[Sandwich osteotomy--a biologic method for vertical augmentation of edentulous alveolar ridges]

Vertical augmentation for rehabilitation with dental implants poses a clinical challenge. The surgical obstacles have been extensively documented within the literature. Outcomes of the multiple methods available are not predictable, and overall success rates are sub-optimal. This paper presents the Sandwich Osteotomy Technique (interpositional rhBMP-2 and bone subtitute grafting) in a young female with congenital oligodontia. The uniqueness of this method, like in distraction osteogenesis, is that the segmental bone remains attached to the mucoperiosteal flap and thus the blood supply is maintained. Bone graft or substitute is introduced into the interpositional space that was created. Advantages of Sandwich Osteotomy are minimal bone exposure, good blood supply, no need for donor bone graft and minimal overall morbidity. Limitations of the technique are soft tissue stretching, gingival fibrosis, and high technical demand. According to our experience with this surgical method, vertical augmentation is stable up to 8 mm. Beyond this height approximately 10% bone resorption was noticed.

Unusual presentation of B-cell lymphoma as a cutaneous abscess

Cutaneous abscesses can result from many conditions and are primarily managed with incision, drainage and antibiotics, without the need for extensive diagnostic workup. We herein report a case of a B-cell lymphoma manifesting as an abscess on the back of a 67-year-old female. Standard therapies failed to improve her condition, and, by the time of tissue diagnosis, a greater than palm-sized necrotic ulcer eroding through skin and fat, and into the psoas muscle had developed. Primary or secondary cutaneous B-cell lymphomas almost never lead to tissue necrosis but should be entertained in cases of abscesses or ulcers with unusual presentation.

Syphilis

In the last half of the 20(th) century, medicine has made tremendous inroads against syphilis chiefly owing to the introduction of penicillin and vigorous public health initiatives. Yet, the world continues to be burdened by this disease. Since 2000, overall rates of syphilis have risen in the US and throughout the world. Furthermore, through its association with an increased risk of HIV infection, syphilis has acquired a new potential for morbidity and mortality. The aim of this review is to survey the latest knowledge about syphilis, including pathogenesis and host response, clinical manifestations, diagnostic methods and, especially, treatment and follow-up.

Patients' perceptions of recovery after surgical exposure of impacted maxillary teeth treated with an open-eruption surgical-orthodontic technique

This study assessed patient perceptions of immediate post-operative recovery after the surgical exposure of impacted maxillary teeth with an open-eruption technique. Thirty patients (24 females and six males) underwent surgical exposure of 39 impacted maxillary teeth using this technique. After surgery the patients were contacted by telephone daily for 7 days, to complete a health-related quality of life (HRQOL) questionnaire, which assessed their perception of recovery in four main areas: pain, oral function, general activity, and other symptoms. Severe pain was reported by 30 per cent of the patients in the first post-operative day (POD 1), which declined to 6.7 per cent by POD 6. Consumption of analgesics declined gradually over the post-operative days (POD 1: 80 per cent, POD 7: 20 per cent). Difficulty in eating required 5 days to reach minimal levels; enjoying everyday food, 2.5 days; school attendance, limitations in daily routine, swallowing, and speech, 2 days each; swelling, bad taste/smell, 1.5 days each; within 1 day all other measures attained minimal levels. The need for bone removal during the exposure resulted in delayed recovery with regard to the ability to eat. In general, females reported delayed recovery for pain. The present data may serve as basic guidelines against which future studies which assess post-operative management of patients after surgical exposure of impacted teeth by an open-eruption technique may be compared.

