Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVES: Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology. METHODS: This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain. RESULTS: When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery. CONCLUSIONS: Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation. SIGNIFICANCE: Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

Do Factors from Admissions and Dental School Predict Performance on National Board Exams? A Multilevel Modeling Study.

The aim of this study was to assess the association among admissions variables, dental school performance, and licensing exam performance for six cohorts of graduates of one dental school. Data from all dental school graduates of Schulich School of Medicine & Dentistry, Western University, Canada, from 2009 to 2014 who had matching National Dental Examining Board of Canada (NDEB) data (N=298) were analyzed. In the results, significant differences between cohorts were found on both the NDEB objective structured clinical examination (OSCE) and written scores. Approximately 18% of the variation in OSCE scores was attributable to cohort differences and 82% to student differences. Approximately 10% of the variation in written scores was attributable to cohort differences and 90% to student differences. Several multilevel models were conducted. The final predictive model for NDEB OSCE scores consisted of age, Canadian Dental Aptitude Test (DAT) reading comprehension scores, year 2 average, and year 4 average. For predicting NDEB written exam scores, the final model consisted of DAT chemistry and year 1, 2, and 4 averages. The findings of this study showed that academic performance on admissions variables and in training predicted performance on dental licensing exams, whereas variables that captured noncognitive or interpersonal skills, such as interview scores, were not predictive. This difference may be due to construct mismatch, such that the outcome variables had no theoretical association with the predictors. Additional outcome measures (including noncognitive) are needed that have greater ecological validity in predicting potential for competence in practice.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

OBJECTIVES: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). METHODS: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. RESULTS: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. CONCLUSIONS: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. SIGNIFICANCE: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

In-vitro comparison of different palatal sites for orthodontic miniscrew insertion: Effect of bone quality and quantity on primary stability.

INTRODUCTION: This experiment was undertaken to assess the primary stability of orthodontic miniscrews inserted at different sites in human cadaveric palatal bone for temporary skeletal anchorage, and to determine the effect of bone quality and quantity on their primary stability using microcomputed tomography imaging. METHODS: A total of 10 cadaveric maxillary hard palates were used for insertion of 130 orthodontic miniscrews (VectorTAS; Ormco, Orange, Calif; length, 6 mm; diameter, 1.4 mm). Upon insertion, maximal insertion torque (IT) was recorded. Imaging (microcomputed tomography) was performed before and after insertion for assessment of bone quality and quantity parameters (bone mineral density [BMD], bone thickness [BT], and length of screw engagement [LSE]). Differences in each parameter were assessed at the various insertion sites. Correlations between IT and measurements of BMD, BT, and LSE were evaluated. RESULTS: Significant differences (P < 0.001) were found among insertion sites for IT, BT, and LSE, but not for BMD (P = 0.004). Correlations were found between IT and BMD (rs = 0.42; P < 0.001), IT and BT (rs = 0.58; P < 0.001), and IT and LSE (rs = 0.58; P < 0.001). Most perforations of miniscrews into the nasal cavity occurred posterior to the permanent second premolars. CONCLUSIONS: The primary stability of orthodontic miniscrews in the palate is affected by bone quality and quantity, with higher primary stability obtained anterior to the second premolars and parasagittally at the level of the permanent first molars.

Effect of Finishing Procedures on the Surface Roughness of Resin-modified Glass-Ionomer Materials.

This study examined the influence of finishing procedures on the surface roughness of different formulations of resin-modified glass ionomers (RMGIs) available in capsules compared with standard resin composites (RCs). Disc samples of three RMGIs and two RCs were fabricated using a metal mold (5 mm x 1.5 mm). Samples were randomly divided into seven groups (N = 10) and subjected to finishing and polishing procedures using a combination of carbide or diamond burs, followed by either rubber points or aluminum-oxide discs. Three different regions of each sample were analyzed using a contact profilometer to determine the average roughness (Ra). The main surface roughness was calculated using a two-way analysis of variance (ANOVA) and the Bonferroni correction for multiple comparisons. A dual-stage combination of a fine carbide bur followed by the use of the finest two grits of aluminum-oxide discs was found to produce the smoothest finished and polished surface. the smoothest surfaces were found to be on the two RCs and one of the RMGIs.

