Dental Caries Postradiotherapy in Head and Neck Cancer

BACKGROUND

Treatment for head and neck cancer (HNC) such as radiotherapy (RT) can lead to numerous acute and chronic head and neck sequelae, including dental caries. The goal of the present study was to measure 2-y changes in dental caries after radiotherapy in patients with HNC and test risk factors for caries increment.

METHODS

Cancer and dental disease characteristics, demographics, and oral health practices were documented before and 6, 12, 18, and 24 mo after the start of RT for 572 adult patients with HNC. Patients were eligible if they were age 18 y or older, diagnosed with HNC, and planned to receive RT for treatment of HNC. Caries prevalence was measured as decayed, missing, and filled surfaces (DMFS). The association between change in DMFS and risk factors was evaluated using linear mixed models.

RESULTS

On average, DMFS increased from baseline to each follow-up visit: 6 mo, +1.11; 12 mo, +2.47; 18 mo, +3.43; and 24 mo, +4.29 (P < 0.0001). The increase in DMFS during follow-up was significantly smaller for the following patient characteristics: compliant with daily fluoride use (P = 0.0004) and daily oral hygiene (brushing twice daily and flossing daily; P = 0.015), dental insurance (P = 0.004), and greater than high school education (P = 0.001). DMFS change was not significantly associated with average or maximum RT dose to the parotids (P > 0.6) or salivary flow (P > 0.1). In the subset of patients who had salivary hypofunction at baseline (n = 164), lower salivary flow at follow-up visits was associated with increased DMFS.

CONCLUSION

Increased caries is a complication soon after RT in HNC. Fluoride, oral hygiene, dental insurance, and education level had the strongest association with caries increment after radiotherapy to the head and neck region. Thus, intensive oral hygiene measures, including fluoride and greater accessibility of dental care, may contribute to reducing the caries burden after RT in HNC.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding how to minimize oral complications related to cancer therapy for patients with head and neck cancer. Identification of modifiable factors (e.g., oral hygiene and prescription fluoride compliance) associated with increased caries risk can minimize radiation caries burden.

The Histopathology of Oral Cancer Pain in a Mouse Model and a Human Cohort

Oral cancer patients often have severe, chronic, and mechanically induced pain at the site of the primary cancer. Oral cancer pain is initiated and maintained in the cancer microenvironment and attributed to release of mediators that sensitize primary sensory nerves. This study was designed to investigate the histopathology associated with painful oral cancers in a preclinical model. The relationship of pain scores with pathologic variables was also investigated in a cohort of 72 oral cancer patients. Wild-type mice were exposed to the carcinogen, 4-nitroquinoline 1-oxide (4NQO). Nociceptive (pain) behavior was measured with the dolognawmeter, an operant device and assay for measuring functional and mechanical allodynia. Lesions developed on the tongues and esophagi of the 4NQO-treated animals and included hyperkeratoses, papillomas, dysplasias, and cancers. Papillomas included lesions with benign and dysplastic pathological features. Two histologic subtypes of squamous cell carcinomas (SCCs) were identified-SCCs with exophytic and invasive components associated with papillary lesions (pSCCs) and invasive SCCs without exophytic histology (iSCCs). Only the pSCC subtype of tongue cancer was associated with nociceptive behavior. Increased tumor size was associated with greater nociceptive behavior in the mouse model and more pain experienced by oral cancer patients. In addition, depth of invasion was associated with patient-reported pain. The pSCC histology identifies 4NQO-induced tongue cancers that are expected to be enriched for expression and release of nociceptive mediators.

No longer a historical ailment: two cases of childhood scurvy with recommendations for bone health providers

PURPOSE

Scurvy, due to vitamin C deficiency, is commonly referenced as a "forgotten" or "historical" disease. A growing number of case reports challenge this notion. Bone health providers are often consulted early in the presentation of scurvy to evaluate musculoskeletal complaints resulting from impaired collagen production and disrupted endochondral bone formation. In this report, we describe two cases of childhood scurvy. Our objective is to summarize the key features of scurvy for bone health providers, with the goal of raising awareness and facilitating diagnosis in future cases.

CASE DESCRIPTIONS

Case one occurred in a 12-year-old non-verbal, non-ambulatory female on a ketogenic diet for refractory epilepsy. Clinical findings included hemarthrosis, transfusion dependent anemia, elevated inflammatory markers, and epiphysiolysis. Magnetic resonance imaging (MRI) revealed multi-focal bone marrow signal abnormalities and physeal irregularities. Case two occurred in a typically developing 5-year-old male presenting with limp and knee pain. Symptoms progressed despite casting and immobilization. Mild anemia, elevated inflammatory markers, and multi-focal marrow and physeal MRI abnormalities were identified. Subsequent dietary history revealed total absence of fruit or vegetable consumption. The diagnosis of scurvy was confirmed in both cases by undetectable plasma vitamin C concentrations. Treatment with vitamin C led to rapid clinical improvement.

CONCLUSION

Scurvy can no longer be considered a historical diagnosis and should not be forgotten when evaluating children with musculoskeletal ailments. Early recognition of the signs, symptoms, and imaging findings of scurvy can reduce the clinical burden of this disease with the timely initiation of vitamin C therapy.

Targeted TNF-α Overexpression Drives Salivary Gland Inflammation

Chronic inflammation of the salivary glands from pathologic conditions such as Sjögren's syndrome can result in glandular destruction and hyposalivation. To understand which molecular factors may play a role in clinical cases of salivary gland hypofunction, we developed an aquaporin 5 (AQP5) Cre mouse line to produce genetic recombination predominantly within the acinar cells of the glands. We then bred these mice with the TNF-αglo transgenic line to develop a mouse model with salivary gland-specific overexpression of TNF-α; which replicates conditions seen in sialadenitis, an inflammation of the salivary glands resulting from infection or autoimmune disorders such as Sjögren's syndrome. The resulting AQP5-Cre/TNF-αglo mice display severe inflammation in the salivary glands with acinar cell atrophy, fibrosis, and dilation of the ducts. AQP5 expression was reduced in the salivary glands, while tight junction integrity appeared to be disrupted. The immune dysregulation in the salivary gland of these mice led to hyposalivation and masticatory dysfunction.