[Maxillofacial gunshot injuries in hostility activities in 2000-2003]

The management of facial gunshot wounded patients requires the coordination of multiple surgical disciplines to optimize the functional and cosmetic outcome while minimizing overall morbidity and mortality. All reports indicate that early management of these patients must focus on the basis of resuscitation, with major attention given to the status of maintaining the airway, hemostasis and hemodynamic resuscitation. Subsequent management of these patients becomes more controversial in terms of surgical reconstruction: immediate or delayed. Involvement of the use of suicide bombers, the type of weapons used in the last 2 years were different than previously described. The injuries were inflicted by explosives mixed with nails bolts and stones, which caused different kinds of wounds ever described. Numerous series in the literature advocate early aggressive intervention of one-stage reconstruction of all involved structures. However, several series published in the literature favor a more conservative approach, some of them even advocating non-operative management of these injuries. We concluded that a delay in final reconstruction of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk. A carefully planned reconstruction schedule is required to achieve satisfactory function and appearance. It is our purpose in this report to indicate the difference of the gunshot wounds in the last 2 years of the hostilities in this part of the world and emphasize the function of the Oral & Maxillofacial Surgeons in treating these patients.

[The overlooked chin trauma in children]

Children seldom experience major facial trauma. However, minor injuries such as facial lacerations, abrasions and dental trauma are more common and naturally get less attention. Children with TMJ trauma usually present with pain, limited jaw movement and even malocclusion. However, these findings are not always recognized and sometimes get overlooked when chin laceration is the only sign. Plain x-rays can contribute to the diagnosis but in many cases are inconclusive and are difficult to interpret. Often, there is a diagnostic dilemma, especially when the clinical findings are not clear and normal occlusion is hard to restore. We present 3 out of 12 children in whom we diagnosed condylar head fracture following minor facial trauma. All children had normal physiological occlusion. Most of them had mild clinical signs such as limited mouth opening, pain and tenderness upon palpation of the joint. Routine plain films were not conclusive. The diagnosis was made or confirmed with CT scan. Early diagnosis of TMJ fracture in children is mandatory for the prevention of long term functional and esthetically debilitating sequela.

CONCLUSION

A thorough clinical examination and normal occlusion do not rule out condylar head fracture after chin trauma. Plain films are of limited value in the diagnosis of such fractures. CT should be considered for the evaluation of these children.

Clinical, histological, and immunophenotypic characteristics of injection site reactions associated with etanercept: a recombinant tumor necrosis factor alpha receptor: Fc fusion protein

OBJECTIVE

To study injection site reactions (ISRs) associated with etanercept therapy.

DESIGN

Retrospective chart review, along with prospective analysis of selected patients experiencing ISRs associated with etanercept therapy.

SETTING

Academic rheumatology/immunology unit and dermatology clinic.

SUBJECTS

Patients with rheumatoid arthritis, juvenile rheumatoid arthritis, inflammatory seronegative arthritis, psoriatic arthritis, psoriasis, or inflammatory bowel disease.

INTERVENTIONS

Skin biopsy specimens were taken from selected patients experiencing ISRs.

MAIN OUTCOME MEASURES

Incidence of IRSs and histological and immunophenotypic analysis of ISRs in 3 patients undergoing prospective study.

RESULTS

Twenty-one (20%) of 103 of all patients receiving etanercept reported ISRs, all within the first 2 months of inception of therapy. The reactions occurred 1 to 2 days after the last injection and resolved within a few days. Moreover, eventual waning of reactions was observed, with none proving to be dose limiting. Histological examination of all biopsy specimens showed an inflammatory infiltrate composed of predominantly lymphoid cells and some eosinophils, in a perivascular cuffing pattern, without evidence of leukocytoclastic vasculitis. The infiltrating lymphoid cells were predominantly activated mature (HLA-DR(+)/CD3(+)/CD4(-)/CD8(+)) cytotoxic T lymphocytes, with a small number of CD4(+) cells. A biopsy specimen from a recall ISR showed strong HLA-DR expression by epidermal keratinocytes.

CONCLUSIONS

Injection site reactions associated with etanercept therapy are common, and may be an example of a T-lymphocyte-mediated delayed-type hypersensitivity reaction, with waning over time due to eventual induction of tolerance.

