in Hong Kong is insufficient, particularly on the handling of permanent tooth avulsion and the appropriate storage medium for avulsed teeth. Receipt of first-aid training with dental contents and acquisition of dental injury information from other sources were positively correlated with knowledge in managing dental trauma.

Bone anchor systems for orthodontic application: a systematic review.

This systematic review was performed to investigate the usefulness and clinical effectiveness of skeletal anchorage devices to determine the most effective bone anchor system for orthodontic tooth movement. Literature on bone anchorage devices was selected from PubMed and the Cochrane Library from January 1966 to June 2010. 55 publications regarding miniplates, miniscrews, palatal implants and dental implants as orthodontic anchorage were identified for further analysis. All bone anchorage devices were found to have relatively high success rates and demonstrated their ability to provide absolute anchorage for orthodontic tooth movement. Significant tooth movement could be achieved with low morbidities and good patient acceptance. The reported success rates for the four groups of anchorage systems were generally high with slight variability (miniplates 91.4-100%; palatal implants 74-93.3%; miniscrews 61-100%; dental implants 100%). It was concluded that bone anchorage systems can achieve effective orthodontic movement with low morbidities. The success rate is generally high with slight variability between miniplates, palatal implants, miniscrews and dental implants. Owing to the lack of randomized controlled trials, there is no strong evidence to confirm which bone anchor system is the most effective for orthodontic tooth movement.

A preliminary study of the effect of low intensity pulsed ultrasound on new bone formation during mandibular distraction osteogenesis in rabbits.

This study assesses the effect of low intensity pulsed ultrasound (LIPUS) on new bone formation during mandibular distraction osteogenesis (DO) in rabbits. 24 rabbits underwent DO on the right side of the mandible. 12 rabbits received a daily 20-min LIPUS (1.5 MHz, 30 mW/cm2) treatment on the first day of the distraction until they were killed at week 0 (immediately after the distraction), week 2 and week 4 after the distraction. Four rabbits were killed at each time point. The other 12 rabbits followed the same protocol without the ultrasound treatment. A plain radiography, a micro-CT scan, a microhardness test and a histological examination were used to evaluate new bone formation in the distraction gap. At week 0 and week 2 after the distraction, the treatment groups showed higher radiopacity and microhardness (p<0.05), and more bone formation was detected by the histological examination. At week 4 after the distraction, there was no statistical difference between the two groups. In this study, LIPUS accelerated new bone formation during the distraction period and 2 weeks after the distraction, which implies that the effective time for using LIPUS is in the early stage of DO.

Orthopaedic gene therapy using recombinant adeno-associated virus vectors.

Use of recombinant adeno-associated virus (rAAV) vectors is increasingly gaining popularity in gene therapy because of their desirable properties, including lack of pathogenicity, efficient transduction of dividing and non-dividing cells, and sustained maintenance of the viral genome. It is these features of rAAV vectors that made them the focus for gene-based therapy of skeletal tissue regeneration. This review outlines the biological characteristics of adeno-associated virus (AAV), states the biological processing as well as current advances of rAAV vectors, and describes the recent achievements of their applications in orthopaedic and craniofacial surgery.

Traditional Chinese medicine and oral diseases: today and tomorrow.

With a history of over 2000 years, traditional Chinese medicine (TCM) evolves into a unique system of diagnosing and treating illnesses. It is a challenge to convey the fundamentals of this traditional medicine to our Western colleagues because of the differences in language, philosophy and concept of diagnosis and treatment. This review attempts to tackle these barriers by introducing several widely used Chinese medicines for treating oral diseases. China Journals Full-text Database and Pubmed were used as the searching engines. Although many studies have demonstrated that the Chinese medicines are effective in treating oral diseases including recurrent aphthous stomatitis, oral lichen planus, leukoplakia, and Sjögren's syndrome, most of them lacked standard criteria of post-treatment assessment and laboratory evidence. Randomized controlled clinical trials with specific assessment criteria are required to close the gap between TCM and evidenced-based medicine.

Risk factors of neurosensory deficits in lower third molar surgery: an literature review of prospective studies.

