Periodontal Ligament Visibility (PLV): validation of PLV to determine adult status

BACKGROUND

Gradual obliteration of the Periodontal Ligament Visibility (PLV) of lower third molars indicates increasing age. This is used to help determine whether or not an age disputed subject is above or below the 18 year threshold.

AIM

The main focus was to determine, in test subjects of known age, whether the PLV system used 'blind' is able to reliably indicate whether the subject was a child (age < 18 years) or adult (age > 18).

MATERIALS AND METHODS

A total of 250 normal subjects in the age range 16 to 26 years, from the archives of Guy's Hospital in London, UK, were used to validate the system of PLV. The radiographic assessment of PLV1 was used to categorize four grades of PLV.

RESULTS

It was found that for both females and males PLV-C and PLV-D gave very high probabilities (p = 1.000) of the test subjects being of adult status.

CONCLUSION

Periodontal Ligament Visibility has the potential to play an important part in the assessment of age disputed asylum seekers who look adult and claim to be children.

Duration, prevalence and intensity of bacteraemia after dental extractions in children

OBJECTIVE

To investigate the duration, prevalence and intensity of bacteraemia after dental extractions in children by comparing within-patient bacteraemia before and after dental extraction.

METHODS

Children were randomly allocated to one of 10 postprocedure time groups from 10 s to 60 min. The differences between intensity and prevalence of the bacteraemia at each time after extractions were used to estimate the duration of the bacteraemia. After attainment of general anaesthesia, pre-extraction and postextraction blood samples were processed by broth culture and lysis filtration to isolate and quantify bacteria present in the patients' blood.

RESULTS

500 subjects between 3 and 16 years old were recruited. The estimated duration of bacteraemia was about 11 min.

CONCLUSIONS

The duration of bacteraemia after dental extractions is less than previously thought. This has implications for the interpretation of odontogenic bacteraemia studies.

Oral health and caries related microflora in children during the first three months following renal transplantation

There is little information on the oral health of children undergoing renal transplantation during the early transplant period.

METHODS

Twenty-four children undergoing renal transplantation aged 4-13.2 years and their matched controls were recruited. The dmfs, dmft, DMFS and DMFT, plaque, gingivitis and gingival enlargement scores were recorded. The oral microflora was sampled and cultured for S. mutans, Lactobacllus species and Candida species.

RESULTS

There was a significantly lower mean dmfs (0.3 +/- 0.9; P = 0.03), dmft (0.3 +/- 0.9; P = 0.03), DMFS (2.3 +/- 5.3; P = 0.01) and DMFT (1.5 +/- 2.6; P = 0.02), respectively, in the transplant group. There was a significantly greater mean plaque score (14.7 +/- 11) for the permanent dentition, at baseline only, compared with 90 days post-transplantation (9.4 +/- 10.4; P = 0.02). There was a significantly greater gingival enlargement score (1.8 +/- 1.4; P = 0.04) 90 days post-transplantation compared with baseline. The S. mutans and Lactobacillus counts were significantly lower both at baseline (P = 0.0001 and P = 0.004) and 90 days post-transplantation (P = 0.02; and P = 0.05), respectively, compared with the controls.

CONCLUSIONS

The transplant children had less active dental disease than the controls although gingival enlargement needs careful monitoring.

Metastatic infiltration of the dental pulp by medulloblastoma

Medulloblastoma is an infratentorial primitive neuroectodermal tumour. It is the most commonly occurring brain tumour of childhood, accounting for 15-20% of all paediatric tumours. Extracranial metastasis is rare, but may involve the skeleton. Jaw lesions, however, have never been described. A case is reported of metastases of a medulloblastoma to the jaw including the dental pulp.

Dental disease indices and caries-related microflora in children with glycogen storage disease

OBJECTIVE

To establish the levels of dental caries, bacterial dental plaque, gingivitis and caries-related microflora in children with glycogen storage disease (GSD). Patients with GSD are treated with regular intakes of glucose polymer and uncooked cornstarch to prevent hypoglycaemia. Dental health data are scarce.

STUDY GROUP

The study group comprised 21 children with GSD attending the Great Ormond Street Hospital for Children.

OUTCOME MEASURES

These included the number of decayed, missing and filled teeth, and surfaces in both the primary and permanent dentitions, plaque and gingivitis scores. Both plaque and saliva were collected from each child and cultured for Mutans streptococci, Lactobacilli and Candida.

RESULTS

The study group included 13 boys and eight girls, aged from 2.7 to 15.5 years. Four of the 21 children had some caries experience. The mean dmft was 0.5 and the mean DMFT, 0.06. Mean plaque and gingivitis scores were 4.8 and 5.9, respectively, for plaque and gingivitis adjacent to the primary teeth, and 11.6 and 12 for those related to permanent teeth.

CONCLUSIONS

Only a small proportion of the children had caries experience but most were found to have plaque associated with both primary and permanent teeth. Preventive care should be targeted to improve plaque control thus minimizing the risk of developing periodontal disease as adults.

The dental health and caries-related microflora in children with craniosynostosis

OBJECTIVE

To compare levels of dental caries, bacterial dental plaque, gingivitis, enamel defects, and caries-related microflora in children with and without craniosynostosis.

STUDY GROUP

Fifty-seven children with craniosynostosis and their matched controls.

OUTCOME MEASURES

The decayed, missing, and filled teeth and surfaces in both the deciduous (dmfs and dmft) and the permanent dentition (DMFS and DMFT). The plaque and gingivitis scores and developmental enamel defects were also recorded. The caries-related microflora was sampled using an alginate swab and the prevalence of Streptococcus mutans and Lactobacillus and Candida species were recorded.