Correlation of intact sensibility and neuropathic pain-related behaviors in eight inbred and outbred rat strains and selection lines

In some rat strains, total hindpaw denervation triggers autotomy, a behavior of self mutilation presumably related to neuropathic pain. Partial sciatic ligation (PSL) in rats produces tactile allodynia and heat hyperalgesia but not autotomy. Our aims in this study were to examine: (1) whether sensibility of intact rats to noxious and non-noxious stimuli is strain-dependent; (2) whether sensibility of intact rats could predict levels of autotomy, or of allodynia and hyperalgesia in the PSL model; and (3) whether autotomy levels are correlated with levels of allodynia or hyperalgesia. Here we report that in two inbred rat strains (Lewis and Fisher 344), two outbred rat strains (Sabra and Sprague-Dawley) and four selection lines of rats (Genetically Epilepsy-Prone Rats, High Autotomy, Low Autotomy and Flinders Sensitive Line), tactile sensitivity and response duration to noxious heat of intact animals were strain-dependent. Levels of autotomy following hindpaw denervation and of allodynia and hyperalgesia in the PSL model were also strain-dependent. Thus, these traits are determined in part by genetic factors. Sensory sensibility of intact rats was not correlated with levels of autotomy following total denervation, or allodynia and hyperalgesia following partial denervation. We suggest that preoperative sensibility of intact rats is not a predictor of levels of neuropathic disorders following nerve injury. Likewise, no correlation was found between autotomy, allodynia and hyperalgesia, suggesting that neuropathic pain behaviors triggered by nerve injury of different etiologies are mediated by differing mechanisms.

c-Src signaling induced by the adapters Sin and Cas is mediated by Rap1 GTPase

Oncogenic Src proteins have been extensively studied to gain insight into the signaling mechanisms of Src. To better understand signaling through wild-type Src, we used an approach that involves activation of Src signaling through the binding of physiologic ligands to the Src SH3 domain. To this end, we used full-length and truncated versions of the multiadapter molecules Cas and Sin to activate c-Src, and we examined the intracellular pathways that mediate Src signaling under these conditions. We show that although all proteins bind to and are phosphorylated by c-Src, quantitative differences exist in the ability of the different ligands to activate c-Src signaling. In addition, we show that Sin- and Cas-induced Src signaling, as assayed by transcriptional activation, is exclusively mediated through a pathway that involves the adapter Crk and the GTP-binding protein Rap1. These data are in contrast to previous observations showing Ras to mediate signaling downstream of transforming Src alleles. In our system, we found that signaling through the oncogenic SrcY527 mutant is indeed mediated by Ras. In addition, we found that Rap1 also mediates oncogenic Src signaling. Our results show for the first time that Rap1 mediates c-Src kinase signaling and reveal mechanistic differences in the signaling properties of wild-type and transforming Src proteins.

Safe orthodontic bonding for children with disabilities during general anaesthesia

General anaesthesia (GA) may be employed to overcome management difficulties in the orthodontic treatment of disabled children. This report introduces the application of a rubber dam as a useful aid for a high quality bonding and as an effective safeguard in bonding of brackets in general anaesthesia, in the handicapped in particular. GA was used in 12 patients, of a cohort of 49 disabled patients, to facilitate the placing of the fixed appliance. The first seven were bonded solely with the use of an oropharyngeal pack and a high velocity suction to prevent aspiration, and the last five additionally underwent placement of a rubber dam. The use of a rubber dam to facilitate the safe and reliable bonding of orthodontic brackets in handicapped children under general anaesthesia is highly recommended.

Accessory parotid gland masses

Three cases of accessory parotid gland lesions are reported. The literature concerning accessory gland disease and its diagnosis and treatment is reviewed.

Preoperative open field behavior predicts levels of neuropathic pain-related behavior in mice

Exploratory open field (OF) activity was assessed in seven different mouse strains and selection lines. We counted the number of beam interruptions made by three cagemate mice at a time. This assay tests reactivity to aversive stimuli, anxiety and emotionality. One hindlimb was then totally denervated by transecting the sciatic and saphenous nerves on one side, and autotomy, a behavior thought to be related to neuropathic pain, was quantified over 35 days. We report that OF activity and autotomy are highly variable across different strains/lines. These results reaffirm the genetic control of these behaviors. We also found that these behaviors are inversely and significantly correlated. We suggest that common genetically-determined neural mechanisms may underlie anxiety, emotionality and neuropathic pain in mice.