RAF Kinase Inhibitory Protein Expression and Phosphorylation Profiles in Oral Cancers

Raf Kinase Inhibitory Protein (RKIP) expression has been profiled for a number of unique tissue cancers. However, certain tissues have not been explored, and oral and oropharyngeal cancers stand out as high priority targets, given their relatively high incidence, high morbidity rate, and in many cases, preventable nature. The purpose of this study was to examine changes in RKIP expression and phosphorylation in tissues resected from oral cancer patients, and compare to results generated from immortalized cell lines raised from primary oral cancer tissues, including oral squamous cell carcinoma line 4 (SCC4) and human squamous cell carcinoma line 3 (HSC3). Out of 4 human samples collected from male and female patients across various ages with variable risk factors, we observed an across the board reduction in RKIP expression. Two human samples demonstrated a significant increase in phosphorylated RKIP when normalized to total RKIP, however all 4 were increased when normalized to total cellular protein. The immortalized oral cancer cell culture HSC3 revealed significant increases in phosphorylated RKIP with no change in total RKIP expression, while line SCC4 demonstrated an increase in both total and phosphorylated RKIP. Results presented here indicate that oral cancers behave similarly to other cancers in terms of changes in RKIP expression and phosphorylation, although immortalized cell line expression profiles significantly differ from human tissue biopsies.

Conditional TNF-α Overexpression in the Tooth and Alveolar Bone Results in Painful Pulpitis and Osteitis

Tumor necrosis factor-α (TNF-α) is a proalgesic cytokine that is commonly expressed following tissue injury. TNF-α expression not only promotes inflammation but can also lead to pain hypersensitivity in nociceptors. With the established link between TNF-α and inflammatory pain, we identified its increased expression in the teeth of patients affected with caries and pulpitis. We generated a transgenic mouse model (TNF-α(glo)) that could be used to conditionally overexpress TNF-α. These mice were bred with a dentin matrix protein 1 (DMP1)-Cre line for overexpression of TNF-α in both the tooth pulp and bone to study oral pain that would result from subsequent development of pulpitis and bone loss. The resulting DMP1/TNF-α(glo) mice show inflammation in the tooth pulp that resembles pulpitis while also displaying periodontal bone loss. Inflammatory infiltrates and enlarged blood vessels were observed in the tooth pulp. Pulpitis and osteitis affected the nociceptive neurons innervating the orofacial region by causing increased expression of inflammatory cytokines within the trigeminal ganglia. With this new mouse model morphologically mimicking pulpitis and osteitis, we tested it for signs of oral pain with an oral function assay (dolognawmeter). This assay/device records the time required by a mouse to complete a discrete gnawing task. The duration of gnawing required by the DMP1/TNF-α(glo) mice to complete the task was greater than that for the controls; extended gnaw time in a dolognawmeter indicates reduced orofacial function. With the DMP1/TNF-α(glo) mice, we have shown that TNF-α expression alone can produce inflammation similar to pulpitis and osteitis and that this mouse model can be used to study dental inflammatory pain.

Review of preclinical studies on treatment of mucositis and associated pain

Oral mucositis is a significant problem in cancer patients treated with radiation or chemotherapy, often hindering definitive cancer treatment. For patients with oral mucositis, pain is the most distressing symptom, leading to loss of orofacial function and poor quality of life. While oral mucositis has been well-described, its pathophysiology is poorly understood. Oral health professionals treating patients with mucositis have almost no effective therapies to treat or prevent oral mucositis. The purpose of this review is to (1) describe the current preclinical models of oral mucositis and their contribution to the understanding of mucositis pathophysiology, (2) explore preclinical studies on therapies targeting mucositis and discuss the clinical trials that have resulted from these preclinical studies, and (3) describe the proposed pathophysiology of oral mucositis pain and preclinical modeling of oral mucositis pain.

Metastatic epithelioid angiosarcoma to the mandible: report of a case and review of the literature

Angiosarcoma and its epithelioid variant are vascular malignancies that rarely affect the facial skeleton. Epithelioid angiosarcoma resembles carcinoma and can be difficult to diagnose. A case is presented of metastatic epithelioid angiosarcoma to the mandible from an angiosarcomatoid portion of renal carcinoma. The diagnostic challenge is outlined and the literature is reviewed.

Biologic mechanisms of oral cancer pain and implications for clinical therapy

Cancer pain is an ever-present public health concern. With innovations in treatment, cancer patients are surviving longer, but uncontrollable pain creates a poor quality of life for these patients. Oral cancer is unique in that it causes intense pain at the primary site and significantly impairs speech, swallowing, and masticatory functions. We propose that oral cancer pain has underlying biologic mechanisms that are generated within the cancer microenvironment. A comprehensive understanding of key mediators that control cross-talk between the cancer and peripheral nervous system, and possible interventions, underlies effective cancer pain management. The purpose of this review is to explore the current studies on oral cancer pain and their implications in clinical management for cancer pain in general. Furthermore, we will explore the endogenous opioid systems and novel cancer pain therapeutics that target these systems, which could solve the issue of opiate tolerance and improve quality of life in oral cancer patients.

Gauze padding: a simple technique to delineate small oral cavity tumors

BACKGROUND AND PURPOSE

Small oral cavity tumors are an imaging challenge. Intimate apposition of vestibular oral mucosa to the alveolar mucosa makes tumor assessment difficult. In CT imaging, the "puffed cheek" method has been used to separate surfaces, though this is not feasible with long MR imaging sequences. We implemented placement of 2 × 2 inch (6.45 cm) gauze into the oral vestibule before the MR imaging examination, to determine whether this might improve tumor visualization.

MATERIALS AND METHODS

MR imaging examinations of all T1 oral malignant tumors treated at University of California, San Francisco, by the Oral and Maxillofacial Department were reviewed by 2 neuroradiologists. Nine patients were included in the final analysis. Six patients were imaged by using a standard protocol. Three patients were imaged with gauze placement. The radiologists evaluated the MR images, assessing whether they could see the tumor and then fully delineate it and its thickness.

RESULTS

Fisher exact analysis was performed on questions 1, 2, and 4 with the following results: P value = .048, Can you see the tumor? P value = .012, Can you fully delineate? P value of .012, How confident are you? MR imaging examinations with gauze clearly delineated the tumor with the tumor thickness measurable. MR imaging examinations without gauze did not clearly show the tumor or its thickness. Confidence of interpretation of the findings was also increased when gauze was used.

CONCLUSIONS

A 2 × 2 inch (6.45 cm) rolled gauze in the oral vestibule significantly improved tumor localization and delineation at MR imaging. This technique is simple and provides superior preoperative imaging evaluation and treatment planning of small oral cavity tumors.