RESULTS

The dmfs (p <.02) and dmft (p <.01) were significantly greater in the control children. The plaque score for the deciduous dentition only (p <.02) and also the gingivitis score for the permanent teeth only (p <.008) in the craniosynostosis group were significantly greater. The total aerobic bacterial count (p <.004), anaerobic count (p <.002), and Candida count (p <.05) were significantly greater in the control group. The proportion of S. mutans both as a percentage of the total anaerobic count (p <.04) and the total streptococcal count (p <.05) was significantly greater in the control group.

Dental disease and caries related microflora in children with dystrophic epidermolysis bullosa

PURPOSE

The purpose of this study was to investigate dental caries, bacterial dental plaque, gingivitis and caries related oral microflora in children with predominantly autosomal recessive Dystrophic Epidermolysis Bullosa (DEB).

METHODS

Thirty children with DEB from The Great Ormond Street Hospital for Children and 31 control children matched for age, gender and ethnicity were included in the study.

RESULTS

The main findings were: 1. A significantly greater mean dmft in the DEB children (p < 0.05). 2. A significantly greater mean plaque score for the DEB children for both the primary (p < 0.001) and permanent teeth (p < 0.02) compared with the control children. 3. A significantly greater mean gingivitis score for the DEB children for both the primary (p < 0.002) and permanent teeth (p < 0.0001) compared with the control children. 4. A significantly greater salivary total anaerobic count for the control children compared with the DEB children (p < 0.001).

CONCLUSIONS

The results reflect the difficulties that children with DEB have with basic oral hygiene procedures combined with slow oral clearance.

Dental health indices and caries-related microflora in children with severe haemophilia

The purpose of this work was to investigate the prevalence of dental caries, bacterial dental plaque, gingivitis, enamel defects and caries- related microflora in children with severe haemophilia. Thirty-eight children with severe haemophilia (factor VIII and IX < 2 U dL(-1)) were recruited from Great Ormond Street Hospital for Children and matched for age, gender and ethnicity with healthy control children from the Eastman Dental Institute. Indices were recorded for decayed, missing, and filled teeth and surfaces in both the deciduous dentition (dmfs/dmft) and the permanent dentition (DMFS/DMFT). The plaque and gingivitis scores and developmental enamel defects were also recorded. The caries-related microflora was sampled and cultured for Streptococcus mutans, and Lactobacilli and Candida species. A significantly greater proportion of children with severe haemophilia were caries-free compared with the controls (36.7% vs. 13.3%; P=0.04). Both the DMFS and DMFT were significantly greater in the controls (3.6 and 2.8, respectively) compared with the haemophilia group, (0.8 and 0.7; P=0.007 and P=0.04). The plaque score for the permanent dentition only was significantly greater for the control children (24.2) compared with the haemophilia group, (10.2; P=0.04). The mean number of colony forming units of S. mutans was significantly greater in the control group compared with the haemophilia group (P=0.05). We conclude that children with severe haemophilia have a significantly lower prevalence of dental caries compared with matched, healthy controls.

Dental disease indices and caries related oral microflora in children with phenylketonuria

The purpose of this study was to investigate the dental caries, plaque and gingivitis indices and caries related oral flora in children with classic phenylketonuria. Forty-one children at The Great Ormond Street Hospital for Children and controls were included in the study. The main findings were: No significant difference in the decayed, missing and filled surfaces of the primary and permanent teeth between the phenylketonuria children and the controls. A significantly greater mean plaque score for the control children compared with the phenylketonuria children (p < 0.01) for the permanent teeth only. A significantly greater number of white opacities in the permanent teeth of the phenylketonuria group compared with the control group (p < 0.02). No significant differences in the caries related microflora.

Dental procedures in children with severe congenital heart disease: a theoretical analysis of prophylaxis and non-prophylaxis procedures

OBJECTIVE

To estimate the cumulative exposure to bacteraemia from dental procedures currently recommended for antibiotic prophylaxis and compare this with cumulative exposure from dental procedures not recommended for prophylaxis.

DESIGN

Retrospective analysis.

SETTING

University and teaching hospital maxillofacial and dental department.

PATIENTS

136 children with severe congenital cardiac disease attending for dental treatment between 1993 and 1998 and for whom full records were available. Each dental procedure was tallied.

MAIN OUTCOME MEASURES

Cumulative exposure per annum to "non-prophylaxis procedures"; cumulative exposure per annum to "prophylaxis procedures".

RESULTS

Cumulative exposure to bacteraemia from prophylaxis procedures was not significantly greater than from non-prophylaxis procedures.

CONCLUSIONS

The data raise important questions about the appropriateness of current guidelines for antibiotic prophylaxis of bacterial endocarditis.

An investigation of the oral status and reported oral care of children with heart and heart-lung transplants

AIM

To investigate the oral health status and oral microflora of children who have received heart and heart-lung transplants. Parental knowledge and current practice of oral health procedures by the child were also investigated.

SAMPLE AND METHOD

Thirty-five children attending the Cardio-Thoracic Transplant Unit, Great Ormond Street Hospital for Children were included. Measurements were compared with children matched by age and gender attending the trauma clinic at the Department of Paediatric Dentistry, Eastman Dental Hospital. Teeth were examined for the presence or absence of caries or enamel defects. Plaque deposition, gingivitis, gingival bleeding and gingival enlargement were measured and a swab was taken to look at the oral microbial flora. A questionnaire was used to assess parental knowledge of dental health procedures and the current practice of these.

RESULTS

There were no significant differences between transplant and control children in caries experience, plaque or gingivitis. Children with heart or heart-lung transplants had significantly greater numbers of enamel defects and more gingival enlargement than control children, children in the heart transplant group had significantly more gingival bleeding. There was little difference in the dental knowledge and reported behaviour of the transplant group compared to the control group.