Angiogenic Rg1 /Sr-Doped TiO2 Nanowire/Poly(Propylene Fumarate) Bone Cement Composites.

A new approach is provided for preparing radiopaque and angiogenic poly(propylene fumarate) (PPF) bone cements by integrating Sr-doped n-TiO2 nanowires and ginsenoside Rg1 suitable for treating osteonecrosis. High aspect ratio radiopaque TiO2 -nanowires are synthesized by strontium doping in supercritical CO2 for the first time, showing a new phase, SrTiO3 . PPF is synthesized using a transesterification method by reacting diethyl fumarate and propylene glycol, then functionalized using maleic anhydride to produce terminal carboxyl groups, which are subsequently linked to the nanowires. The strong interfacial adhesion between functionalized PPF and nanowires is examined by scanning electron microscopy, Fourier transform infrared, X-ray photoelectron spectroscopy, thermal analysis, and mechanical testing. An angiogenic modulator, ginsenoside Rg1 , is integrated into the bone cement formulation with the mechanical properties, radiopacity, drug release, and angiogenesis behavior of the formed composites explored. The results show superior radiopacity and excellent release of ginsenoside Rg1 in vitro, as well as a dose-dependent increase in the branching point numbers. The present study suggests this new methodology provides sufficient mechanical properties, radiopacity, and angiogenic activity to be suitable for cementation of necrotic bone.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

The Effectiveness of Noninvasive Interventions for Temporomandibular Disorders: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: To determine the effectiveness and cost-effectiveness of noninvasive interventions for temporomandibular disorders (TMD). METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central register from 1990 to 2014 for effectiveness studies and the Cochrane Health Technology Assessment Database, EconLit, NHS Economic Evaluation Database, and Tufts Medical Center Cost-Effectiveness Analysis Register from 1990 to 2014 for cost-effectiveness studies. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Evidence from eligible studies was synthesized using best-evidence synthesis methodology. RESULTS: Our search for effectiveness studies yielded 16,995 citations; 31 were relevant and 7 randomized controlled trials (published in 8 articles) had a low risk of bias. We found no relevant cost-effectiveness studies. The evidence suggests that for persistent TMD: (1) cognitive-behavioral therapy and self-care management lead to similar improvements in pain and disability but cognitive-behavioral therapy is more effective for activity interference and depressive symptoms; (2) cognitive-behavioral therapy combined with usual treatment provides short-term benefits in pain and ability to control pain compared with usual treatment alone; (3) intraoral myofascial therapy may reduce pain and improve jaw opening; and (4) structured self-care management may be more effective than usual treatment. The evidence suggests that occlusal devices may not be effective in reducing pain and improving motion for TMD of variable duration. Evidence on the effectiveness of biofeedback is inconclusive. DISCUSSION: The available evidence suggests that cognitive-behavioral therapy, intraoral myofascial therapy, and self-care management are therapeutic options for persistent TMD.

Effect of preheating on microhardness and viscosity of 4 resin composites.

OBJECTIVE: This study was undertaken to determine the effect of temperature on the microhardness and viscosity of 4 resin composite materials. METHODS: To investigate microhardness, samples of each of the 4 composite materials, prepared by standard insertion of resin into prefabricated moulds, were divided into 2 groups (n = 10 per group). On the first group, the resin composite materials were inserted into the moulds at room temperature and cured. On the second group, the resin composite materials were pre-heated in a heating device, inserted into the moulds and immediately cured. Microhardness after curing (both immediately and after 24 hours of storage) was determined (using a 300 g load applied for 10 seconds) and averaged for 5 randomly selected points on the top and bottom surfaces of each sample. To investigate viscosity, 0.5 g samples of room temperature or preheated resin composite (n = 15 per group) were placed under a 454 g load for 45 seconds before light-curing (40 seconds). After curing, each sample was photographed and the surface area calculated. Data were analyzed by t tests or one-way analysis of variance and Tukey's test. RESULTS: Preheating the resin composites increased the microhardness and decreased the viscosity of the samples. Filtek Supreme Ultra resin composite had the highest mean microhardness, and Vit-l-escence resin composite had the lowest viscosity. CONCLUSIONS: The effects of preheating resin composites may allow easier placement of restorations and greater monomer conversion.