Serine proteases and protease-activated receptor 2-dependent allodynia: a novel cancer pain pathway

Mediators involved in the generation of pain in patients with cancer are poorly understood. Using a combined molecular, pharmacologic, behavioral, and genetic approach, we have identified a novel mechanism of cancer-dependent allodynia induced by protease-activated receptor 2 (PAR2). Here we show that human head and neck carcinoma cells have increased levels of proteolytic activity compared to normal human cell controls. Supernatant from human carcinoma cells, but not controls, caused marked and prolonged mechanical allodynia in mice, when administered into the hindpaw. This nociceptive effect was abolished by serine protease inhibition, diminished by mast cell depletion and absent in PAR2-deficient mice. In addition, non-contact co-culture of trigeminal ganglion neurons with human head and neck carcinoma cells increased the proportion of neurons that exhibited PAR2-immunoreactivity. Our results point to a direct role for serine proteases and their receptor in the pathogenesis of cancer pain. This previously unrecognized cancer pain pathway has important therapeutic implications wherein serine protease inhibitors and PAR2 antagonists may be useful for the treatment of cancer pain.

Lingual nerve damage due to inferior alveolar nerve blocks: a possible explanation

BACKGROUND

An explanation for the predominance of injuries to lingual nerves over those to inferior alveolar nerves as a result of inferior alveolar nerve blocks may be due to the nerves' fascicular pattern. A unifascicular nerve may be injured more easily than a multifascicular nerve.

METHODS

The authors unilaterally dissected lingual and inferior alveolar nerves from 12 cadavers. They cut the specimens 2 millimeters above the lingula for both the lingual nerve and inferior alveolar nerve and opposite the site of the middle of the third molar for the lingual nerve, and they counted the number of fascicles at each site.

RESULTS

For the lingual nerve at the lingula, the mean number of fascicles was three (range, one to eight). Four of the 12 nerves (33 percent) were unifascicular at this point. Opposite the third molar, the lingual nerve had a mean of 20 fascicles (range, six to 39). In every case, there were more fascicles in the third molar region than above the lingula in the same nerve. At the lingula, the inferior alveolar nerve had a mean of 7.2 fascicles (range, three to 14).

CONCLUSION

This study may explain the observation that when an inferior alveolar nerve block causes permanent nerve impairment, the lingual nerve is affected about 70 percent of the time and the inferior alveolar nerve is affected only 30 percent of the time. In 33 percent of cases, the lingual nerve had only one fascicle at the lingula; a unifascicular nerve may be injured more easily than a multifascicular one.

CLINICAL IMPLICATIONS

There is no known way to avoid the remote possibility of nerve damage resulting from an inferior alveolar nerve block. The lingual nerve may be predominantly affected because of its fascicular pattern.

Importance of sample preparation for molecular diagnosis of lyme borreliosis from urine

Urine PCR has been used for the diagnosis of Borrelia burgdorferi infection in recent years but has been abandoned because of its low sensitivity and the irreproducibility of the results. Our study aimed to analyze technical details related to sample preparation and detection methods. Crucial for a successful urine PCR were (i) avoidance of the first morning urine sample; (ii) centrifugation at 36,000 x g; and (iii) the extraction method, with only DNAzol of the seven different extraction methods used yielding positive results with patient urine specimens. Furthermore, storage of frozen urine samples at -80 degrees C reduced the sensitivity of a positive urine PCR result obtained with samples from 72 untreated erythema migrans (EM) patients from 85% in the first 3 months to <30% after more than 3 months. Bands were detected at 276 bp on ethidium bromide-stained agarose gels after amplification by a nested PCR. The specificity of bands for 32 of 33 samples was proven by hybridization with a GEN-ETI-K-DEIA kit and for a 10 further positive amplicons by sequencing. By using all of these steps to optimize the urine PCR technique, B. burgdorferi infection could be diagnosed by using urine samples from EM patients with a sensitivity (85%) substantially better than that of serological methods (50%). This improved method could be of future importance as an additional laboratory technique for the diagnosis of unclear, unrecognized borrelia infections and diseases possibly related to Lyme borreliosis.

Nicotine withdrawal hyperalgesia and opioid-mediated analgesia depend on nicotine receptors in nucleus accumbens

The nucleus accumbens, as part of the mesolimbic dopaminergic reward pathway, mediates both addiction to and withdrawal from substances of abuse. In addition, activity of substances of abuse such as opioids in the nucleus accumbens has been implicated in pain modulation. Because nucleus accumbens nicotinic receptors are important in nicotine addiction and because nicotinic activity can interact with opioid action, we investigated the contribution of nucleus accumbens nicotinic receptors to opioid-mediated analgesia/antinociception. The response of the nociceptive jaw-opening reflex to opioids was studied in the rat, both before and during chronic nicotine exposure. In nicotine-naive rats, intra-accumbens injection of the nicotinic receptor antagonist mecamylamine blocked antinociception produced by either systemic morphine, intra-accumbens co-administration of a mu- and a delta-opioid receptor agonist, or noxious stimulation (i.e., subdermal capsaicin in the hindpaw); intra-accumbens mecamylamine alone had no effect. The antinociceptive effect of either morphine or noxious stimulation was unchanged during nicotine tolerance; however, intra-accumbens mecamylamine lost its ability to block antinociception produced by either treatment. Intra-accumbens mecamylamine by itself precipitated significant hyperalgesia in nicotine-tolerant rats which could be suppressed by noxious stimulation as well as by morphine. These results indicate that nucleus accumbens nicotinic receptors play an important role in both opioid- and noxious stimulus-induced antinociception in nicotine-naive rats. This role was attenuated in the nicotine-dependent state. The suppression of withdrawal hyperalgesia by noxious stimulation suggests that pain can ameliorate the symptoms of withdrawal, thus suggesting a possible mechanism for pain-seeking behavior.

The use of enucleation and liquid nitrogen cryotherapy in the management of odontogenic keratocysts

PURPOSE

This study evaluated the use of enucleation and cryosurgery in the management of odontogenic keratocysts.

PATIENTS AND METHODS

This study involved a retrospective review of 26 patients. All of the patients received a combination of enucleation and cryosurgery. Postoperative follow-up consisted of clinical and radiographic examinations.

RESULTS

Before enucleation and cryotherapy, 22 of the 26 patients had received previous treatment consisting of enucleation alone. The average time from initial treatment to recurrence was 6.2 years. Twenty-three cases occurred in the mandible, 22 in the posterior (proximal to the canine), and 1 in the anterior mandible. Three cases involved the maxilla. Three of the 26 patients (11.5%) developed a recurrence after treatment. The average time from treatment to recurrence in these 3 patients was 1.6 years (range, 1.2 to 1.9 years). The remaining 23 patients (88.5%) had no evidence of clinical or radiographic recurrence. The average time of follow-up was 3.5 years (range, 2.0 to 10.0 years).

