Identification of Body Dysmorphic Disorder in Patients Seeking Corrective Procedures From Oral and Maxillofacial Surgeons.

INTRODUCTION: Body dysmorphic disorder (BDD) is an obsessive-compulsive related disorder characterized by an individual's preoccupation with the appearance of at least 1 perceived physical flaw. The bodily concerns held by individuals with BDD are largely unnoticeable, if at all, to other individuals. Those living with BDD are compelled to engage in repetitive behaviors or cognitive acts that interfere with daily function and activities. Despite the high prevalence of BDD in patients who seek cosmetic procedures (ie, as high as 1 in 5 such patients) and the availability of validated screening tools for this disorder, implementing a protocol of regularly screening for BDD is only rarely practiced by surgeons. Few studies have investigated its prevalence in the setting of elective dentoalveolar and orthognathic procedures. With the scope of practice of maxillofacial surgeons expanding in recent years to include facial cosmetic procedures, it is becoming increasingly important to screen for such disorders so that patients and physicians can appropriately weigh the risks and benefits of surgical intervention. METHODS: We conducted a cross-sectional cohort study (n = 46) consisting of 3 groups of patients, who were seeking either facial cosmetic, orthognathic, or dentoalveolar procedures. All patients in the study were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ) and assessed for severity of disorder using the BDDQ severity scale. Additional patient variables included age, sex, history of psychiatric diagnosis, primary diagnosis, and type of operation/procedure being sought. RESULTS: Among the 3 groups, patients seeking dentoalveolar surgery were the most represented (67%) in this sample, followed by cosmetic surgery (27%) and orthognathic surgery (6%). Twenty-six female participants and 20 male participants were included, with an overall mean age of 38 years. Two percent of participants carried a previous psychiatric diagnosis and 10.8% of the sample were classified as high-risk for BDD. The group containing the highest proportion of patients at high-risk for BDD were those seeking facial cosmetic procedures (16.7%), followed by those seeking dentoalveolar procedures (10%); none of the patients seeking orthognathic procedures were found to be at high-risk for BDD (0%). CONCLUSIONS: The BDDQ is an efficient way to screen for BDD in patients who are seeking orthognathic or facial cosmetic surgery. In our sample, patients presenting to maxillofacial surgeons for facial cosmetic surgery were found to score significantly higher on the BDDQ than those presenting for dentoalveolar surgery. In contrast to results of previous literature, patients seeking orthognathic surgery in our sample demonstrated no elevated risk for BDD, a finding which may be attributable to our small sample size. Ultimately, the data obtained from this study can aid surgeons in identifying patients with BDD in their own surgical practice, so that they may appropriately triage patients who may, or may not, benefit from surgical intervention.

The Role of Vitamin D in Pediatric Orthopedics.

Understanding the role of vitamin D is an important component of the proper care of the pediatric orthopedic patient. Vitamin D is an essential component of bone metabolism in the growth and development of the pediatric skeleton, which can be acutely affected by changes to the body's vitamin D, calcium, and phosphate levels, resulting in pathologic conditions such as rickets or fractures. This article reviews the main areas in which vitamin D relates to pediatric orthopedics and highlights some of the areas where future research is being directed.

Comparative assessment of 3D reconstruction technique and Cavalieri's principle in predicting the mandibular bone defect volumes.

PURPOSE: The objective of this study was to compare the accuracy of the Cavalieri's principle and 3D reconstruction in predicting the volume of a bony defect. MATERIALS AND METHODS: Defects of the same approximate size were created on nine artificial mandibles. The actual volume of the defect on each mandible was measured by water displacement, and served as the control. Each mandible was then scanned using a CBCT and volume measurements were made for each defect using two techniques: Cavalieri's principle and 3D reconstruction. For each defect, the volume obtained by each of the two techniques was compared to the control volume using the analysis of variances (ANOVA) with p<0.05. RESULTS: ANOVA between the control, 3D reconstruction and Cavalieri's principle groups showed no statistically significant differences (p=.058). When the control group was further analyzed by Dunnett's post-hoc test, the results from Cavalieri's principle were found to be statistically different than the control group (p=.035), whereas the results of 3D reconstruction technique did not reach the level of significance (p=.523). CONCLUSION: Cavalieri's principle significantly underestimates the actual control volume, and is less accurate than the 3D reconstruction technique. The 3D reconstruction method is a reliable technique in measuring volume of bony defects.