CONCLUSION

The dental needs of heart and heart-lung transplant patients treated at the Great Ormond Street Hospital for Children were similar to those of the control group in this study, however further improvement could be made in educating parents and children on the importance of caries prevention and good oral hygiene.

Dental health indices and caries associated microflora in children with unilateral cleft lip and palate

OBJECTIVE

To investigate the dental health and caries related microflora of children with unilateral cleft lip and palate.

STUDY GROUP

Sixty children with unilateral cleft lip and palate and matched controls.

OUTCOME MEASURES

The decayed, missing, and filled teeth and surfaces in both the deciduous and permanent dentitions. The presence of developmental defects and plaque and gingivitis scores were also recorded. Plaque was collected from 25 of the children and their matched controls from three different sites, which were (1) the first approximal site distal to the cleft, (2) a contralateral anterior site, and (3) a remote site. It was cultured for Streptococcus mutans and lactobacilli. Plaque was collected from two sites in the matched controls.

RESULTS

There was no significant difference in the caries, plaque, and gingivitis scores between the children with cleft palate and the controls. A greater number of enamel opacities were recorded in the control group, and there was a higher prevalence of enamel discoloration in the children with cleft lip and palate. There was no significant difference in the proportion of S. mutans or lactobacilli at the cleft site, compared with the unaffected site in the study group, although there was an anterior-posterior gradient in the proportion of S. mutans. There was no significant association between the stagnation area at the cleft site and the bacteria associated with dental caries.

Bacterial endocarditis and orthodontics

The purpose of this article is to discuss the prevalence and intensity of bacteraemia associated with orthodontic procedures and help formulate practical guidelines for orthodontists treating children with congenital or acquired heart disease. Preliminary results demonstrate a significant increase in the intensity of bacteraemia from baseline following insertion of an orthodontic separator. The potential for development of bacterial endocarditis (BE) is extremely low, questioning the need for antibiotic prophylaxis for procedures other than extractions. However, for patients who are 'at risk' a very high standard of oral hygiene is essential and much of the responsibility lies with the individual patients to learn to protect themselves.

A preliminary investigation of dental disease in children with HIV infection

OBJECTIVE

To establish the levels of dental caries and gingivitis in a group of HIV-positive children.

STUDY GROUP

The study group comprised 35 children with the Human Immunodeficiency Virus attending The Great Ormond Street Hospital For Children.

OUTCOME MEASURES

Outcome measures included the number of decayed, missing and filled teeth and surfaces in both the primary and permanent dentitions; plaque and gingivitis scores.

RESULTS

The children included 18 boys and 17 girls. They were aged from 6 months to 18 years, with 17 aged 5 years or less and 15 aged 6 years or older. Twenty-four of the 35 children had some caries experience. The mean DMFT was 4.4 and for those with permanent teeth the mean DMFT was 0.7. Mean plaque and gingivitis scores were 16.7 and 5.1 for plaque and gingivitis adjacent to primary teeth and 8.0 and 5.7 for that related to permanent teeth.

CONCLUSIONS

There is a significant treatment need for children with HIV.

Phase I and pharmacologic study of oral fluorouracil on a chronic daily schedule in combination with the dihydropyrimidine dehydrogenase inactivator eniluracil

PURPOSE

To determine the maximum-tolerated dose (MTD), toxicities, and pharmacokinetics of oral fluorouracil (5-FU) administered twice daily in combination with oral eniluracil, an inactivator of dihydropyrimidine dehydrogenase, administered for 28 days every 35 days.

PATIENTS AND METHODS

Oral 5-FU 1.35 mg/m(2) twice daily was administered with oral eniluracil 10 mg daily for 14 to 28 days, followed by a 1-week rest period. Eniluracil was started 1 day before 5-FU. Patients then received escalated doses of oral 5-FU 1. 35 to 1.8 mg/m(2) twice daily with an increased dose of eniluracil 10 mg twice daily for 28 days. A reduced dose of 5-FU 1.0 mg/m(2) with eniluracil 20 mg twice daily was evaluated.

RESULTS

Thirty-six patients with solid malignancies were enrolled onto the study. Diarrhea was the principal dose-limiting toxicity of oral 5-FU and eniluracil given on this chronic schedule. The recommended phase II dose is 5-FU 1.0 mg/m(2) twice daily with eniluracil 20 mg twice daily. Mean (SD) values for terminal half-life, apparent volume of distribution, and systemic clearance of 4.5 hours (0.83 hours), 19 L/m(2) (3.0 L/m(2)), and 51 mL/min/m(2) (13 mL/min/m(2)), respectively. An average of 77% of 5-FU was excreted unchanged in urine after 28 days of treatment. The mean (range) 5-FU C(SS,min) values achieved at the 1.0 mg/m(2) dose level were 22 ng/mL (8 to 38 ng/mL).

CONCLUSION

Chronic oral administration of 5-FU with oral eniluracil is tolerable and produces 5-FU steady-state concentrations similar to those achieved with protracted intravenous administration of 5-FU on clinically relevant dose schedules. Eniluracil provides an attractive means of administering 5-FU on protracted schedules.

Intensity of bacteraemia associated with conservative dental procedures in children

OBJECTIVES

To explore the individual dento-gingival manipulative procedures that together lead to the placement of a restoration and to estimate the associated intensity of bacteraemia.

PATIENTS AND METHODS

Healthy children receiving dental treatment under general anaesthesia provided blood samples 30 seconds after one of four dento-gingival manipulative procedures: 1. Placement of rubber dam, 2. Use of the high speed drill, 3. Use of the slow speed drill, and 4. Placement of matrix band and wedge. Blood cultures were processed to give the percentage prevalence of bacteraemia, the intensity of organisms per millilitre of blood and the identity of the organisms cultured.