CONCLUSIONS

Based on these results, the combination of enucleation and liquid nitrogen cryotherapy may offer patients improved therapy in the management of odontogenic keratocysts.

The course of the temporal branch of the facial nerve in the periorbital region

PURPOSE

This study identified the terminal temporal and zygomatic branches of the facial nerve as they enter the orbicularis oculi muscle and related these branches to identifiable surface markings.

MATERIALS AND METHODS

The temporal and zygomatic branches of the facial nerve were dissected from 5 preserved cadavers (10 sides). The most superior temporal branch entering the orbicularis oculi muscle was identified and related to the lateral canthus of the eye. A vertical line was passed through this point so that the line was equidistant from the nasal tip and chin point. A line perpendicular to the vertical line through the lateral canthus served as the horizontal scale. Vertical and horizontal lines through the lateral canthus were used to establish the anatomic relationship between the lateral canthus and the branch of the temporal nerve entering the orbicularis oculi muscle.

RESULTS

The temporal branch was an average of 2.85 +/- 0.69 cm superior to the lateral canthus and an average of 2.54 +/- 0.43 cm lateral to the lateral canthus as it courses into the orbicularis oculi muscle. At the lateral border of the orbicularis oculi muscle, where the temporal and zygomatic nerves insert into the muscle, the mean vertical distance between the temporal and zygomatic nerves was 1.72 +/- 0.62 cm.

CONCLUSION

Incisions superior or inferior and parallel to the course of the facial nerve, can provide access to the fronto zygomatic suture and the superior and lateral orbit without damaging its branches.

A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures

PURPOSE

The aim of this study was to compare the cost-effectiveness of mandibular fracture treatment by closed reduction with maxillomandibular fixation (CRF) with open reduction and rigid internal fixation (ORIF).

PATIENTS AND METHODS

This was a retrospective study of 85 patients admitted to the Oral and Maxillofacial Surgery Service at San Francisco General Hospital and treated for mandibular fractures from January 1 to December 31, 1993. The patients were divided into 2 groups: 1) those treated with CRF and 2) those treated with ORIF. The outcome variables were length of hospital stay, duration of anesthesia, and time in operating room. The charge for primary fracture treatment included the fees for the operation and hospitalization without any complications. Within the group of 85 patients treated for mandibular fractures in 1993, 10 patients treated with CRF and 10 patients treated with ORIF were randomly selected, and hospital billing statements were used to estimate the average charge of primary treatment. The average charge to manage a major postoperative infection also was estimated based on the billing statements of 10 randomly selected patients treated in 1992 (5 treated with CRF, 5 with ORIF) who required hospital admission for the management of a complication. The average total charge was computed by using the average charge for primary treatment plus the incidence of postoperative infection multiplied by the average charge for management of that complication.

RESULTS

Eighty-five patients were included in the study. The average charge for primary treatment was $10,100 for the CRF group and $28,362 for the ORIF group. The average charge for the inpatient management of a major postoperative infection was $26,671 for the CRF group and $39,213 for the ORIF group. The average total charge for management of a mandible fracture with CRF was $10,927; the total charge for the ORIF group was $34,636.

CONCLUSION

The results of this retrospective study suggest that the use of CRF in the management of mandibular fractures at our institution provides considerable savings over treatment by using ORIF. The use of ORIF should be reserved for patients and fracture types with specific indications.

Significance of laboratory findings for the diagnosis of neurosyphilis

Our objective is to assess the specificity and sensitivity, and thus elaborate the relevance, of different laboratory findings for the diagnosis of neurosyphilis. One hundred and fourteen HIV-negative pairs of serum and cerebrospinal fluid (CSF) samples were examined by the Venereal Disease Research Laboratory (VDRL) test, a fluorescent treponemal antibody-absorption (FTA-ABS) test, microhaemagglutination assay with Treponema pallidum antigen (MHA-TP) test (serum) and Treponema pallidum haemagglutination assay (TPHA) test (CSF); further, albumin, total protein, and total IgG were determined and, in the CSF, cell count was performed. The donors were 60 patients with active neurosyphilis and 54 healthy persons with a former history of syphilis and with persisting positive results in the T. pallidum haemagglutination tests (serum: MHA-TP, CSF: TPHA), who supplied specimens for control. Albumin quotient, IgG index, TPHA index, modified TPHA index, Intrathecally produced T. pallidum Antigen (ITpA) index, its 2 modifications and, in 12 samples, the adenovirus group antibody (AVGA)/TPHA index were ascertained. The specificity and sensitivity of the TPHA index were 100% and 98.3%, of the modified TPHA index 50.0% and 96.7%, of the ITpA index 42.6% and 90.0%, of the modified ITpA indices 51.8% and 68.3% (first modification) and 53.7% and 63.3% (second modification). The AVGA/TPHA index yielded a specificity of 91.7% (11/12). The CSF VDRL test was positive in 55/60 (91.7%) of samples from patients with neurosyphilis and in none of the controls (0/54). A CSF-TPHA titre greater than 1:320 was observed in 59/60 (98.3%) of the neurosyphilis specimens and in none of the controls (0/54). A TPHA index above an outcome of 70, a positive CSF-TPHA test at a titre greater than 1:320 and, with lower sensitivity, the criteria of the Centers for Disease Control (CDC) guidelines yield the most reliable results for laboratory support to a diagnosis of neurosyphilis. The modified TPHA index, the ITpA index, and its 2 modifications produce results of minor sensitivity and poor specificity. Observations on the AVGA/THPA index are too limited yet for judgement. The diagnostic significance of a CSF-TPHA titre above 320 needs further confirmation on a greater number of observations made by different laboratories.

Comparative evaluation of nine different enzyme-linked immunosorbent assays for determination of antibodies against Treponema pallidum in patients with primary syphilis

Nine different enzyme-linked immunosorbent assays (ELISAs) with a sonicate or recombinant proteins of Treponema pallidum as antigen have been evaluated comparatively by testing 52 highly selected sera from patients with primary syphilis, all negative in the microhemagglutination test for T. pallidum (MHA-TP). Eight tests exhibited greater sensitivity (48.5 to 76.9%) than the commonly used Venereal Disease Research Laboratory test (44.2%). Higher sensitivity could be related to (i) the volume and dilution of the serum, (ii) the design of the assay (capture and competitive tests showed higher sensitivity than sandwich-based assays), and (iii) the ability to detected specific immunoglobulin M antibodies. The specificity of the ICE Syphilis and the Enzygnost Syphilis tests was 99.5 and 99.8%, respectively, as determined by routine testing of 2, 053 unselected sera in comparison with the MHA-TP test. ELISAs tested offered high sensitivity in patients with primary syphilis; however, recommendations to use these tests as screening assays do need further data on specificity and reactivity in late stages of the disease.