This literature review assessed the risk factors linked to inferior dental nerve (IDN) and lingual nerve (LN) deficits following lower wisdom tooth surgery. A computer search of several databases with specified key words was performed. 32 articles were selected; the risk factors for IDN deficit were reported in 4 articles, LN in 9 and both IDN and LN in 19. Data were analysed statistically to evaluate the potential risk factors. Literature review showed specific radiographic signs and intra-operative IDN exposure increased the risk of IDN deficit. Raising the lingual flap significantly increased the risk of LN deficit. Unerupted tooth and lingual split technique increased IDN and LN deficit risks significantly. Age was linked to IDN and LN deficits, and deep impaction was related to IDN deficit, but no statistical tests were performed on these two risk factors owing to the heterogeneity of data from the studies. This literature review found increased age, unerupted tooth, deep impaction, specific radiographic signs, intra-operative IDN exposure and lingual split technique were risk factors for IDN deficit; increased age, unerupted tooth, distal impaction, raising of lingual flap and lingual split technique were risks factors for LN deficit in lower wisdom tooth surgery.

Facial soft tissue response to anterior segmental osteotomies: a systematic review.

Bimaxillary protrusion is prevalent among Asians and anterior segmental osteotomies are commonly used for its surgical correction. The objective of this study was to evaluate the soft tissue changes resulting from anterior segmental osteotomies. The electronic databases PubMed, Scopus and ISI Web of knowledge were searched for potentially eligible studies using a set of predetermined keywords. Full texts meeting the inclusion criteria were retrieved and their references were manually searched for additional relevant articles. The study details and outcome data of these reports were extracted using spreadsheets for comparison. The methodological quality of each study was assessed. Eleven studies met the inclusion criteria. Lateral cephalometry was used in all studies. A reduction of the labial prominence with an increase in the nasolabial angle was noted subsequent to anterior segmental osteotomies. The magnitude of the reported soft tissue changes and their ratios corresponding to the osseous movements varied among studies. Long-term, prospective, methodologically sound clinical trials with larger samples and three-dimensional quantification are required to provide sufficient information for predicting the soft tissue response to anterior segmental osteotomies.

Bilateral sagittal split osteotomies versus mandibular distraction osteogenesis: a prospective clinical trial comparing inferior alveolar nerve function and complications.

The aim of this study was to conduct a prospective clinical trial comparing the neurosensory function of the inferior alveolar nerve (IAN) after mandibular advancement surgery with either bilateral sagittal split osteotomies (BSSO) or mandibular distraction ostoegenesis (MDO). 23 Class II mandibular hypoplasia patients requiring mandibular advancement were randomized into two groups for either BSSO or MDO. Subjective and objective neurosensory evaluations were performed preoperatively and at the following postoperative times: 2 weeks (TBD1), 6 weeks (TBD2), 12 weeks (TBD3), 6 months (TBD4) and 12 months (TBD5). Subjective evaluation included the use of a visual analogue scale (VAS). Objective evaluation included the use of light touch (LT), two-point discrimination (2PD) and pain detection threshold (PD) tests. Intra-operative or postoperative complications were recorded. Using a mixed model, no significant differences were reported in subjective VAS scores and objective LT, 2PD and PD scores between the BSSO and MDO groups over 12 months (p>0.05). Common postoperative complications included localized wound infection (BSSO=2, MDO=6) and condylar resorption (BSSO=1, MDO=1).

Maxillary distraction versus orthognathic surgery in cleft lip and palate patients: effects on speech and velopharyngeal function.

This clinical randomized controlled trial was performed to compare the effects of distraction osteogenesis (DO) and conventional orthognathic surgery (CO) on velopharyngeal function and speech outcomes in cleft lip and palate (CLP) patients. Twenty-one CLP patients who required maxillary advancement ranging from 4 to 10 mm were recruited and randomly assigned to either CO or DO. Evaluation of resonance and nasal emission, nasoendoscopic velopharyngeal assessment and nasometry were performed preoperatively and at a minimum of two postoperative times: 3-8 months (mean 4 months) and 12-29 months (mean 17 months). Results showed no significant differences in speech and velopharyngeal function changes between the two groups. No correlation was found between the amount of advancement and the outcome measures. It was concluded that DO has no advantage over CO for the purpose of preventing velopharyngeal incompetence and speech disturbance in moderate cleft maxillary advancement.

Incidence of neurosensory deficits and recovery after lower third molar surgery: a prospective clinical study of 4338 cases.

