Antagonist enamel tooth wear produced by different dental ceramic systems: A systematic review and network meta-analysis of controlled clinical trials

OBJECTIVES

The aim of this study was to evaluate the amount of enamel tooth wear induced by different antagonistic ceramic crown materials in the posterior area within a follow-up period up to 24 months in function. A network meta-analysis was performed to assess the effect of the materials on the mean vertical loss (MVL) of the antagonist enamel tooth surface.

DATA

Main search terms used in combination: ceramic, dental materials, metal ceramic, tooth wear and dental enamel.

SOURCES

An electronic search was conducted in PubMed/Medline, Embase, and Cochrane CENTRAL plus hand-searching.

STUDY SELECTION

Eligibility criteria included clinical studies reporting on MVL on antagonist's tooth up to 24 months following the permanent crown placement. From a total of 5697 articles, 7 studies reporting on 261 crowns for 177 subjects with 3 ceramic materials (Lithium disilicate, metal-ceramic, monolithic zirconia) were included. Among all, metal-ceramic and zirconia caused significantly higher enamel tooth wear on antagonist teeth, representing 82.5 µm [54.4; 110.6]) and 40.1 µm [22.2; 58.0]) more MVL than natural teeth group. In contrast, lithium disilicate showed only 5.0 µm [-48.2; 58.1]) more MVL than occurs on opposing natural teeth.

CONCLUSIONS

This systematic review demonstrated that prosthodontic ceramic materials produced significantly more antagonist enamel tooth wear than opposing natural enamel tooth wear, and ceramic material type was correlated to the degree of enamel tooth wear. Additional well-conducted, randomized controlled trials with homogeneous specimens are required due to inadequate sample size and number of the clinical studies included in the analyses.

CLINICAL SIGNIFICANCE

The amount of wear caused by different restorative materials has a high influence on the antagonistic natural teeth and should therefore be evaluated intensively by the dentist.

Peculiar reaction of oxidized zirconium from a total knee arthroplasty prosthesis: A case report

Oxidized zirconium (OxiniumTM) prostheses, made up of a metallic alloy of zirconium with a ceramic surface formed by oxidizing the outer layer, were developed as an alternative bearing surface to reduce polyethylene wear and decrease failure of total knee arthroplasty (TKA). We report a unique catastrophic failure of an Oxinium TKA with consequent accelerated wear and severe metallosis. Intraoperatively, we observed extensive wear grooving of the femoral component with exposure of the underlying silver layers and the complete wear of polyethylene on the medial side. Metallic debris had a peculiar arthrogram appearance, noted within the cut surface of the femur and tibia, indicative of the osteolysis that occurred, leading up to the failure of the implants. The histopathologic examination revealed a collection of macrophages with foreign-body reactions and black-pigmented metal-induced wear particles. Oxinium has clear benefits regarding superior wear properties; however, surgeons need to be aware that there is a risk of exposure to the underlying layers that may precede accelerated wear, deformation, and metallosis. Uncovering the deeper layers could result in the appearance of an arthrogram on plain radiographs. Early identification of polyethylene wear and prompt revision is crucial to avoid the rapid progression of subsequent metallosis and catastrophic implant failure, specifically when using oxidized zirconium components for TKA. To the best of our knowledge, this is the first report presenting a detailed histologic analysis to provide insight into the mechanisms of the failed Oxinium components.

Randomized clinical study of wear of enamel antagonists against polished monolithic zirconia crowns

OBJECTIVES

To test the hypothesis that there is no difference in the in vivo maximum wear of enamel opposing monolithic zirconia crowns, enamel opposing porcelain fused to metal crowns and enamel opposing enamel.

METHODS

Thirty patients needing single crowns were randomized to receive either a monolithic zirconia or metal-ceramic crown. Two non-restored opposing teeth in the same quadrants were identified to serve as enamel controls. After cementation, quadrants were scanned for baseline data. Polyvinylsiloxane impressions were obtained and poured in white stone. Patients were recalled at six-months and one-year for re-impression. Stone models were scanned using a tabletop laserscanner to determine maximum wear. Statistical analysis was performed using Mann-Whitney U to determine any significant differences between the wear of enamel against zirconia and metal-ceramic crowns.

RESULTS

Sixteen zirconia and 14 metal-ceramic crowns were delivered. There were no statistical differences in mean wear of crown types (p=0.165); enamel antagonists (p=0.235) and enamel controls (p=0.843) after one year.