RESULTS

A total of 257 children were recruited to the study. The percentage positive prevalence of blood cultures was baseline--9.3%, rubber dam placement--31.4%, slow drill--12.2%, fast drill--4.3%, and matrix band and wedge--32.1%. The intensity of bacteraemia was baseline--1.2 cfu, rubber dam placement--1,962 cfu, slow drill--0.3 cfu, fast drill--1.9 cfu, matrix band and wedge--4.8 cfu.

CONCLUSIONS

These data indicate that dento-gingival manipulative procedures comprising a simple dental restoration can lead to a bacteraemia comparable to that from dental extractions. It is suggested that these data may indicate the need for antibiotic prophylaxis for some aspects of conservative dentistry.

Composition of the oral streptococcal flora in healthy children

OBJECTIVES

To identify the predominant streptococcal species in the mouths of healthy children and to investigate the composition of the oral streptococcal flora over a period of 4 months.

PATIENTS AND METHODS

The subjects were 33 fit, healthy schoolchildren aged between 5 and 16 years. These children were part of a large study and were the matched controls for a group of subjects undergoing bone marrow transplantation. The oral flora was sampled using an oral rinse technique on two separate occasions 4 months apart. The outcome measures were the number of each streptococcal species per millilitre of oral rinse; the isolation frequency of each species; the proportion of each species as a percentage of both the total streptococcal count and the total anaerobic count.

RESULTS

The predominant species were Streptococcus salivarius, S. oralis and S. mitis. There was no significant variation in the composition of the oral streptococcal flora over the 4 month period.

CONCLUSIONS

The oral rinse technique provides a reliable method of sampling the streptococcal flora of children.

Oral health of children undergoing allogeneic bone marrow transplantation

The objective of this study was to investigate changes in the oral health of children undergoing allogeneic bone marrow transplantation. The study group comprised 23 children undergoing allogeneic bone marrow transplantation and their matched controls. The study group comprised 23 children undergoing allogeneic bone marrow transplantation and their matched controls. Measurements were taken of the mean decayed, missing and filled surfaces and the mean decayed, missing and filled teeth in both deciduous and permanent dentition at baseline, the mean bacterial plaque and gingival inflammation indices and mucositis at specific event-related times during the transplantation period, were measured. The number of decayed, missing and filled surfaces in deciduous teeth was significantly greater in the transplant children than the matched controls (P < 0.05) at baseline. There was a significant increase in both the mean bacterial plaque score for the deciduous teeth (P < 0.003) and the permanent teeth (P < 0.001) and the mean gingival inflammation score for the deciduous (P < 0.001) and the permanent teeth (P < 0.001), at 7 days post-transplantation. At 4 months post-transplantation the plaque and gingival inflammation score had returned to baseline levels. There were significantly increased mean bacterial plaque and gingival inflammation scores during the period of intense immunosuppression following allogeneic bone marrow transplantation.

Phase I clinical and pharmacologic study of eniluracil plus fluorouracil in patients with advanced cancer

PURPOSE

To determine the highest dose of fluorouracil (5-FU) that could be safely administered with Eniluracil (776C85; Glaxo Wellcome Inc, Research Triangle Park, NC), an inactivator of dihydropyrimidine dehydrogenase (DPD), on a daily schedule for 5 days, and to define the toxicities of the combination and the pharmacokinetics of 5-FU when administered with 776C85.

PATIENTS AND METHODS

Patients with advanced solid tumors refractory to standard therapy were enrolled at two institutions. The study consisted of three periods designed to evaluate the safety, pharmacokinetics, and pharmacodynamics of 776C85 alone (period 1); the effects of 776C85 on the pharmacokinetics of 5-FU (period 2); and the maximum-tolerated dose (MTD) of 5-FU, with or without leucovorin, that could be safely administered with 776C85 (period 3). Cohorts of at least three patients each received oral 776C85 alone at doses of 3.7 mg/m2/d, 18.5 mg/m2/d and 0.74 mg/m2/d. After a 14-day washout period, each patient then received 776C85 daily for 3 days, with a single intravenous (i.v.) bolus dose of 5-FU 10 mg/m2 on day 2. After a second washout period, patients were treated with 776C85 daily for 7 days and 5-FU i.v. bolus on days 2 through 6. The starting dose of 5-FU 10 mg/m2/d was escalated until the MTD was determined. After determination of the MTD of 5-FU given with 776C85, oral leucovorin 50 mg/d on days 2 through 6 was added to determine the MTD of 5-FU with leucovorin in the presence of 776C85. Near the completion of the study, additional cohorts of patients were treated with 776C85 at 50 mg/d and oral 5-FU with or without leucovorin.

RESULTS

Sixty-five patients were enrolled onto the study and 60 were assessable for toxicity and response. Bone marrow suppression was the primary and dose-limiting toxicity of this regimen. Other toxicities included diarrhea, mucositis, anemia, anorexia, nausea, vomiting, and fatigue. 776C85 suppressed DPD activity in peripheral-blood mononuclear cells (PBMCs) by at least 90% for at least 24 hours at all dose levels tested. In the presence of 776C85, 5-FU half-life was prolonged, clearance was reduced, and the drug displayed linear pharmacokinetics. Recommended doses for further testing on a daily for 5-day schedule are 776C85 10 mg/d with i.v. 5-FU 25 mg/m2/d; 776C85 10 mg/d with i.v. 5-FU 20 mg/m2/d plus leucovorin 50 mg/d; 776C85 50 mg/d with 5-FU given orally at 15 mg/m2/d with leucovorin at 50 mg/d.

CONCLUSION

5-FU can be safely administered with 776C85; however, the MTDs are considerably lower than those conventionally used, caused, at least in part, by marked alterations in 5-FU plasma pharmacokinetics.