Intraorbital squamous epithelial cyst: an unusual complication of Silastic implantation

Thin Silastic sheet alloplasts (Dow Corning, Midland, MI, U.S.A) are commonly used to reconstruct posttraumatic orbital floor defects. Complications associated with orbital Silastic implantation include infection, migration, and extrusion. The authors report an unusual case of an intraorbital, squamous, epithelial-lined cyst appearing as progressive vertical globe dystopia and proptosis occurring after Silastic reconstruction of a traumatic orbital floor defect.

The distribution of the auriculotemporal nerve around the temporomandibular joint

OBJECTIVE

The purpose of this cadaver dissection was to study the position of the auriculotemporal nerve in relation to the mandibular condyle, capsular tissues, articular fossa, and lateral pterygoid muscle and to evaluate the anatomic possibility of nerve impingement or irritation by the surrounding structures.

STUDY DESIGN

Eight cadaveric heads (16 sides) were dissected. The auriculotemporal nerve was identified by following its course around the middle meningeal artery. The course of the nerve trunk was dissected from the middle meningeal artery to the terminal branches within the temporomandibular disk. The horizontal distance between the auriculotemporal nerve and the medial portion of the condyle/condylar neck was measured. The vertical distance from the most superior portion of the articular condyle to the superior border of the auriculotemporal nerve was measured.

RESULTS

The auriculotemporal nerve was identified on each side, and a single trunk was evident along the medial aspect of the condylar neck. At the posterior border of the lateral pterygoid muscle, the nerve trunk was in direct contact with the condylar neck in every specimen. The average vertical distance between the superior condyle and the nerve was 7.06 mm (+/- 3.21 mm); the range was 0 to 13 mm. The vertical distance between the nerve and the superior condyle on one side of the specimen did not correlate with the distance on the contralateral side.

CONCLUSION

The auriculotemporal nerve trunk has a close anatomic relationship with the condyle and the temporomandibular joint capsular region, and there is evidence of a possible mechanism for sensory disturbances in the temporomandibular joint region. In all cases, the nerve was in direct contact with the medial aspect of the capsule or condylar neck. Because there is no correlation between the positions of the nerves on the right and left sides, only one side may be affected. The nerve was also observed to course in direct apposition to the lateral pterygoid muscle. The findings support the hypothesis that the anatomic and clinical relationship of the auriculotemporal nerve to the condyle, articular fossa, and lateral pterygoid muscle may be causally related to compression or irritation of the nerve, producing numbness or pain, or both, in the temporomandibular joint region.

The removal of plates and screws after Le Fort I osteotomy

PURPOSE

This study is a retrospective chart review designed to evaluate the incidence and reasons for removal of plates and screws after Le Fort I osteotomy.

PATIENTS AND METHODS

The study sample consisted of patients who underwent Le Fort I osteotomy at the University of California, San Francisco, and Northwestern University in Chicago between December 1985 and December 1994. All patients in the study were treated with internal fixation using 2.0-mm plates and screws. All data were obtained from medical records and operative reports. The following intraoperative variables were evaluated: hardware material, plate size and shape, plate location, screw size, graft material, and intraoperative complications. For patients requiring removal of hardware, the number, location and type of plates and screws removed were recorded, as well as the reasons for removal.

RESULTS

A total of 738 plates were placed in 190 patients. Twenty-one of the 190 patients (11.1%) had at least a portion of the hardware removed because they either requested removal or required removal secondary to complications related to the plate or screw. This represented 70 of 738 plates (9.5%). The percentage of titanium plates removed was greater than the percentage of Vitallium plates removed. The reasons for removal included pain, palpation by the patient, sinusitis, temperature sensitivity, infection, and patient request.

CONCLUSION

Only a small number of patients (10.6%) develop complications from plates or screws that required their removal. In each case, prompt removal constituted adequate management.

Comparison of full thickness skin graft "take" after excision with the carbon dioxide laser and scalpel

SPECIFIC AIM. To evaluate the take of skin grafts on conventionally prepared beds and on beds prepared by a carbon dioxide laser, with and without abrasion of the bed. SIGNIFICANCE. Graft take is dependent on hemostasis, immobility, and nutrition of the graft. Scalpel excision of the skin graft can be associated with hemostatic difficulties and laser treatment of the skin graft bed can provide hemostasis. Abrasion of the bed after laser treatment may then be a means of opening small lymphatic and blood vessels to maintain the graft. Laser treatment followed by abrasion of the bed may provide an ideal graft base before suturing of the skin graft. MATERIAL AND METHODS. Full-thickness skin grafts were taken with a scalpel at three sites on the dorsal skin of 24 guinea pigs. The three beds were prepared with pressure alone to provide hemostasis, laser vaporization followed by abrasion with gauze to produce pinpoint bleeding, and laser vaporization alone. The original skin from each of the sites was then sutured back in place. At postoperative days 1, 3, 5, 10, 21, and 35 the graft sites were assessed clinically for "take." Laser Doppler measurements were also made to evaluate blood flow. Histologic sections of the three sites were prepared. Immunohistochemical analysis was performed to evaluate cell proliferation and angiogenesis. RESULTS. For the animals sacrificed through day 10 the rate of take for the sites that were not lased was 100%. For the sites that were lased alone and lased and abraded the rate of take was 71% with no difference between the two techniques. The lased sites demonstrated increased inflammatory response and graft necrosis. Immunohistochemical analysis showed increased cellular proliferation and angiogenesis in the bed. DISCUSSION. Grafts take best on a scalpel-prepared bed. Laser preparation of the bed, with or without abrasion, demonstrates decreased "take." Therefore the carbon dioxide laser is not a recommended means to take a graft or prepare the graft bed.