CONCLUSION

Monolithic zirconia exhibited comparable wear of enamel compared with metal-ceramic crowns and control enamel after one year.

SIGNIFICANCE

This study is clinically significant because the use of polished monolithic zirconia demonstrated comparable wear of opposing enamel to metal-ceramic and enamel antagonists.

Extensive Bone Reaction From Catastrophic Oxidized Zirconium Wear

The use of alternative bearing surfaces for total hip arthroplasty has become popular to minimize wear and increase longevity, especially in young patients. Oxidized zirconium (Oxinium; Smith & Nephew, Memphis, Tennessee) femoral heads were introduced in the past decade for use in total hip arthroplasty. The advantages of oxidized zirconium include less risk of fracture compared with traditional ceramic heads. This case report describes a patient with a history of bilateral avascular necrosis of the femoral head after chemotherapy for acute lymphoblastic leukemia. Nonoperative management of avascular necrosis failed, and the patient was treated with bilateral total hip arthroplasty. The patient was followed at regular intervals and had slow eccentric polyethylene wear during a 10-year period. After 10 years, the patient had accelerated wear, with femoral and acetabular bone changes as a result of Oxinium and ultrahigh-molecular-weight polyethylene wear during a 6-month period. This article highlights the unusual accelerated bone changes that occurred as a result of Oxinium wear particles.

[(89)Zr]oxinate4 for long-term in vivo cell tracking by positron emission tomography

PURPOSE

(111)In (typically as [(111)In]oxinate3) is a gold standard radiolabel for cell tracking in humans by scintigraphy. A long half-life positron-emitting radiolabel to serve the same purpose using positron emission tomography (PET) has long been sought. We aimed to develop an (89)Zr PET tracer for cell labelling and compare it with [(111)In]oxinate3 single photon emission computed tomography (SPECT).

METHODS

[(89)Zr]Oxinate4 was synthesised and its uptake and efflux were measured in vitro in three cell lines and in human leukocytes. The in vivo biodistribution of eGFP-5T33 murine myeloma cells labelled using [(89)Zr]oxinate4 or [(111)In]oxinate3 was monitored for up to 14 days. (89)Zr retention by living radiolabelled eGFP-positive cells in vivo was monitored by FACS sorting of liver, spleen and bone marrow cells followed by gamma counting.

RESULTS

Zr labelling was effective in all cell types with yields comparable with (111)In labelling. Retention of (89)Zr in cells in vitro after 24 h was significantly better (range 71 to >90%) than (111)In (43-52%). eGFP-5T33 cells in vivo showed the same early biodistribution whether labelled with (111)In or (89)Zr (initial pulmonary accumulation followed by migration to liver, spleen and bone marrow), but later translocation of radioactivity to kidneys was much greater for (111)In. In liver, spleen and bone marrow at least 92% of (89)Zr remained associated with eGFP-positive cells after 7 days in vivo.

CONCLUSION

[(89)Zr]Oxinate4 offers a potential solution to the emerging need for a long half-life PET tracer for cell tracking in vivo and deserves further evaluation of its effects on survival and behaviour of different cell types.

Effect of sodium zirconium cyclosilicate on potassium lowering for 28 days among outpatients with hyperkalemia: the HARMONIZE randomized clinical trial

IMPORTANCE

Hyperkalemia is a common electrolyte abnormality that may be difficult to manage because of a lack of effective therapies. Sodium zirconium cyclosilicate is a nonabsorbed cation exchanger that selectively binds potassium in the intestine.

OBJECTIVE

To evaluate the efficacy and safety of zirconium cyclosilicate for 28 days in patients with hyperkalemia.

DESIGN, SETTING, AND PARTICIPANTS

HARMONIZE was a phase 3, multicenter, randomized, double-blind, placebo-controlled trial evaluating zirconium cyclosilicate in outpatients with hyperkalemia (serum potassium ≥5.1 mEq/L) recruited from 44 sites in the United States, Australia, and South Africa (March-August 2014).

INTERVENTIONS

Patients (n = 258) received 10 g of zirconium cyclosilicate 3 times daily in the initial 48-hour open-label phase. Patients (n = 237) achieving normokalemia (3.5-5.0 mEq/L) were then randomized to receive zirconium cyclosilicate, 5 g (n = 45 patients), 10 g (n = 51), or 15 g (n = 56), or placebo (n = 85) daily for 28 days.