Changes in the oral streptococcal flora of children undergoing allogeneic bone marrow transplantation

The changes in the oral streptococcal flora of twenty children undergoing allogeneic bone marrow transplant are described. Saliva was collected from each child on four separate occasions: (i) before the conditioning regimen; (ii) 7 days post-transplantation; (iii) when the neutrophil count had risen above 0.5 x 10(9)/l; (iv) 119 days post-transplantation. Indices for dental caries, plaque, gingivitis, herpetic stomatitis and mucositis were also recorded. There was a significant decrease in the total aerobic (P<0.001) and anaerobic counts (P<0.0002) between baseline and 7 days post-transplantation. The proportion of the 'Streptococcus oralis group' (Streptococcus mitis and S. oralis) increased significantly from baseline 12.1% to 48.4% at 7 days post-transplantation (P<0.003). The plaque and gingivitis indices increased significantly from baseline to 7 days post-transplantation (P<0.001). Twenty percent of the children had either positive blood cultures or Hickman line cultures for the 'S. oralis group', and it is possible that the inflamed gingival tissues are a further site of entry for these streptococci. There were no differences in the total anaerobic counts or the proportion of the 'S. oralis group' between baseline and the end of the study in the transplant children, or between the transplant and control children.

The effects of food and divided dosing on the bioavailability of oral vinorelbine

The effects of food and divided dosing on the bioavailability of a liquid-filled gelatin capsule formulation of vinorelbine (Navelbine), a semisynthetic vinca alkaloid with broad clinical activity, was evaluated in patients with advanced solid tumors. A group of 13 patients were randomized to treatment with the oral formulation at the recommended phase II dose of 80 mg/m2 per week either in the fasting state or after ingestion of a standard meal. Patients were treated 1 week later in the alternate state relative to their first dose. The effects of divided dosing were assessed during the 3rd week, at which time vinorelbine was administered in two divided doses. After the completion of pharmacokinetic and bioavailability studies, patients received the oral formulation at a dose of 80 mg/m2 per week in two divided doses to evaluate the feasibility of chronic oral drug administration. Both manipulations resulted in small, albeit statistically significant, reductions in the relative bioavailability of this oral formulation. The relative bioavailability decreased by 22 +/- 28% when treatment followed the ingestion of a standard meal, possibly due to a delay in gastrointestinal transit time. The mean time of maximum plasma concentration (Tmax) increased from 1.3 +/- 1.6 h in the fasting state to 2.5 +/- 1.6 h in the fed state, although this difference was not statistically significant. Similarly, the relative bioavailability declined by 16 +/- 51% when vinorelbine was administered in two divided doses. An analysis of dose proportionality revealed disproportionate increases in dose-normalized Cmax and AUC values with single oral doses above 120 mg, which may account for this phenomenon. The high clearance of vinorelbine, which approaches hepatic blood flow, and the lack of dose proportionality after oral administration, indicate that there is a large first-pass effect which may be saturable, or nonlinear, above single doses of 120 mg. In addition, the toxicological and pharmacological characteristics of oral vinorelbine indicate that treatment after a standard meal or on a divided dosing schedule is safe. Chronic oral administration of the agent in two divided doses was also well tolerated. However, the small reduction in the relative bioavailability following the ingestion of a standard meal and with divided dosing suggest the need for further pharmacodynamic studies to determine if reductions in drug exposure of this magnitude may portend diminished antitumor activity.

Post-insertion visits in medicated complete denture wearers

The effect of systemic disease and medication on the number of post-insertion visits was investigated in 157 patients requiring new complete dentures, who were referred to a specialist prosthodontic practice. We found that the number of recall visits increased with age, particularly in patients medicated for central nervous system or psychiatric disorders, and more so with cardiovascular diseases treated with diuretics.

The clinical pharmacokinetics of vinorelbine (Navelbine)

Vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Médicament, Paris, France) is a semisynthetic vinca alkaloid agent that has been structurally modified on the catharanthine nucleus to impart increased lipophilicity. As a result, vinorelbine appears to possess a higher therapeutic index and different pharmacokinetic properties from other marketed vinca alkaloids. Vinorelbine has been quantified in biologic matrices by measurement of total radioactivity, radioimmunoassay, and high-performance liquid chromatography. Because it is specific for the parent drug, high-performance liquid chromatography has generated the most reliable pharmacokinetic data. Vinorelbine is highly bound to platelets and lymphocytes, and is also bound to alpha 1-acid glycoprotein, albumin, and lipoproteins. The drug undergoes significant metabolism and elimination via the liver and metabolites are excreted primarily in the bile. Two likely vinorelbine metabolites, vinorelbine N-oxide and deacetylvinorelbine, have been isolated and identified in human urine and very low concentrations appeared in plasma. Urinary excretion of unchanged drug accounts for less than 20% of an intravenous dose, with fecal elimination accounting for an additional 30% to 60%. The pharmacokinetic profile of vinorelbine after intravenous bolus or infusion is characterized by triexponential decay. Initial rapid decay is due primarily to distribution into tissues in the peripheral compartments. There is a prolonged terminal phase due to relatively slow efflux of the drug from peripheral compartments, which results in a long terminal phase half-life, with average values ranging from 27.7 to 43.6 hours. Plasma clearance of vinorelbine is high, approaching hepatic blood flow in humans, and its volume of distribution is large, indicating extensive extravascular distribution. In comparison to vinblastine or vincristine, vinorelbine has a higher clearance and a larger volume of distribution than either drug, and a half-life shorter than vinblastine but longer than vincristine. There is no relationship between the age of the patient and the pharmacokinetic parameters of vinorelbine, and coadministration of cisplatin does not appear to influence the pharmacokinetics of vinorelbine. Vinorelbine is the first vinca alkaloid to show promising efficacy following oral administration, and this has led to the development of a liquid-filled, soft-gelatin capsule dosage form. The absolute bioavailability of vinorelbine from this dosage form was 27% when intravenous doses of 30 mg/m2 were compared with oral doses of 100 mg/m2.