PCR in laboratory diagnosis of human Borrelia burgdorferi infections

The laboratory diagnosis of Lyme borreliosis, the most prevalent vector-borne disease in the United States and endemic in parts of Europe and Asia, is currently based on serology with known limitations. Direct demonstration of Borrelia burgdorferi by culture may require weeks, while enzyme-linked immunosorbent assays for antigen detection often lack sensitivity. The development of the PCR has offered a new dimension in the diagnosis. Capable of amplifying minute amounts of DNA into billions of copies in just a few hours, PCR facilitates the sensitive and specific detection of DNA or RNA of pathogenic organisms. This review is restricted to applications of PCR methods in the diagnosis of human B. burgdorferi infections. In the first section, methodological aspects, e.g., sample preparation, target selection, primers and PCR methods, and detection and control of inhibition and contamination, are highlighted. In the second part, emphasis is placed on diagnostic aspects, where PCR results in patients with dermatological, neurological, joint, and ocular manifestations of the disease are discussed. Here, special attention is given to monitoring treatment efficacy by PCR tests. Last, specific guidelines on how to interpret PCR results, together with the advantages and limitations of these new techniques, are presented.

Diagnosis and management of root fractures and periodontal ligament injury

Although root fractures are among the less common oral injuries (6 percent), a careful diagnostic evaluation of such injuries is required to arrive at an appropriate treatment plan. The position of the fracture in the root will determine the proper management. The problem of luxation due to trauma often involves the use of dental splints, which, if not properly designed, may cause root resorption, loss of alveolar bone, pulpal necrosis and pulp canal obliteration. The guidelines for the type of splint to use and conditions under which it should be placed are presented.

Massive gingival enlargement and alveolar bone loss: report of two cases

We present two cases of massive gingival enlargement and osteolysis of alveolar bone in a 30-year-old female and a 36-year-old male. The etiology could not be established in either case. Histologically, both lesions contained hyperplastic fibrous connective tissue and intense plasma cell infiltrates. Both patients responded well to extensive gingivectomy, extraction of all teeth, and alveoplasty.

The presence of the antilingula and its relationship to the true lingula

20 cadaver mandibles were studied for the presence of an antilingula and its relationship to the true lingula and mandibular foramen. Three independent observers evaluated the mandibles for the presence of an antilingula. It could be identified on all 40 sides. On 9 of the sides, there was complete concordance on the position of the antilingula between the three observers. On the other 31 sides, however, there was a variation between observers of up to 11 mm. In only 43% of the cases was the antilingula within 5 mm of the true lingula. In most cases, the true lingula was postero-inferior to the antilingula. There was a negative horizontal and positive vertical correlation between the position of the antilingula on one side and its position on the contralateral side.

Detection of Borrelia burgdorferi DNA by polymerase chain reaction in the urine and breast milk of patients with Lyme borreliosis

Current laboratory diagnosis of Lyme borreliosis relies on tests for the detection of antibodies to Borrelia burgdorferi with known limitations. By using a simple extraction procedure for urine samples, B. burgdorferi DNA was amplified by a nested PCR with primers that target the specific part of the flagellin gene. To control possible inhibition of the enzyme (polymerase), a special assay using the same primers was developed. We examined 403 urine samples from 185 patients with skin manifestations of Lyme borreliosis. Before treatment, B. burgdorferi DNA was detected in 88 of 97 patients with Lyme borreliosis. After treatment, all but seven patients became nonreactive. Six of these seven persons suffered from intermittent migratory arthralgias or myalgias, and one from acrodermatitis chronica atrophicans. Two of 49 control patients with various dermatologic disorders and none out of 22 presumably healthy persons were reactive in the PCR. In addition to urine, breast milk from two lactating women with erythema migrans was tested and also found reactive. Borrelia burgdorferi DNA can be detected with high sensitivity (91%) by a nested PCR in urine of patients with Lyme borreliosis. In addition, this test can be a reliable marker for the efficacy of treatment.

[Specific IgM tests in syphilis diagnosis]

A total of 359 sera of untreated patients with syphilis were examined by three methods for the detection of Treponema pallidum specific IgM antibodies, the 19S-IgM-FTA-ABS test, the IgM solid phase haemadsorption assay (IgM-SPHA), and the IgM Captia assay. The results were compared and evaluated. In primary syphilis, the 19S-IgM-FTA-ABS and IgM-captia yielded reactive results in all patients, whereas only 40% were positive in the IgM-SPHA; the corresponding values for early latent syphilis wee 96.0%, 89.8% and 73.1%, respectively. In secondary syphilis, the reactivity of one serum out of 27 was missed by IgM captia and that of another, by the IgM-SPHA. Mean values (ELISA units = extinction/cut-off) of IgM-captia were higher in primary (2.25) than in secondary syphilis (1.70). In neurosyphilis, only the IgM-SPHA test detected reactivity in all sera, sensitivity for 19S-IgM FTA-ABS and IgM-Captia was 50.0% and 23.1%, respectively. Specificity of the IgM-Captia test results, determined in 386 sera, was 91.2%. The results of specific IgM tests are essential in the diagnosis of congenital syphilis as well as in the recognition of reinfection; they indicate the need for treatment and are useful in the assessment of the effectiveness of therapy.

Anatomic evaluation of anterior platysma muscle

The structure of the submental platysma muscle was evaluated in 20 preserved cadavers. Four distinct patterns were identified, depending on the pattern of merging of the right and left platysma bundles. Fifteen percent of cases showed a complete platysma diaphragm submentally, while in the other 85% there was some degree of midline dehiscence. In the 85% of cases where right and left fibers merged or crossed to form a V or U shape, the apex of the V or U was measured relative to the chin point. The distance between right and left fibers was measured at two locations posterior to the chin point. The width of the midline dehiscence (when present) was 6-24 mm (mean 11.8 mm) 1 cm posterior to its apex and 10-44 mm (mean 20.00 mm) 2 cm posterior to the apex. The wider and more divergent the dehiscence and the more U-shaped the dehiscence between left and right platysma bundles, the greater may be the tendency to a "turkey gobbler" deformity with inadequate medial support for the skin and subcutaneous tissues.

[Detection of causal agents of AIDS using polymerase chain reaction and chemiluminescence measurement]

The polymerase chain reaction (PCR) allows the detection of minimal amounts of DNA segments, and thus is used for the laboratory diagnosis of HIV (human immunodeficiency virus). In the present study a solution hybridization assay using acridinium ester-labelled probes was applied for detection of amplified HIV-1 DNA segments. Amplification was achieved by 30 cycles of the polymerase chain reaction using SK38/SK39 primers specific for a constant region of the HIV-1 gag region. Amplified products were hybridized with acridinium phenyl ester-labelled probes and measured by chemiluminescence. All of 163 blood samples obtained from HIV-infected patients (CDC II-CDC IV) were reactive, while autoradiography with a 32P-labelled SK19 probe only detected 146 patients (89.5%). The combination of PCR with chemiluminescence avoids the use of radioactive material and is sensitive and quick, allowing the "PCR results" to be reported on the same day.