Ehlers-Danlos syndrome, fibromyalgia and temporomandibular disorder: report of an unusual combination

An unusual case of temporomandibular disorder in the presence of both fibromyalgia and Ehlers-Danlos syndrome is presented. Some of the problems in treating these patients are discussed. It is suggested that early conservative treatment of the temporomandibular disorder with a stabilization splint and physical therapy is effective, and this approach should be attempted before any surgical intervention is chosen.

The condylar asymmetry-age relationship in determining myogenous or arthrogenous origin of pain in patients with temporomandibular disorders

The relation of age to asymmetry index of the condyles of the temporomandibular joint differs for groups of patients with a myogenous and arthrogenous origin of pain. It was decided to investigate if this has clinical diagnostic significance. Twenty-eight patients complaining of temporomandibular disorders (TMD) were included in this study. All were dentate with a maximum of five missing teeth including third molars allowed. Condylar asymmetry was measured according to the method of Habets, and this was used to compute the expected patient age for both curves. The patient was assigned to the group with computed age closest to true age. The association between category derived from graphs and that from clinical diagnosis was studied. There was agreement clinically and graphically in 25 of 28 patients. The Kappa statistic to explore the agreement between the two methods gave a value of 0.78, which allows rejection of the hypothesis that agreement was based on chance alone.

Multiple mechanisms may contribute to the cellular anti-adhesive effects of phosphorothioate oligodeoxynucleotides

Phosphorothioate oligodeoxynucleotides complementary to the p65 (Rel A) subunit of the NF-kappaB nuclear transcriptional regulatory factor have been suggested to be sequence specific blockers of cellular adhesion. We studied the effects of Rel A antisense, Rel A sense and other phosphorothioate oligodeoxynucleotides on cellular adhesion and found that blockade of adhesion was predominately non-sequence specific. Phosphorothioate oligodeoxynucleotides bind to the extracellular matrix (ECM) of NIH 3T3 cells, and to the ECM elements laminin and fibronectin. By use of a gel mobility shift assay, the association of the A subunit of laminin with a probe 12mer phosphodiester oligodeoxynucleotide could be demonstrated. This interaction was described by a single-site binding equation (K d = 14 microM). Human Rel A antisense and sense oligodeoxynucleotides, and two synthetic persulfated heparin analogs were excellent competitors of the binding of the probe oligodeoxynucleotide to laminin. Taken together, these data indicate that oligodeoxynucleotide binding occurred at or near the heparin-binding site. Competition for 5' 32p- SdT18 (an 18mer phosphorothioate homopolymer of thymidine) binding to fibronectin with the discrete heparin analogs, as well as with SdC28, was also observed. Phosphorothioate oligodeoxynucleotides (Rel A antisense >> Rel A sense) inhibited the binding of laminin to bovine brain sulfatide, but not to its cell surface receptors on MCF-7 cells. By flow cytometric analysis we have also shown, in contrast to what was observed with laminin, that phosphorothioates a non-specifically block the specific binding of fluoresceinated fibronectin to its cell surface receptors on phorbol-12,13-myristate acetate treated Jurkat cells. Blockade of specific binding occurred in the oligodeoxynucleotide treated cells in the presence or absence of oligomer in the media.

Binding of phosphorothioate oligodeoxynucleotides to basic fibroblast growth factor, recombinant soluble CD4, laminin and fibronectin is P-chirality independent

Antisense oligodeoxynucleotides can selectively inhibit the expression of individual genes and thus have potential applications in anticancer and antiviral therapy. A critical prerequisite to their use as therapeutic agents is the understanding of their non-specific interactions with biological structures, e.g. proteins. In this study we examined the interactions of P-chiral phosphorothioate oligodeoxynucleotides with several proteins. The Rp- and Sp- diastereomers, and racemic machine-made mixtures, or M-oligodeoxynucleotides were used independently as competitors of the binding of a probe, phosphodiester oligodeoxynucleotide bearing a 5' alkylating moiety, to rsCD4, bFGF and laminin. These oligodeoxynucleotides were also used as competitors of the binding of a non-alkylating probe M-phosphorothioate oligodeoxynucleotide, 5'-32P-SdT18 to fibronectin. The average values of and quantitative estimates for the IC50 of competition and the constant of competition (Kc) of Rp-, Sp- and M-stereoisomers of several homo- and heteropolymer oligodeoxynucleotides were determined and compared. Surprisingly, in the proteins we studied, the values of IC50 and Kc for the Rp-, Sp- and M-oligodeoxynucleotides were essentially identical. Thus, the ability of the phosphorothioate oligodeoxynucleotides we employed, to bind to the proteins studied in this work, is virtually independent of P-chirality. Our results also imply that the role of the purine and pyrimidine bases in oligodeoxynucleotide-protein interactions, as well as the nature of the contact points (sulfur versus oxygen) between the oligomer and the protein, may be relatively unimportant.