Pharmacokinetic, bioavailability, and feasibility study of oral vinorelbine in patients with solid tumors

PURPOSE

The feasibility of administering vinorelbine (Navelbine, Burroughs Wellcome Co, Research Triangle Park, NC), a semisynthetic vinca alkaloid with broad activity, as a liquid-filled gelatin capsule was evaluated in a bioavailability (F) and pharmacokinetic study.

PATIENTS AND METHODS

Each of 17 cancer patients had pharmacokinetic studies performed after receiving vinorelbine 30 mg/m2 intravenously (IV), which is the maximum-tolerated dose (MTD) for weekly IV administration, and twice after receiving the oral formulation at a nominal dose of 100 mg/m2. Subsequently, these patients and 10 other subjects received the oral formulation at a dose of 100 mg/m2/wk to evaluate the feasibility of chronic oral administration.

RESULTS

Plasma drug disposition was well described by a triphasic model. Mean central volume of distribution and steady-state volume of distribution (Vss) were large (0.66 +/- 0.46 L/kg and 20.02 +/- 8.55 L/kg, respectively); the mean harmonic terminal half-life (t1/2) was long (18 hours); and the high mean clearance (CI) rate (0.80 +/- 0.68 L/h/kg) approached hepatic blood flow. F was low (0.27 +/- 12), and absorption was rapid (mean time of maximum plasma concentration [Tmax], 0.91 +/- 0.22 hours). Absorption parameters after the first and second oral doses were similar, with mean F values of 0.27 +/- 0.14 and 0.25 +/- 0.11, respectively. Coefficients of variability (CVs) for F, maximum plasma concentration (Cmax), and Tmax were 32%, 42%, and 78%, respectively, indicating moderate intraindividual variability. The pharmacologic profile of this oral formulation indicates that there is a large first-pass effect. Neutropenia was the principal toxicity of oral vinorelbine. Grade 3 or 4 neutropenia occurred in 63% of patients, but only 11% developed neutropenia and infection. Nausea, vomiting, and diarrhea were also common with oral administration, but these effects were rarely severe and could be ameliorated by using a divided-dose schedule and/or prophylactic antiemetic and antidiarrheal agents. The mean nominal oral dose was 82 mg/m2, and the mean percentage of intended dose that was received was 92%. Although dose escalations were permitted for negligible toxicity, doses were not escalated to greater than 100 mg/m2/wk in any patient. Vinorelbine given as a liquid-filled gelatin capsule at 100 mg/m2 provided equivalent pharmacologic exposure as 30 mg/m2 IV.

CONCLUSION

The oral administration of vinorelbine, specifically as a liquid-filled, soft gelatin capsule, is a feasible route of administration. Weekly oral dosing at 100 mg/m2 induces a consistent degree of myelosuppression, but the high frequency of grade 3 or 4 neutropenia, albeit brief and uncomplicated, warrants the recommendation of a slightly lower starting dose, ie, 80 mg/m2/d, for subsequent phase II evaluations, especially in heavily pretreated patients.

Growth of the nasal septum in the Snell strain of hypopituitary dwarf mouse

The literature relating to experimental investigation of growth of the nasal septum has been reviewed in detail. A total of 156 skulls from the Snell hypopituitary mouse, six controls and six dwarfs at each age group were radiographed in lateral view to enable measurement of the different components of the nasal septum. By 80 days of age, the snout of the nasal septum in the Snell strain of mice was 56 per cent the size of the snout in normal mice (n = 12, t = 8.07, P = 0.0005). It is concluded that the Snell strain of mouse is an example of a specific genetic defect causing severe growth retardation of cartilaginous tissues, particularly the nasal complex.

Patterns of breast and bottle feeding and their association with dental caries in 1- to 4-year-old South African children. 2. A case control study of children with nursing caries

In a case control study, 109 children with nursing caries (> or = 2 decayed, missing, or filled labial or palatal surfaces of primary incisor teeth) were matched for age, race, gender, and social class to 109 children without nursing caries from the same study areas. Mean dmfs and dmft scores were statistically higher in the nursing caries group but no statistically significant differences were found for feeding patterns between the groups in relation to the prevalence of nursing caries. In the present study nursing caries was found to be unrelated to the length of type of feeding (breast or bottle).

Erythema migrans: an unusual presentation

A case of erythema migrans affecting the attached gingivae and the upper and lower labial mucosa is described. No lesions were found on the tongue although this is the site most commonly affected.

Association of psychotropic drugs, prevalence of denture-related stomatitis and oral candidosis

The aims of this study were 1) to determine the association between the prevalence of denture-related stomatitis and oral candidosis in patients undergoing long-term treatment with psychotropic drugs and 2) to identify the relationships between an increased prevalence of oral candidosis, denture cleanliness, dietary habits and cigarette smoking in these patients. Clinical and laboratory investigation of psychiatric patients under treatment with psychotropic drugs and who were wearing complete maxillary dentures, compared with control (non-psychiatric) patients revealed that 1) the isolation frequency of candida was 64.7% compared with 33.3% in the controls; 2) palatal inflammation was present in 74.5% compared with 55% of the controls; 3) oral staphylococcus carriage was present in 56.9% compared with 17.6% of the controls; 4) cigarette smoking, sugar consumption and a poor standard of denture hygiene were more common in the psychiatric patients than in the controls.