Effectiveness of antiviral agents for the prevention of recurrent herpes labialis: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this study was to complete a systematic review and, if possible, a meta-analysis on the effectiveness of systemic and topical nucleoside antiviral agents in the prevention of recurrent herpes labialis (RHL) in immunocompetent subjects. STUDY DESIGN: Multiple comprehensive electronic and manual literature searches without language restrictions identified the studies to be included. Quality assessment and data synthesis methods followed those described in the Cochrane guidelines. RESULTS: Of 2,683 papers reviewed, 10 met the inclusion criteria. Oral acyclovir (800-1,600 mg daily) and valacyclovir (500 mg daily for 4 months) were shown to be effective in the prevention of RHL when taken prior to the appearance of any symptoms or exposure to triggers. Of the 10 papers reviewed, only 1 was determined to have a low risk of bias. CONCLUSIONS: This review found support for the use of systemic acyclovir and valacyclovir for the prevention of RHL.

Can patients help teach professionalism and empathy to dental students? Adding patient videos to a lecture course.

A key aspect of predoctoral dental education involves ethics/professionalism and interpersonal communications. Empathy is an integral aspect of both. This study at the Schulich School of Medicine and Dentistry, University of Western Ontario, examined predoctoral students' perspectives to determine the impact of new educational methodologies designed to integrate patients' voices into a patient management lecture course. Videos of patients describing their dental experiences were added along with classroom discussion and students' reflective journals on the topics raised. Early results indicate that students perceived this innovation enhanced the teaching of professionalism, raised their awareness of the importance of empathy, and was a well-received addition to the course.

The application of alveolar distraction osteogenesis following nonresorbable hydroxyapatite grafting in the anterior maxilla: a clinical report.

Distraction osteogenesis is a method of increasing bone length through the application of slow, controlled force on bone segments where periosteum and medullary blood supply are maintained. Recently, the procedure has been adapted to alveolar augmentation prior to prosthodontic rehabilitation. This report describes the use of alveolar distraction in the anterior maxilla and presents, to the authors' knowledge, the first reported successful application of the technique following nonresorbable hydroxyapatite grafting.

Micro-computed tomography of a 500-year-old tooth: technical note.

OBJECTIVE: To determine whether micro-computed tomography (micro-CT) could be used to reconstruct ancient dental anatomy accurately and differentiate the enamel from the dentin, as well as to verify whether micro-CT could detect tooth disorders such as attrition or caries accurately. METHODS: Micro-CT imaging was performed, using a cone-beam micro-CT specimen scanner, on a 500-year-old human tooth found in a burial jar in the Cardomom Mountains in southwestern Cambodia. RESULTS: The occlusal surface of the tooth showed marked attrition, with the dentin extending close to the enamel layer on the crown. In addition to this, micro-CT images depicted calculus on the buccal surface and a cervical root caries lesion present on the distal surface. The sclerotic zone of the carious lesion (located deep in the destroyed dentin) and the dentin were effectively differentiated through excellent resolution and superior tissue contrast of the volume data set. Axial slices from apical to coronal show the carious lesion extending vertically along the dentin-enamel junction with an intact outer enamel surface. CONCLUSION: Micro-CT is a reproducible, nondestructive and highly accurate technique that can be successfully applied to the study of ancient teeth.

A preliminary radiographic study of mandibular para-radicular third molar radiolucencies.

OBJECTIVES: To determine the frequency and describe a poorly documented radiographically observed variation of normal associated with the roots of mandibular third molars--the mandibular third molar para-radicular radiolucency (MPR). STUDY DESIGN: A systematic random sample of 822 dental school surgery and emergency charts was reviewed for radiographic evidence of the MPR. The frequency was determined and the variation in radiographic appearance was described. Clinical signs and symptoms were correlated with the presence of an MPR. RESULTS: The frequency of the MPR was 7.8% with a female-to-male ratio of 2.6:1.0. Of 6 bilateral cases (9.4%) all occurred in female patients. The most common location was the distal surface of the mandibular third molar. Most (58.6%) were oval in shape. CONCLUSION: This radiographic finding most likely represents a variation of normal anatomy and based on this retrospective study does not appear to require treatment.