MMP-8 overexpression and persistence of neutrophils relate to stress-impaired healing and poor collagen architecture in mice.

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinase (TIMPs) are critical for tissue remodeling during wound repair. Psychological stress has been found to impair wound healing in humans and animals. The objective of this study was to assess MMP and TIMP gene expression during stress-impaired healing. Female SKH-1 mice (n=299) were divided into control and stress groups (13h restraint/day for 3days prior to and 5days post-wounding). Two 3.5mm cutaneous full-thickness wounds were placed on the dorsum of each mouse and wound measurements were performed daily. RT-PCR for gene expression of MMP-2, MMP-8, MMP-9, TIMP-1 and TIMP-2 was performed at days 1, 3 and 5. Immunohistochemical analyses of the healed wounds were performed at days 15 and 28. As expected, wounds healed more slowly in restraint-stressed mice compared to controls. Stressed mice exhibited MMP-8 overexpression and lower TIMP-1 levels during healing, and poorer collagen organization once healed. MMP-8 overexpression may have stemmed from a higher level of neutrophils, observed in wound tissue on days 3 and 5. These findings implicate higher neutrophil numbers, MMP-8 overexpression, and TIMP-1 under-expression, as mechanisms that may compromise wound outcomes such as scarring under conditions of stress.

Resorbable screw fixation for cortical onlay bone grafting: a pilot study with preliminary results.

PURPOSE: The current "gold standard" in alveolar ridge augmentation is autogenous bone grafting. Autologous cortical onlay grafts provide predictable increases in bone volume when used for alveolar ridge augmentation; however, rigid fixation of the graft to the recipient site is essential. Titanium screws are commonly used to provide rigid fixation for onlay grafting but have potential drawbacks including the need for a second surgery for removal before implant placement and screw fracture during removal. The present study investigated the efficacy of resorbable fixation screws to secure autologous cortical onlay grafts to the maxilla or mandible to augment alveolar bone height and/or width before implant placement. PATIENTS AND METHODS: Eleven patients requiring alveolar ridge augmentation were enrolled in this study. All patients received autologous cortical onlay grafts. Patients were randomly assigned to receive grafts fixated with 2.0-mm resorbable (experimental) or 1.5-mm titanium (control) screws. Integration and survivability of the graft was assessed using cone-beam computed tomography. Graft resorption was calculated at 4 to 7 months postoperatively and used as a quantitative outcome measurement. Statistical analysis was performed using NCSS/PASS (Dawson edition; Kaysville, UT) for Windows XP. Data are presented as mean ± standard error of the mean. Intergroup differences were assessed using Student's t test. RESULTS: Nine of the 11 patients initially enrolled completed the study. In these patients, 12 bone grafts were placed, 4 fixated with 2.0-mm resorbable screws and 8 fixated with 1.5-mm titanium screws. Integration and survivability of the grafts was 100% regardless of fixation type. Cone-beam computed tomographic data indicated that all grafts integrated regardless of fixation type. At 5 to 7 months postoperatively, cone-beam computed tomographic analysis indicated there were 28.07 ± 3.15% and 40.03 ± 3.67% bone resorption in grafts fixated with 2.0-mm resorbable and 1.5-mm titanium screws, respectively (P > .05). CONCLUSION: These data suggest that cortical onlay graft integration and survivability are similar using 2.0-mm resorbable or 1.5-mm titanium screw fixation. Therefore, use of resorbable fixation devices in alveolar ridge augmentation will obviate screw removal, which may result in screw breakage and may be difficult if bony overgrowth occurs. Further studies need to be performed with a larger sample to confirm these data.

Reduced nonprotein thiols inhibit activation and function of MMP-9: implications for chemoprevention.

