Surgical safaris with the East Africa Flying Doctor Service.

A few hundred small mission and government hospitals serve the 20 million people who live in rural East Africa. The physician-patient ratio is 1:25,000. Surgical support to many of these hospitals is provided through the East Africa Flying Doctor Service of the African Medical and Research Foundation. Small aircraft that are coordinated by a wide radio network bring surgical capability to a maximum number of patients in this area of 1,300,000 sq km (500,00 sq miles). The clinical problems, differential diagnoses, operative decisions, risk, and complications of surgical care all have a distinctly African quality. The working conditions and variety and magnitude of problems provide a stimulating challenge. Surgical safaris are a catalyst for gaining acceptance of modern scientific methods by Africa's tradition-oriented tribesmen.

Ocular manifestations and treatment of hemifacial atrophy.

Enophthalmos, flattening of the maxilla that may progress to inferior orbital rim and floor defects, eyelid atrophy, and slight relative hypotony occurred in patients with hemifacial atrophy. Less common manifestations included pupillary and iris abnormalities, vertical muscle imbalances, and retinal changes. The prognosis for vision was good. Fluid silicone injection was the major modality in treatment and the results were generally excellent.

Recurrent aphthous stomatitis.

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease in North America. In some instances, RAS represents the central feature of the multisystem disease complex Behcet's syndrome. This article reviews the clinical features, contributing etiologic factors, and etiopathogenesis of RAS and Behcet's syndrome and describes therapeutic considerations and strategies essential to management of patients suffering from recurrent mouth ulcers.

Phenothiazine--another possible etiologic agent in erythema multiforme. Report of a case.

A case report is presented which offers evidence that administration of a phenothiazine drug resulted in erythema multiforme of the oral cavity in a psychotic patient. The condition remissed after discontinuation of the medication.

Oral ulcerations with use of hydrogen peroxide.

Hydrogen peroxide has been advocated for many years as an oral rinse useful in control of various oral conditions. Several authorities, however, have suggested that this material may be harmful to oral tissues, especially if the tissues have been previously injured. This article presents two case reports demonstrating harmful oral effects from hydrogen peroxide rinses. The findings suggest that oral hygiene techniques emphasizing the use of 3% hydrogen peroxide in periodontal therapy may require reevaluation.

Histologic observations on the topography of a human periodontal pocket viewed in transverse step-serial sections.

A histologic overview of a periodontal pocket at the distal of a maxillary first premolar is presented. The material studied is part of the Bernhard Gottlieb collection. This material demonstrated the topography of the periodontal pocket through its complete circumference as seen in transverse step serial sections. From these observations, it is also clear that multiple pockets had formed, each involving a different area of the root surface. The pockets terminated independently and are separated from each other by areas of tissue which progress from pocket epithelium to junctional epithelium to connective tissue attachment. The existence of independent pockets around the root surface of a single tooth points to the problem of access and thus the predictability of non-surgical therapy as well as concerns that surgical access will necessarily involve areas of unaffected tissues.

A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding.

BACKGROUND: Periodontal plastic surgery has increased the use of palatal wounds for donor tissue, with the most common complication being excessive bleeding from the palate after harvesting tissue. This study was conducted to evaluate the efficacy of 3 methods for achieving hemostasis on the palate after harvesting donor tissue for autogenous soft tissue grafts. METHODS: Thirty sites were evaluated at surgery for hemostasis and followed over 21 days for healing and adverse events. Three treatment groups were randomly selected and patients received either a test product or control comprising: 1) oxidized regenerated cellulose; 2) absorbable gelatin sponge; or 3) sterile gauze with external pressure as the control. All patients received a surgical stent for the palate. RESULTS: The results were analyzed for smokers and non-smokers, and the median time to hemostasis was significantly shorter when a hemostatic agent was applied to the palatal wounds compared to controls in both groups. Pain assessment showed no differences across treatment groups. However, by 21 days, only the oxidized regenerated cellulose group had complete healing based on blinded clinical evaluation with all sites rated as normal to rapid healing, compared to the absorbable gelatin sponge group where 40% of the sites were rated as slow healing. Adverse events, primarily bleeding episodes during the first 7 days after surgery, were found in 40% of the oxidized regenerated cellulose and gauze control groups, while no sites in the absorbable gelatin sponge group had an adverse event. The patients were followed for an average of 10 months and demonstrated a mean shrinkage of their recipient grafts of 24% in total surface area. CONCLUSIONS: This study concluded that the use of hemostatic agents for palatal wounds is confirmed as the treatment of choice when performing free soft tissue grafts.