A prospective study of all lower third molar surgery performed in the outpatient extraction clinic of a teaching dental hospital was conducted from January 1998 through October 2005 to determine the incidence of subsequent neurosensory deficit due to inferior alveolar nerve (IAN) and lingual nerve (LN) injury, to examine possible contributing risk factors and to describe the pattern of recovery. 3595 patients were included (61% female, 39% male; age range, 14-82 years). Of the 4338 lower third molar extractions performed by various grades of operators, 0.35% developed IAN deficit and 0.69% developed LN deficit. Distoangular impaction was found to increase the risk of LN deficit significantly (p<0.001). Depth of impaction was related to the risk of IAN deficit (p<0.001). Undergraduates caused more LN deficits (p<0.001). Sex, age, raising of a lingual flap, protection of LN with a retractor, removal of distolingual cortex, tooth sectioning and difficulty in tooth elevation were not significantly related to IAN or LN injury. Postoperative recovery from IAN and LN deficits was noted most significantly at 3 and 6 months, respectively. By the end of the follow-up period, 67% of IAN deficits and 72% of LN deficits had recovered completely.

High-rhythm automatic driver for bone traction: an experimental study in rabbits.

The distractors currently used in clinics are activated manually by intermittent advancement. An automatic driver has been developed to attach to custom-made or commercially available distractors and activate advancement at a high rhythm of 8 steps per second. One 1.5-V lithium button battery is used as the power source to drive a step motor and the driving torque is transmitted to the distractor through a flexible shaft at a rate of 2 revolutions per day. This automatic driver was tested in 5 rabbits for mandibular lengthening. Osteotomy was performed on one side of the mandible and the custom-made distractor was adapted. After a latency period of 3 days, the automatic driver was attached to the distractor's arm and mandibular lengthening was activated. After 11 days of continuous distraction the automatic driver was detached from the distractor's arm. All the rabbits were euthanized after 4 weeks of consolidation. The distraction regenerates were analysed by plain radiography, micro-computerized tomography and histological examination. All 5 rabbits completed the experimental process and healed uneventfully. The mandibles were confirmed to have lengthened successfully and the distraction gap was filled with newly formed bone.

Stability and morbidity of Le Fort I osteotomy with bioresorbable fixation: a randomized controlled trial.

A randomized controlled clinical trial was conducted to compare the use of bioresorbable and titanium mini-plates and screws in Le Fort I maxillary osteotomies for evaluation of clinical morbidity and stability. Forty patients requiring Le Fort I osteotomies were randomly assigned to two groups. One group underwent bioresorbable mini-plate fixation and the other titanium mini-plate fixation. Stability of the maxilla was determined by serial cephalometric analysis at 2 and 6 weeks and at 3, 6 and 12 months postoperatively. Subjective and objective assessment of clinical morbidity was made prospectively. There were no differences in complications between the two fixation materials. Maxillae with bioresorbable fixation were significantly more mobile at the second postoperative week. Bioresorbable plates were initially more easily palpable, but their palpability decreased with time. Titanium plates became significantly more palpable at the 1-year follow-up. There was no difference in neurosensory disturbance between groups. Patients with bioresorbable plate fixation showed significantly more upward displacement in anterior maxilla following impaction and posterior maxilla following downgrafting from the 2nd to 6th postoperative week. The horizontal and angular relapses in the two groups were comparable. Le Fort I osteotomy with bioresorbable fixation results in no greater morbidity than with titanium fixation up to 1 postoperative year.

Distraction or orthognathic surgery for cleft lip and palate patients: which is better?

Maxillary deformities of cleft lip and palate (CLP) can be treated by either conventional osteotomies (CO) or distraction osteogenesis (DO). Which one is better for CLP patients suffering from a moderate extent of maxillary hypoplasia? The aim of the study was to evaluate the treatment outcomes of CO and compared with DO in correction of moderate maxillary hypoplasia. The results showed that CLP patients receiving DO were more anxious and depressed during the first three months but became happier in the long-term. The nasalance of DO and CO was found to be similar. However, on the skeletal stability, DO was shown to be significantly more stable when compared with CO in the horizontal plane within the first six months and in vertical plane during the first three months and between 1-2 year.

Influence of nicotine on blood perfusion and bone healing during distraction osteogenesis.