A rapid chemiluminescence detection method for PCR-amplified HIV-1 DNA

A solution hybridization assay using acridinium ester labelled probes is described for detection of amplified HIV-1 DNA segments. Amplification was achieved by 30 cycles of the polymerase chain reaction using SK38/SK39 primers specific for a constant region of the HIV-1 gag region together with HLA DQ alpha primers as internal control. Discrimination between hybridized and non-hybridized probes by differential hydrolysis resulted in a three log reduction of the chemiluminescence signal of the non-hybridized probe within 6 min without significant changes in the hybridized probes due to protection of the acridinium ester to hydrolysis by intercalation formation. Chemiluminescence was measured by a two-step-injection method with hydrogen-peroxide and NaOH. About 50 attomols of HIV-1 gag DNA could be detected. Chemiluminescence results, given in relative light units (RLU) of 159 HIV-1-infected patients (range 4013-458319) showed clear discrimination from 64 noninfected control samples (range 838-1477) (cut off 2000 RLU). Comparison with parallel detection of amplified products with autoradiography (32P) and ethidium bromide-stained agarose gels or a p24 antigen ELISA demonstrated better sensitivity and reproducibility of the chemiluminescence assay. The time required for the assay, including measurements, is less than 30 min, which allows reporting 'PCR results' on the same day.

[Detection of HIV infection by serologic procedures]

We briefly describe the principal techniques of antigen detection and discuss the pros and cons of routine screening and conformation assays. Regarding the differentiation of HIV 1 and HIV 2 infection, synthetic peptides corresponding to the antigenic epitopes of gp36 (HIV 2) and gp41 (HIV 1) yielded the best results. Commercially available antigen tests are relatively insensitive. New techniques, such as the polymerase chain reaction, allow the dedection of viral DNA in one infected cell out of 100,000 non-infected cells. However, since these methods are based on nucleic acid probes, they are rather laborious and cannot replace antibody tests; but they may be of use for early identification of HIV-infected infants or for the confirmation of the acute phase of the infection (CDCI). With regard to early prognosis--i.e. up to 2 years before the development of clinical symptoms__the following markers have been found useful: neopterine, beta-2-microglobulin, the lymphocyte subsets CD4, CD8, Leu2+7+, activated T-cells, as well as the decrease of antibodies against p31, p24 and p17.

[Serology of HIV infection]

Serological testing aimed at the detection of antibodies against the human immunodeficiency virus (HIV) is now performed throughout the world to screen stored blood for transfusion, for the diagnosis of HIV infection and of AIDS, and to determine the prognosis of AIDS patients. The present report, based on 258,090 serum samples screened for HIV antibodies, gives an overview of the theoretical and practical aspects of both modern screening methods and confirmation tests for HIV1 and HIV2, the demonstration of serological antigen and IgM, and HIV serology of the cerebrospinal fluid. Knowledge of HIV serology appears to be important for any physician, and in particular for the dermatologist, since HIV infection (like syphilis) can cause a variety of dermatological manifestations mimicking other dermatoses.

[AIDS diagnosis: virus detection, antibody detection, diagnostic and prognostic significance of the findings]

AIDS serology is of worldwide importance for the diagnosis of HIV-infection and AIDS, for conducting epidemiological studies, for the control of blood donations and blood products and for the determination of infectivity and prognosis in AIDS patients. In future serological methods may be of importance for the management of anti-HIV-therapy. Screening methods, such as ELISA and hemagglutination assays and confirmatory tests (Western blot and immunofluorescence) nowadays offer clear cut and reliable results. Discussions on the "AIDS-tests" in the past have not been free from emotions; from the medical standpoint, however, it is for sure that the affected patient should know about his infection, in order to protect himself as well as others. The physician must know the HIV-status of his patient, in case major diagnostic or therapeutic measures, such as operations are to be performed or drugs are going to be prescribed, which may influence the immune system. The present paper describes the AIDS serologic methods based upon 197.956 tests performed in our laboratories, HIV-IgM-diagnostic methods, HIV-status in the cerebrospinal fluid and the serologic diagnosis of HIV 2-infection are discussed. In future the serologic control and the serologic prognosis parameters will gain major importance for monitoring AIDS-patients before and under treatment. This paper describes the methods (virus specific antibody tests; tests for the demonstration of immune system activation; immunstatus) which might be used for this purpose.

[Serology in HIV infection: comparison of indirect immunofluorescence, Western blot and enzyme immunoassay]

145.990 sera obtained from AIDS-risks groups, hospitalized patients, blood donors etc. were tested for the presence of antibodies against the AIDS-Virus (HIV:Human Immunodeficiency Virus). All sera were submitted to ELISA screening. Sera with positive and questionable results were submitted to two independent confirmatory tests (Western Blot and immunofluorescence). In case of discordant confirmatory tests sera were additionally tested with the Abbott anti-HIV envelope/anti HIV core ELISA. The results of the present study demonstrate: 1. HIV serology has been definitely improved during the last year due to the development of high quality reagents. 2. Provided skilled and trained personnel the combined use of HIV confirmatory tests (Western Blot and immunofluorescence) does not give false negative or false positive results. 3. The results of both confirmatory assays may not always be interpretable ("problem sera"); this occurs more often with the Western Blot technique than with immunofluorescence. 4. Discrepant results in confirmatory tests necessitate the evaluation of many additional tests as possible. Such persons or patient should be further controlled serologically and clinically. 5. Checking the "problem sera" for antibodies against HTLV I gave only one single positive result in a Japanese.