An unusual cause of bilateral mental neuropathy in an AIDS patient. Report of a case.

A case is reported of a patient with sudden onset, generalized toothache accompanied with a numb chin and lower lip. A thorough oral examination was negative. A complete medical evaluation revealed a positive HTLV-III antibody titer and acute lymphoblastic leukemia (Burkitt's-type). An unexplained trigeminal neuropathy should prompt the dentist to refer the patient for complete medical evaluation. A high index of suspicion of a malignant process should be maintained in all cases of unexplained numb lower lip and/or chin.

Esthetic management of multiple recession defects in a patient with cicatricial pemphigoid.

Cicatricial pemphigoid is one of a number of mucocutaneous disorders that can present in the oral cavity with desquamation, pain, and bleeding of the gingiva and oral mucosa. This case report describes the management of cicatricial pemphigoid in a patient with multiple sites of gingival recession using connective tissue grafting to alleviate root surface sensitivity and improve esthetics. The treatment rationale is presented and discussed in terms of timing of therapy and implications for wound healing in patients who present with desquamative gingivitis.

Chronic ulcerative stomatitis: a case report.

BACKGROUND: Certain mucocutaneous diseases present with painful, ulcerative, or erosive oral manifestations. Chronic ulcerative stomatitis is a newly recognized disease of unknown origin which presents clinically with features of desquamative gingivitis. This report marks only the thirteenth case reported in the world literature. A review of previous reports and studies is presented along with a review of immunofluorescence techniques critical to proper diagnosis. These diseases are difficult to diagnose without the use of immunofluorescence techniques. A 54-year-old Caucasian woman presented with a 2- to 3-year history of stomatitis and dry mouth. METHODS: Direct immunofluorescence revealed a speckled pattern of IgG deposits in the basal one-third of the epithelium, while indirect immunofluorescence confirmed the presence of stratified epithelium-specific antinuclear antigen (SES-ANA), both pathognomonic for chronic ulcerative stomatitis. RESULTS: The patient was successfully treated using topical corticosteroid therapy.

Complications of free grafts of masticatory mucosa.

A discussion has been presented and examples provided to illustrate some of the complications that may be encountered in conjunction with free grafts of masticatory mucosa. The clinical problems presented are seen infrequently, but the clinician must be aware of the possibility of their occurrence when counseling patients on the possible sequelae of such surgical procedures. A knowledge of complications that may occur in free soft tissue grafting procedures, and of the underlying mechanisms causing these problems, may aid the clinician in anticipating and avoiding similar experiences.

Solitary eosinophilic granuloma (histiocytosis X) of the gingiva. A report of two cases.

Two cases are reported in which the patients presented with solitary ulcers on the gingiva. The lesions were excised and examined histologically. A connective tissue infiltrate of large mononuclear cells was identified with immunohistochemical staining as Langerhans cells and a diagnosis of histiocytosis X was made. Further medical evaluation revealed no other lesions in one of the patients but did locate an infiltrate in the right mastoid of the other patient. Solitary lesions of histiocytosis in oral mucosa are extremely rare. The manifestations of the disease, pathogenesis, and treatment are discussed.

The effects of platelet-derived growth factor-BB and insulin-like growth factor-1 on epithelial dysplasia.