Diseases, medication, and postinsertion visits in complete denture wearers

The records of 268 patients were used to assess the effects of five disease/drug complexes on the number of postinsertion visits in complete denture wearers. The data were analyzed with SAS and BMDP computer packages. The results showed a statistically significant increase in the number of postinsertion visits in patients who had central nervous system or psychiatric disorders. Practitioners are alerted to consider the ergonomic implications at the outset of treatment.

Phase I clinical and pharmacology study of 502U83 given as a 24-h continuous intravenous infusion

502U83 is an arylmethylaminopropanediol that displays significant antitumor activity in a number of murine and human tumor-model systems. In the present phase I study, a 24-h continuous intravenous infusion of this agent was given every 28 days to patients with advanced or refractory solid tumors. In all, 46 patients received a total of 96 cycles of 502U83 at doses ranging from 25 to 8,000 mg/m2. No significant hematologic, gastrointestinal, or neurologic toxicity was observed. At doses of 2,000 mg/m2 and higher, prolongation of the corrected QT interval on ECG was evident in most patients but was completely reversible, was not associated with arrhythmias, and was not dose-limiting. Dose-limiting pulmonary toxicity characterized by acute onset of dyspnea, severe hypoxemia, interstitial pulmonary edema, and death occurred in three patients treated at the highest dose levels. Plasma concentrations of 502U83 and its metabolites were measured by high-performance liquid chromatography. The 502U83 maximal concentration (Cmax) and area under the concentration-time curve (AUC) were proportional to the delivered dose; however, substantial interpatient variability in total body clearance was noted at all dose levels. Significant conversion of 502U83 to two glucuronide metabolites was detected. Metabolite concentrations were highest in the three patients who succumbed to pulmonary toxicity, although the precise contribution of these metabolites to the observed toxic effects is unknown. In view of the unfavorable clinical profile of QTc prolongation and pulmonary toxicity produced by 502U83, further clinical development of this agent has been suspended.

Phase I and clinical pharmacology trial of 502U83 using a monthly single dose schedule

502U83 is an arylmethylaminopropanediol derivative exhibiting significant antineoplastic activity in a number of murine and human tumor models. In this Phase I trial, a 1-h or 4-h infusion of the agent was administered i.v. in 250 ml of 5% dextrose in water every 28 days. Fifty-three courses at doses of 25 to 2000 mg/m2 were administered to 36 patients with refractory solid tumors. Prolongation of the PR, QRS, and QT intervals on electrocardiograms was dose limiting at 2000 mg/m2. This prolongation appeared dose related and was reversible upon discontinuation of the infusion. No hematological toxicity was observed. Other toxicities included only sporadic and mild to moderate nausea and vomiting. No tumor responses were noted. 502U83 plasma concentrations were determined by high-pressure liquid chromatography. Complete pharmacokinetic profiles were obtained for 21 of the 36 patients. After infusion, plasma concentrations declined in a biexponential or in a triexponential manner with a harmonic mean terminal t 1/2 of 8.83 h. Using a three-compartment model, the mean apparent volume of distribution at steady state and total-body clearance were 195 liters/m2 and 42.5 liters/h/m2, respectively, indicative of extensive tissue distribution. No correlation could be found between the pharmacokinetic parameters and prolongation of the cardiac conduction intervals. Because of the cardiac effects with the drug, the schedule of administration of 502U83 used in this study cannot be recommended.

Phase I and clinical pharmacology trial of crisnatol (BWA770U mesylate) using a monthly single-dose schedule

Crisnatol is a novel lipophilic arylmethylaminopropanediol with significant antineoplastic activity in a variety of murine and human tumor models which functions as a DNA intercalator. In this Phase I trial, a 6-h infusion of the drug was administered i.v. in 700 to 1500 ml of 5% dextrose in water every 28 days. Eighty-five courses at doses of 7.5 to 516 mg/m2 were administered to 43 patients with refractory solid tumors. Reversible neurological toxicity was dose limiting at 516 mg/m2 and was manifested as somnolence, dizziness, blurred vision, unsteady gait, and alpha-slowing on electroencephalogram at the end of infusion. All neurological signs and symptoms were reversible. No hematological toxicity was observed. Other toxicities included phlebitis, mild to moderate nausea and vomiting, reversible sinus node arrest in one patient, and hypertension. Crisnatol plasma concentrations were determined by high-pressure liquid chromatography. After infusion, plasma concentrations declined biexponentially with a terminal t1/2 of 2.9 h. Using a two-compartment model, the mean apparent volume of distribution at steady state and total-body clearance were 58.8 liters/m2 and 18.3 liters/h/m2, respectively, indicative of extensive tissue distribution and rapid hepatic clearance. Peak plasma levels occurred at the end of infusion and correlated with the onset of neurological toxicity. The recommended Phase II dose for this schedule is 388 mg/m2.

Maxillary myxoma in a child of 11 months. A case report

A myxoma of the maxilla in an infant is presented. It was initially treated as an inflammatory lesion. Failure to respond led to biopsy, which showed that the lesion was neoplastic; initially an incorrect diagnosis was made and totally inappropriate treatment was given. Reassessment of the biopsy material established the correct diagnosis and appropriate management was initiated.

Phase I study of pharmacological and immunological effects of human lymphoblastoid interferon given to patients with cancer

An extensive Phase I evaluation of human lymphoblastoid interferon has been completed which, in addition to describing its clinical and pharmacological effects, emphasized a broad-scale evaluation of the immune response as a function of interferon dosage. Dose-limiting toxicity was generally due to constitutional symptoms which are remarkably similar to those produced by influenza, although transient peripheral and central neurotoxicity (including deterioration in cognitive and behavioral functions) is observed at higher doses. It is difficult to establish "clean" dose-response effects except for fever and bone marrow suppression, neither of which is a major dose limitation. Enhancement of the immune system was limited to natural killer cells which had a complex dose-response relationship, whereby low interferon concentrations were less stimulatory (than were high doses) following a single dose but gave more sustained stimulation over a 5-week course of 3 times per week i.m. administration. The effects on various measures of monocyte function and of nonspecific immunity (hypersensitivity, immunoglobulins, complement) were negative. We suspect that in practice it may be difficult to exploit the narrow dosage window of immunostimulation, but it is important to note that the nontoxic lower doses were more stimulatory than were the very high doses which are being used in numerous clinical trials.