MAIN OUTCOMES AND MEASURES

The primary end point was mean serum potassium level in each zirconium cyclosilicate group vs placebo during days 8-29 of the randomized phase.

RESULTS

In the open-label phase, serum potassium levels declined from 5.6 mEq/L at baseline to 4.5 mEq/L at 48 hours. Median time to normalization was 2.2 hours, with 84% of patients (95% CI, 79%-88%) achieving normokalemia by 24 hours and 98% (95% CI, 96%-99%) by 48 hours. In the randomized phase, serum potassium was significantly lower during days 8-29 with all 3 zirconium cyclosilicate doses vs placebo (4.8 mEq/L [95% CI, 4.6-4.9], 4.5 mEq/L [95% CI, 4.4-4.6], and 4.4 mEq/L [95% CI, 4.3-4.5] for 5 g, 10 g, and 15 g; 5.1 mEq/L [95% CI, 5.0-5.2] for placebo; P < .001 for all comparisons). The proportion of patients with mean potassium <5.1 mEq/L during days 8-29 was significantly higher in all zirconium cyclosilicate groups vs placebo (36/45 [80%], 45/50 [90%], and 51/54 [94%] for the 5-g, 10-g, and 15-g groups, vs 38/82 [46%] with placebo; P < .001 for each dose vs placebo). Adverse events were comparable between zirconium cyclosilicate and placebo, although edema was more common in the 15-g group (edema incidence: 2/85 [2%], 1/45 [2%], 3/51 [6%], and 8/56 [14%] patients in the placebo, 5-g, 10-g, and 15-g groups). Hypokalemia developed in 5/51 (10%) and 6/56 patients (11%) in the 10-g and 15-g zirconium cyclosilicate groups, vs none in the 5-g or placebo groups.

CONCLUSIONS AND RELEVANCE

Among outpatients with hyperkalemia, open-label sodium zirconium cyclosilicate reduced serum potassium to normal levels within 48 hours; compared with placebo, all 3 doses of zirconium cyclosilicate resulted in lower potassium levels and a higher proportion of patients with normal potassium levels for up to 28 days. Further studies are needed to evaluate the efficacy and safety of zirconium cyclosilicate beyond 4 weeks and to assess long-term clinical outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02088073.

In vivo evaluation of Zr-based bulk metallic glass alloy intramedullary nails in rat femora

Zr-based bulk metallic glasses (BMG) show high corrosion resistance in vitro and higher strength and lower Young's modulus than crystalline alloys with the similar composition. This study aimed to perform an in vivo evaluation of Zr65Al7.5Ni10Cu17.5 BMG. Osteotomy of the femur was done in rats and stabilized with intramedullary nails made of Zr65Al7.5Ni10Cu17.5 BMG, Ti-6Al-4V alloy, or 316L stainless steel. Systemic and local effects of each type of nail were evaluated by measuring the levels of Cu and Ni in the blood and the surrounding soft tissue. Changes of the surface of each nail were examined by scanning electron microscopy (SEM). Healing of the osteotomy was evaluated by peripheral quantitative computed tomography and mechanical testing. No increase of Cu and Ni levels was recognized. Surface of the BMG showed no noticeable change, while Ti-6Al-4V alloy showed Ca and P deposition and 316L stainless steel showed surface irregularities and pitting by SEM observation. The stress strain index, maximum torque, torsional stiffness, and energy absorption values were larger for the BMG than those for Ti-6Al-4V alloy, although there was no significant difference. The Zr-based BMG can promote osteotomy healing as fast as Ti-6Al-4V alloy, with the possible advantage of the Zr-based BMG that bone bonding is less likely, allowing easier nail removal compared with Ti-6Al-4V alloy. The Zr-based BMG is promising for the use in osteosynthetic devices that are eventually removed.