Growth factors are multi-functional and multi-targeted proteins which play a significant role in wound healing. Platelet-derived growth factor B-chain homodimer (PDGF-BB) and insulin-like growth factor-1 (IGF-1) have demonstrated efficacy for periodontal regeneration in animal models. Although primarily associated with wound healing, PDGF-BB and IGF-1 also facilitate growth of a number of malignant neoplasms. Of particular concern to periodontists is epithelial dysplasia, a necessary precursor to squamous cell carcinoma, the most common oral malignancy. Certain risk factors for oral cancer, such as tobacco, age, and alcohol, are also associated with an increased incidence of periodontal disease. The effects of the combination of PDGF-BB and IGF-1 on epithelial dysplasia have not previously been reported. The purpose of this study was to examine the effects of the combination of PDGF-BB and IGF-1 on epithelial dysplasia induced in the buccal cheek pouch of the Syrian golden hamster. A total of 66 hamsters received 18 applications of 0.5% dimethylbenzanthracene (DMBA), a topical carcinogen, over a 6-week period for the induction of dysplasia. The hamsters were subsequently divided into a baseline and 3 experimental groups (growth factors, saline vehicle, untreated control). Following the final DMBA application (day 0), the baseline group (N = 6) was sacrificed, the growth factor group (N = 21) received a single injection in the cheek pouch containing 4 micrograms of PDGF-BB and 4 micrograms of IGF-1 in saline, the saline group (N = 19) received an injection in the cheek pouch containing the saline vehicle only, and the untreated control group (N = 20) received no injection. Animals in experimental groups were sacrificed on days 3, 6, and 10. The cheek pouches were harvested for histologic and histochemical evaluation. Dysplasia was histologically graded from 0 to 4. Statistical analysis of the histologic data revealed no significant differences either by sacrifice date or by group. Histochemical evaluation, via staining for gamma-glutamyl transpeptidase (GGT), a marker for dysplastic cell colonies, revealed that the density of GGT-positive cells in experimental groups differed significantly from baseline levels. No significant differences were detected between experimental groups. There was poor correlation between the density of GGT-positive cells and the histologic grading of dysplasia. It is concluded that exposure to PDGF-BB and IGF-1 had no demonstrable effect on epithelial dysplasia in this hamster model.

Quantitative measurement of volume changes induced by oral plastic surgery: validation of an optical method using different geometrically-formed specimens.

The purpose of this research was to study the validity and variability of a projection Moiré system, measuring volume differences of geometrically different formed specimens mimicking localized alveolar ridge defects. Nine pairs of specimens were fabricated, each of which simulated a preoperative ridge defect and a corresponding surgically-corrected postoperative ridge defect. All specimen pairs had a mathematically defined form which allowed the accurate assessment of their volume differences by a mechanical 3-D coordinate measuring machine or by a software-controlled milling machine. Measurements achieved with these methods were used as the references for comparison. Six specimen pairs, A1 to A6, possessed a simple rectangular geometrical form which facilitated their fabrication. Three specimen pairs, B1 to B3, were milled and consisted of geometrically more complex 3-D sculptured surfaces, which came closest to a true imitation of a localized ridge defect. An optical measurement system in the form of the projection Moiré was utilized, applying a 4-phase shift technique, and results obtained with this device were regarded as test volumes. The absolute variability of the test volume measurements differed between 0.397 mm3 to 15.872 mm3, corresponding to a relative variability of 0.83% to 2.83%. The mean of the relative variability was within 1.68% for the "A" specimens and 2.15% for the "B" specimens. However, the difference was not significant, probably due to the limited number of "B" specimens. The systematic error of the Moiré measurements in relation to the reference methods was surprisingly low, ranging from -0.12 mm3 to 7.67 mm3. The relative systematic error, expressed as a percentage of reference volume, ranged between 0.06% and -2.23%. The mean of the relative error for the more complex "B" specimens was 1.37%, which was less accurate in comparison to the more simply formed "A" specimens with a relative systematic error of 0.35%. Therefore, in this in vitro model it was possible to measure volume differences of geometrically different formed specimens, mimicking localized alveolar ridge defects, with a validity within 2.2% and with a variability of less than 2.8%.

PDGF-B producing cells and PDGF-B gene expression in normal gingival and cyclosporine A-induced gingival overgrowth.