Levonantradol for chemotherapy-induced emesis: phase I-II oral administration

Thirty five patients were enrolled into a Phase I-II study of oral levonantradol being tested as an antiemetic for chemotherapy patients who were refractory to the aggressive use of standard antiemetic agents. Sixty-nine total courses were given. Dysphoric reactions (fear, anxiety, hallucinations) were the most serious side effects, and were most prevalent at the highest dose tested (2.0 mg q4h). Somnolence, a "high" feeling, hypotension were also noted. Antiemetic responses were seen at 0.5, 1.0, 1.5 and 2.0 mg dose levels: the two intermediate doses gave responses comparable to those previously reported for oral THC. It is suggested that a combination of oral and parenteral levonantradol may prove to be a very effective program to relieve the otherwise disabling problems of persistent nausea and vomiting.

Antiemetic effect of intramuscular levonantradol in patients receiving anticancer chemotherapy

Positive results of investigations of the antiemetic activity of delta-9-tetrahydrocannabinol (THC) in patients receiving cancer chemotherapy have led to the development of levonantradol, a synthetic derivative of THC. We assessed both the antiemetic activity and toxicity of intramuscular levonantradol in patients receiving cancer chemotherapy who were refractory to conventional antiemetic therapy. An open dose-finding study was conducted using initial doses of 0.5 mg. Doses were escalated by 0.5 mg when an incomplete response with no toxicity was observed. Of the 28 patients initially treated, 25/28 (89 per cent) achieved a complete or partial antiemetic response at doses ranging from 0.5 to 1.5 mg. There was no difference in response rate with respect to age or patient size. Of the 31 patients evaluable for toxicity, six reported none. Dysphoria, the dose-limiting toxicity, occurred in five patients (16 per cent) at 1.0 to 1.5-mg doses. The most commonly reported side effects were somnolence (48 per cent) and dry mouth (32 per cent). We conclude that intramuscular levonantradol is an effective antiemetic at doses as low as 0.5 mg.

DTIC, CCNU, bleomycin and vincristine (BOLD) in metastatic melanoma

Treatment of 91 consecutive patients having metastatic, Stage IV melanoma who had not received any previous chemotherapy was begun between January 1977 and April 1978. The therapy included bleomycin (B) at 7.5 units subcutaneously in the first course and 15 units in subsequent courses on days 1 and 4; vincristine or Oncovin (O) at 1 mg/m2 intravenously on days 1 and 5; CCNU or lomustine (L) at 80 mg/m2 p.o. on day 1 and DTIC (D) 200 mg/m2 intravenously on days 1 through 5. Evaluable patients (72) were those who had measurable tumours in the viscera and on the skin. Seven patients (9%) responded with complete tumor regression (CR), 22 (31%) with partial regression (PR) (50% or more tumor regression), 12 (17%) with stabilization of disease, and 31 (43%) with progression of the disease. Patients who responded with CR, PR, and stable disease (41 patients) had a median survival of 67 weeks, while those who did not respond (31 patients) had a median survival of 20 weeks (P < .0001). Overall median survival was 31 weeks. The bleomycin-Oncovin-lomustine-DTIC (BOLD) regimen is an effective alternative treatment for metastatic melanoma; there is good tumor response and prolongation of survival in the responding patients. Its overall toxicity is mild to moderate.

A trial of outpatient chemotherapy for recurrent head and neck tumors

A four-drug combination chemotherapy (bleomycin-methotrexate-vinblastine-CCNU) had been used in 38 evaluable patients with recurrent squamous cell carcinoma of the head and neck region on an outpatient basis. A large number of these patients had carcinoma of the oral cavity (45% of total). Nineteen patients (50%) responded to this regimen with a greater than or equal to 50% regression of their measured tumors. The median survival of all patients was 34 weeks. There was one chemotherapy-related death and the overall toxicity was mild. This convenient regimen can be considered a useful alternative to more aggressive therapy.

delta 9-Tetrahydrocannabinol for refractory vomiting induced by cancer chemotherapy

Fifty-three patients receiving antineoplastic chemotherapy who had experienced severe nausea and vomiting refractory to standard antiemetic agents were treated with delta 9-tetrahydrocannabinol (THC). These patients were given THC 8 to 12 hours before, during, and for 24 hours after chemotherapy. Ten patients (19%) had no further nausea and vomiting; 28 (53%) had at least a 50% reduction of nausea and vomiting compared to previous courses with the same agents. No appreciable reduction of nausea and vomiting was seen in 15 patients (28%). Toxic reactions were generally mild, with only four patients experiencing reactions that necessitated stopping THC therapy. We suggest that, since THC is a useful antimetic agent in patients having refractory chemotherapy-induced vomiting, existing restrictions prohibiting its therapeutic use should promptly be eased.

Sudden death during doxorubicin administration

Three patients are described who either died suddenly or had severe, life-threatening arrhythmias during or immediately after doxorubicin administration. Since doxorubicin and daunorubicin administration is known to be associated with acute EKG abnormalities, the acute decompensation in these patients appeared to be caused by the administration of these agents. The importance of careful observation of patients receiving doxorubicin, because of the possibility of acute cardiac arrhythmias, is stressed.