Diagnosis of Chlamydia trachomatis infection--culture versus serology

The diagnostic value of different laboratory methods in detecting Chlamydia trachomatis infections in high risk groups was analysed. The efficiency of a direct specimen test was compared with serology (IgG and IgM ELISA) and culture in L929 cells, stained either with fluorescein conjugated monoclonal antibodies or with iodine. Patients (no. = 1041) with localized genital infections attending a STD clinic, sexual contacts and patients with ascending infections from urological and gynecological clinics were examined. Chlamydia trachomatis was detected in 225 patients: 210 (93.3%) were reactive in the direct test (smears stained with monoclonal antibodies), whereas culture missed only 5 (sensitivity 97.8%) when stained by the same method. Cultures stained with iodine produced the lowest recovery rate (73.8%), but this rate increased to 80.9% when a second passage was performed. In addition the prevalence of Neisseria gonorrhoeae, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans and Trichomonas vaginalis was investigated. In patients with non-gonococcal urethritis (no. = 331) and cervicitis (no. = 353), Chlamydia trachomatis was isolated in 32.3% and 12.8% respectively. However, this pathogen could be isolated in only 3 (15.8%) out of 19 patients with epididymitis and 15 (14%) out of 107 patients with adnexitis, although 66.7% and 93.3% respectively had specific IgG antibodies. Specific IgM could by detected with a sandwich ELISA in patients with adnexitis (46.7%), epididymitis (33.3%), cervicitis (22.2%), non-gonococcal urethritis (14%) and in the sexual partners of patients with genital infections (35.7%). The direct specimen test with monoclonal antibodies is the method of choice for the diagnosis of a C. trachomatis infection in patients with urethritis and cervicitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[HIV (HTLV III/LAV) serology: experiences based on more than 42,000 tests]

1,032 sera of diverse origin (AIDS risk groups, prostitutes, inpatients, blood donors) exhibiting a positive HIV (HTLV III/LAV) ELISA result (Organon and/or Abbott) were investigated with different HIV confirmation assays (Western blot, WB; immunofluorescence, IF; competitive enzyme immunoassay against cloned gp41- and p24-antigen). Sera were finally evaluated as positive if at least two confirmation assays turned out positive (IF and WB; IF and p24, gp41; WB and p24, gp41; IF and WB and p24, gp41). Test results were considered false if the respective finding (IF or WB or p24, gp41) differed from two other confirmatory assays. 1,001 out of 1,032 sera (97%) yielded corresponding results in IF and WB. The remaining 3% of the investigated sera showed false positive, false negative, non-interpretable IF results and non-interpretable WB findings. The present study demonstrates that a positive HIV test should be confirmed by at least two confirmatory tests, one of which should be the WB. Non-corresponding results in confirmatory tests necessitate a third test system.

[Diagnosis of Chlamydia infections]

Tissue culture for Chlamydiae requires facilities that are not generally available, are costly and require 3 to 7 days for completion. With the introduction of specific monoclonal antibodies Chlamydia trachomatis can be recognized within 30 minutes. Therefore the direct specimen test should be performed as the method of choice. In complicated, ascending forms of the disease requiring special methods for sample collection (e.g. laparoscopy), serology may aid in the diagnosis of a Chlamydia trachomatis infection.

[Molecular biology of human T-lymphotropic retroviruses (HTLV)]

The first human retroviruses have been discovered during the past seven years. They cause two diseases which involve disturbances of the growth of the T4-lymphocyte. This target cell type, which is central to the regulation of the immune system is induced by human T-lymphotropic virus type I (HTLV-I) to excessive proliferation (leukaemia) and by HTLV-III/LAV (lymphadenopathy associated virus) to premature death (acquired immune deficiency syndrome [AIDS]). Both also seem to be indirectly involved in several other disorders. The genetic structures of these retroviruses and the mechanisms by which they usurp host-cell functions are novel among retroviruses. The continuous increase in the number of AIDS cases for whom no effective therapy is currently possible mandates attempts at developing primary prevention by a vaccine. Based on past attempts at developing vaccines against retroviruses, the most feasible configuration will be the glycoprotein linked to its transmembrane protein. Any virus preparation containing nucleic acids could be considered less safe. Potential problems exist in that there is extensive heterogeneity among various HTLV-III isolates, particularly in the env-gene. This fact and the known relationship of HTLV-III to some Lentiviruses suggest that functional antigenic variation could be encountered. The methodology of developing a vaccine against the retroviruses causing AIDS should also be helpful in designing vaccine strategies against human leukaemia and lymphomas caused by other members of this virus family.

[The enzyme-linked immunosorbent assay technic in syphilis serology (report on experiences)]

A serological study with an enzyme-linked immunosorbent assay using the axial filament of Treponema phagedenis biotype Reiter as antigen was performed on 1899 sera to evaluate the sensitivity and specificity. The sensitivity as compared with the fluorescent treponemal antibody-absorption test (FTA-ABS) and the automated microhaemagglutination assay with Treponema pallidum antigen ( AMHA -TP) was 94.6% and 93.1%, respectively. The specificity was 98.5% compared to both assays. Furthermore, preliminary results for the determination of IgM antibodies with the same antigen are presented. All procedures including dispensing, washing, optical reading and evaluation of results were performed automatically using a newly-developed ELISA processor connected with an electronic surveillance and control device.

[Specificity and sensitivity of the solid phase hemadsorption test: a study of treated and untreated syphilitics]

SPHA-test was performed on 317 treated and 78 untreated patients with syphilis and partly compared to 19S-IgM-FTA-ABS- as well as VDRL-test. Equivalent results were obtained in a reference laboratory, the correspondence being 94.8 percent regarding SPHA and 95.6 percent concerning 19S-IgM-FTA-ABS. In comparison to 19S-IgM-FTA-ABS, increased numbers of weakly reactive values occurred in SPHA correlating with the Latex-test. Because of its specificity and sensitiveness, SPHA turned out to be superior to VDRL with regard to the control of treatment. The biological significance of weakly reactive SPHA results is still unclear and does not indicate a necessity for therapy.

[Recent progress in syphilis serology]

Serological investigations for the diagnosis of syphilis have been performed in a special subunit at the Department of Dermatology to Lainz Hospital, Vienna, since 70 years. At present 80,000 to 100,000 sera are tested annually. The classical test systems VDRL, TPHA, AMHA-TP and FTA-ABS demonstrate, in particular, the presence of IgG antibodies and are, thus, suitable for the diagnosis of the disease, but do not permit conclusions on the activity of the disease and the actual need for antisyphilitic treatment. The newly developed IgM diagnosis of syphilis with the IgM-SPHA- and the 19S-IgM-FTA-ABS test solve these problems and can be performed even under routine conditions using the methods of solid phase haemadsorption and computerized high pressure liquid chromatography. In addition, the serological diagnosis of neurosyphilis has been worked out by the determination of the TPHA-index and the detection of antitreponemal IgM-antibodies in the cerebrospinal fluid. The relative frequency of latent syphilis infections has increased over the past years and serodiagnosis of syphilis, thus, become more and more important. The availability of five independent test systems has enabled the elaboration of a test profile which keeps the margin of error to below 0.1%. A further method, the ELISA technique is at present under investigation and renders promising results by the use of recently developed reagents.