It has been proposed that healthy gingiva is in a continuous state of wound repair. Thus, one might expect to find cells in normal gingiva producing growth factors associated with wound healing such as platelet-derived growth factor B chain (PDGF-B). One might also expect to find increased numbers of these cells or increased amounts of these growth factors in conditions which involve increased tissue volume such as drug-induced gingival overgrowth (DGO). The purpose of this study was to quantify PDGF-B gene expression and identify cells producing PDGF-B in normal gingiva and DGO. Cyclosporine A (CSA) was selected as a prototype of the overgrowth condition. Twelve patients with clinical CSA DGO and 12 patients with no DGO or history of drugs known to cause DGO were selected for study. Frozen sections of gingival specimens from these patients were subjected to in situ hybridization for PDGF-B mRNA. Positive cells were counted and expressed as mean +/- SEM cells/mm2 of lamina propria. Morphometric analysis revealed 6.2 +/- 1.9 cells/mm2 for control gingiva and 10.3 +/- 3.4 cells/mm2 for CSA DGO samples. There was no statistically significant difference between groups. PDGF-B gene expression was measured in these cells and expressed as mean +/- SEM silver grains/cells. There was a significant upregulation of PDGF-B gene expression in cells from the CSA DGO group (39.5 +/- 14.7 silver grains/cell for normal gingiva vs. 255.3 +/- 77.1 silver grains/cell for CSA DGO samples; P < 0.001). The presence of PDGF-B in these cells was confirmed in all cases by immunocytochemical localization. Additionally, PDGF-B producing cells were identified as macrophages in sections taken from an additional patient with CSA DGO by double immunofluorescence labeling of the CD51 membrane marker for macrophages and intracellular PDGF-B. These findings are consistent with the concept that healthy gingiva is in a continuous state of wound repair and support the hypothesis that CSA DGO is associated with enhanced macrophage PDGF-B gene expression rather than an increase in the number of PDGF-B producing macrophages.

Spectrophotometric determination of platinum in experimental catalysts.

Conditions have been established and procedures are described for the colorimetric determination of platinum in experimental catalysts and miscellaneous materials. The methods are based on the measurement of the intensity of colour produced by the reaction of chloroplatinic acid with tin(II) chloride. Interference from metals such as chromium, molybdenum and nickel, which are often also present in catalysts, is overcome by selective extraction of the complex into isoamyl alcohol followed by measurement of the absorbance of the alcohol layer.

Facial atrophy.

The author's personal experience with 84 patients demonstrating varying degrees of facial atrophy is reported. Of these, 59 patients had forms of progressive hemifacial atrophy. Hemifacial atrophy seems best classified into two groups: those who demonstrate inflammatory changes during the course of the disease as opposed to the more benign or noninflammatory types. The inflammatory type of hemifacial atrophy is usually associated with skin and ophthalmic pathology. It is suggested that it is often difficult, if not impossible, to distinguish between Romberg's disease and hemifacial atrophy from scleroderma; therefore, these terms might best be eliminated in classifying hemifacial atrophy. The etiology of facial atrophy remains unknown in the overwhelming majority of cases.

Current concepts of rhinoplasty.

Like all surgical operation, aesthetic rhinoplasty is a technique that is constantly undergoing change. These changes are brought about by accumulated experience, improved instrumentation, and not the least by the pressure of changing cultural and social requirements. The fine subtleties of rhinoplasty are difficult to learn by the student and difficult to master by the mature surgeon. Technique improves with the accumulation of surgical experience and constant observation and study of one's results. The learning process should never stop. The most significant changes in rhinoplasty technique since the operation was designed are emphasis on attention to detail and less, rather than more, extensive surgery. The removal of less bone, cartilage, and soft tissue is emphasized as well as meticulous attention to details of repositioning and alignment of all structures.

Mammary asymmetry.

Significant mammary asymmetry is not uncommon although accurate statistics are not available. Modern techniques of mammary augmentation and breast reduction have resulted in effective methods of treatment of most such deformities. The management of this problem was discussed.

The tuberous breast.

The tuberous breast deformity cannot usually be corrected satisfactorily by standard augmentation mammaplasty or mastopexy. The two operative techniques described have been most helpful in dealing with this difficult problem. Anatomic differences in patients may permit or require modification of the techniques to correct a specific deformity. Although our experience to date with these techniques has been limited in number, we have been pleased with the postoperative results.