Pathoses of coronoid process as a cause of mouth-opening restrictions

The mandible coronoid process is another site subject to various pathoses that may result in limited jaw movement. Six different pathoses that prevented the free rotation of the coronoid are presented. Differential diagnosis and treatment approach are emphasized.

Lip carcinoma in renal allograft recipient with long-term immunosuppressive therapy

Five years after a kidney transplant and immunosuppressive therapy a 42-year-old woman had squamous cell carcinoma of the lower lip with an innocent appearance. We present this as the first case of lip squamous cell carcinoma in a kidney transplant recipient to be reported in the dental literature. We review the medical literature.

Suppression of neuropathic pain behavior in rats by a non-psychotropic synthetic cannabinoid with NMDA receptor-blocking properties

HU211 is a novel synthetic derivative of tetrahydro-cannabinol (THC), the active marijuana ingredient. The stereochemistry of HU211 is enantiomeric to that of THC. In contrast to THC, HU211 is not psychotropic. This agent exhibits other types of biological activities; it is a non-competitive NMDA receptor blocker and has antinociceptive activity when injected with cupric chloride. This study examined its effects in autotomy, a behavioral model of neuropathic pain. Autotomy, a behavior of self-mutilation of denervated areas, was induced in Sabra rats by cutting the sciatic and saphenous nerves. We found that injections of HU211 (2.5 mg/kg) with cupric chloride (0.8 mg/kg) every 2nd day markedly suppressed autotomy during the injection period by delaying its average onset day and reducing the incidence of severe autotomy. Moreover, suppression of autotomy was retained in the postinjection period (for at least 30 days) but only when the drug was injected intraperitoneally. Lesser effects were achieved by subcutaneous injections. Cupric chloride or HU211 alone were ineffective. The general behavior and open field motor activity indicated that the effects of HU211 with Cu++ on autotomy were not due to sedation or ataxia but presumably due to antinociception mediated by NMDA receptor blockade.

AIDS and oropharyngeal candidiasis

Oropharyngeal candidiasis occurred in a previously healthy young Israeli homosexual male. Additional symptoms included persistent diarrhea, weight loss, fever, generalized lymphadenopathy and peripheral neuropathy. Immunologic studies revealed lymphopenia with reversed T-helper/T-suppressor cells ratio and antibodies to human immunodeficiency virus, all compatible with the diagnosis of subclinical AIDS. Repeated courses of antimonilial treatment failed to eradicate the oropharyngeal lesions. The clinical picture of AIDS, particularly its oral manifestations, is described. The diagnostic and prognostic implications of oropharyngeal candidiasis as a presenting sign of the disease are discussed. In addition, precautionary measures that should be taken when treating persons infected with HIV are described.

Oral clinicopathologic manifestations in maple syrup urine disease

Maple syrup urine disease is a rare inborn error of metabolism that manifests mainly by neurologic deterioration, coma, and death in early childhood. Oral manifestations described in this article were mostly gingival enlargement and rampant caries, while histopathologic findings revealed a picture compatible osteomyelitis.

Synovial chondromatosis of the temporomandibular joint. Review of the literature and case report

Synovial chondromatosis is an uncommon, benign condition of unknown etiology which affects articular joints. Foci of cartilage develop through metaplasia in the underlying connective tissue of the synovial membrane. These foci of cartilage enlarge with time into cartilage fragments, and may be detached from the affected synovium and released into the joint cavity. These cartilaginous foci and fragments may undergo calcification and ossification. The literature is reviewed and an additional case reported.