Nicotine is the main chemical component in tobacco products and its effect on bone healing remains controversial. This study aims to evaluate the influence of nicotine on blood perfusion and bone healing using a rabbit model of mandibular distraction osteogenesis. The dose dependent effect of nicotine on bone regeneration, and the effect of nicotine on blood perfusion and angiogenesis were assessed by radiography, micro-computed tomography, histological and immunohistochemical analysis, real time PCR and Laser Doppler monitoring. Results showed that bone healing was compromised by high dose nicotine treatment. Nicotine exposure increased microvessel density, whereas inhibited blood flow and bone formation. The expression of bone morphogenetic protein (BMP)-2 in osteoblasts was also decreased. The present study supported that nicotine has a dose dependant influence on bone healing in distraction osteogenesis. Nicotine compromises bone regeneration possibly by causing ischemia and inhibiting BMP expression in osteoblasts. Nicotine exposure enhances angiogenesis but can not compensate for the adverse effect of vasoconstriction.

Quantitative evaluation of tissue invasion by wild type, hyphal and SAP mutants of Candida albicans, and non-albicans Candida species in reconstituted human oral epithelium.

BACKGROUND: Oral candidiasis is a common problem in compromised patients. Although several non-albicans Candida species have emerged as pathogens the majority of candidal infections are caused by Candida albicans. Morphogenesis from the blastospore to filamentous phase, and production of secretory aspartyl proteinases (SAP) are two major virulence attributes of these opportunistic yeast. Histopathology of oral candidiasis is characterized by fungal invasion of the superficial epithelium although the invasive potentials of different Candida species vary. Computerized image analysis systems (IAS) utilizing immunohistochemistry have been successfully employed for quantification of such histopathological features. The purpose of this study was to evaluate quantitatively the in vitro invasive potential of C. albicans and its hyphal and SAP mutants, and five other non-albicans Candida species using a computerized IAS. METHODS: In vitro human oral candidiasis was produced using five wild type and one reference C. albicans isolates, hyphal and SAP mutants of C. albicans SC 5314, and one wild type and one reference isolate each of C. tropicalis, C. dubliniensis, C. glabrata, C. parapsilosis and C. krusei in a reconstituted human oral epithelium (RHOE) model. The infected tissues were examined histologically at 12, 24 and 48 h. Invading fungal elements were visualized by periodic acid-Schiff (PAS) staining and quantitatively evaluated as a percentage of total tissue invasive area, using a computerized IAS. RESULTS: All C. albicans isolates including hyphal mutant cph1/cph1 and SAP mutants; sap 1-3, sap 4-6 produced hyphae and differentially (P < 0.05) invaded the tissue over 48 h. The invasive potential of hyphal mutant cph1/cph1 and SAP mutants (sap 1-3, sap 4-6) were similar to the parent wild-type isolate at 12 h although after 24 h their invasion was dissimilar (P < 0.05). Non-albicans Candida species and hyphal mutants; efg1/efg1, efg1/efg1 cph1/cph1 were all non-invasive. CONCLUSIONS: RHOE model in combination with computerized image analysis permits for the first time, the assessment of invasive potential of Candida species in a quantitative manner. The differential tissue invasive patterns of various C. albicans isolates, their mutants and other Candida species are also described.

A comparison of post-operative complications following wisdom tooth surgery performed with sterile or clean gloves.

This randomised prospective study aimed at evaluating possible differences in the post-operative complication rate following lower wisdom tooth surgery performed with either sterile or clean surgical gloves. The microbiological profiles of the tooth sockets and glove surfaces were also evaluated and compared. A total of 275 ASA I, non-smoking and non-drinking patients consented to be randomly assigned into two groups for lower wisdom tooth surgery, performed by operators wearing either sterile or clean gloves. All the patients returned for a post-operative assessment visit one week later. An additional 40 patients were recruited and randomised into the sterile glove group (n = 20) or the clean glove group (n = 20) for the microbiology study. Specimens were taken from the glove surfaces and the post-operative socket wounds during wisdom tooth surgery. This clinical trial showed no significant difference between the sterile and clean glove groups in the incidence of acute inflammation, acute infection and dry sockets in the wounds. No single peri-operative factor had a statistically significant effect on post-operative pain intensity. Most of the bacterial isolates from the clean gloves were Gram-positive cocci or spore-forming bacilli. The total number of colony forming units and the variety of bacterial isolates from the socket wounds in the sterile and clean glove groups were similar. The study concluded that there was no advantage in using sterile surgical gloves rather than clean gloves to minimize post-operative complications in wisdom tooth surgery. There was also no apparent relationship between the bacteria contaminating the clean glove surfaces and those isolated from the socket wounds.