Clinical studies demonstrate a positive correlation between the extent of matrix metalloproteinase (MMP) activation and malignant progression of precancerous lesions. Therefore, identification of effective, well-tolerated MMP inhibitors represents a rational chemopreventive strategy. A variety of agents, including proteinases and thiol-oxidizing compounds, activate MMPs by initiating release of the propeptide's cysteine sulfur "blockage" of the MMP active site. Despite the importance of the propeptide's cysteine thiol in preserving MMP latency, limited studies have evaluated the effects of reduced thiols on MMP function. This study investigated the effects of two naturally occurring nonprotein thiols, i.e., glutathione (GSH) and N-acetylcysteine (NAC), on activation, function, and cellular-extracellular matrix interactions of the basement-membrane-degrading gelatinase, MMP-9. Our results reveal that NAC and GSH employ protein S-thiolation to inhibit organomercurial activation of pro-MMP-9. Gelatinase activity assays showed that GSH and NAC significantly inhibited MMP-9 but not MMP-2 function, implying isoform structural specificity. Immunoblot analyses, which suggested GSH interacts with MMP-9's active-site Zn, were corroborated by computational molecular modeling. Cell invasion assays revealed that NAC enhanced endostatin's ability to inhibit human cancer cell invasion. Collectively, these data demonstrate that nonprotein thiols suppress MMP-9 activation and function and introduce the prospect for their use in chemopreventive applications.

Impaired wound contraction and delayed myofibroblast differentiation in restraint-stressed mice.

Previous research has shown that psychological stress delays wound closure by >25%. Gene expression of pro-inflammatory cytokines and the maturation of the epithelium were also impaired by stress (Mercado et al.). Wound contraction contributes to the speed of wound closure (Hunt and Hopf). In the current study, wound contraction was decreased by >45% (p<.01) in restraint stressed mice. Fibroblast migration and differentiation into smooth muscle alpha-actin (SmalphaA) -expressing myofibroblasts were delayed in RST mice through day 7 post-wounding. In addition, there was a 25 (p<.01), 48 (p<.01), and 38% (p<.05) decrease in SmalphaA mRNA levels at days 1, 3, and 5 post-wounding in RST mice, respectively. Cytokines that regulate fibroblast migration and differentiation include transforming growth factors-beta1, -beta2, and -beta3 (TGF-betas). Although expression of TGF-beta1 mRNA was downregulated by >25% (p<.01) in RST mice on day 3 post-wounding, no significant differences were detected in active or total TGF-beta1 protein levels. Stress did not alter the expression of TGF-beta2 or -beta3 through day 5 post-wounding. Thus, these data indicate that stress delays wound contraction and myofibroblast differentiation, which are likely independent of expression of TGF-beta1, -beta2, and -beta3.

Hyperbaric oxygen therapy ameliorates stress-impaired dermal wound healing.

Psychological stress has been shown to dysregulate healing in both humans and animals. Studies indicate the possibility for decreased oxygen supply, and increased oxygen demand, in the wounds of the stressed animals. Oxygen is an important mediator of wound healing, and its availability can limit healing rate. Hence, in a mouse model of stress-impaired healing, the hypothesis that hyperbaric oxygen therapy would ameliorate the effect of stress on dermal wound healing was tested. Hyperbaric oxygen therapy (HBO) twice a day during early wound healing significantly ameliorated the effects of stress, bringing healing to near-control levels. There was no significant effect of HBO on the wounds of control animals. Wound inducible nitric oxide synthase (iNOS), modulated by psychological stress and oxygen balance, was studied for gene expression by real-time PCR. Expression of iNOS increased in stressed mice on days 1 (205%; p<.0001), 3 (96%; p<.03), and 5 (249%; p<.03), post-wounding. HBO treatment of the stressed animals decreased iNOS expression by 62.6% (p< .02) day 1 post-wounding. There was no significant effect of HBO on wound healing and iNOS expression in the control animals. Methods aimed at increasing tissue oxygenation, like HBO, have a high therapeutic potential. Their molecular mechanisms, implicated in wound healing, elude clarification due to the lack of appropriate animal models. Our current findings represent the first experimental evidence, demonstrating that HBO corrects stress-impaired dermal wound healing.