[Development of modified zirconia based dental material]

Ceramic materials are increasingly used in dentistry, because of their excellent biocompatibility. Zirconia based ceramic is unique among others due to its high flexural strength. This study examined physical and mechanical properties, as well as toxic and sanitary-chemical characteristics of zirconia based ceramics to select optimum compositions, in comply with the relevant requirements for medical consumables, particularly with materials for all-ceramic frameworks. The initial powders were synthesized in the systems ZrO2-Y2O3 (I), ZrO2-Yb2O3 (II), ZrO2-Y2O3-Yb2O3 (III). Four different zirconia based ceramics were investigated. We studied specific surface of powders, phase composition of the samples, relative density and porosity, flexural strength, fracture toughness, microstructure at x10 000 magnification. Toxicological and sanitary-chemical tests were conducted in accordance with ISO10993, GOST 52770-2007, GOST R 51148-98, GN 2.3.3.972-00 etc.

In vitro corrosion resistance and cytocompatibility of nano-hydroxyapatite reinforced Mg-Zn-Zr composites

Due to good biocompatibility and mechanical properties, magnesium (Mg) and its alloys are considered promising degradable materials for orthopedic applications. In this work, a Mg metal matrix composite (MMC) was fabricated using Mg-2.9Zn-0.7Zr alloy as the matrix and 1 wt% nano-hydroxyapatite (n-HA) particles as reinforcements. In vitro corrosion behavior and cytocompatibility of a Mg-Zn-Zr/n-HA composite and a Mg-Zn-Zr alloy were investigated. In contrast with the Mg-Zn-Zr alloy, the MMC has better properties. The average corrosion rate of MMC is 0.75 mm/yr after immersion in simulated body fluid (SBF) for 20 days, and the surface of MMC is covered with white Ca-P precipitates. The electrochemical test results show that the corrosion potential (E(corr)) of MMC increases to -1.615 V and its polarization resistance (R(p)) is 2.56 KOmega with the addition of n-HA particles. The co-cultivation of MMC with osteoblasts results in the adhesion and proliferation of cells on the surface of the composite. The maximum cell density is calculated to be (1.85+/-0.15) x 10(4)/l after 5 days of co-culture with osteoblasts. The average cell numbers for two groups after culturing for 3 and 5 days (P<0.05) are significantly different. All the results demonstrate that the Mg-Zn-Zr/n-HA composite can be potentially used as biodegradable bone fixation material.

Genotoxicity in primary human peripheral lymphocytes after exposure to radiopacifiers in vitro

Taking into consideration that DNA damage plays an important role in carcinogenesis, the purpose of this study was to evaluate whether some radiopacifiers widely used in clinical practice are able to induce genetic damage in primary human cells in vitro. Human peripheral lymphocytes obtained from 10 healthy volunteers were exposed to barium sulphate (BaSO(4)), zirconium oxide (ZnO(2)) and bismuth oxide (Bi(2)O(3)) at final concentrations ranging from 1 to 1000 microg/mL for 1 h at 37 degrees C. The negative control group was treated with vehicle control (phosphate buffer solution) for 1 h at 37 degrees C and the positive control group was treated with hydrogen peroxide (at 100 microM) for 5 min on ice. Results were analyzed by the Friedman non-parametric test. The results pointed all compounds tested out did not induce DNA breakage in human peripheral lymphocytes as depicted by the mean tail moment and tail intensity in all concentrations tested. In summary, our results indicate that exposure to these radiopacifiers may not be a factor that increases the level of DNA lesions in human peripheral lymphocytes as detected by single cell gel (comet) assay.

Early failure of a zirconia femoral head prosthesis: fracture or fatigue?

BACKGROUND

Zirconium ceramics are one of the most controversial prosthetic biomaterials with good mechanical properties on the one hand, but early failure incidents on the other hand. A case of an early failure of zirconia femoral head in a 73-year-old clergy man, who underwent a total hip arthroplasty 28 months before, is reported.

METHOD

The retrieved femoral head fragments, during revision surgery, were studied using scanning electron microscopy.

FINDINGS

Although a randomly occurred fracture without biomechanical significance can be a possible explanation, the collected data give evidence that initial non-critical microcracks or crazes due to contact stresses or strain mismatches or both between the ceramic head and the metallic tapered neck of the prosthesis led to the fatigue of the material. The final outcome was a catastrophic fracture of the head.

INTERPRETATION

Fixation of the neck into the zirconia head, with no mismatching or stress differences, would solve the fatigue-induced head destruction.

In vitro color changes of soft tissues caused by restorative materials

A crucial factor influencing implant esthetics is the color of the peri-implant mucosa. This in vitro study analyzed the effect of titanium and zirconia with and without veneering ceramic on the color of mucosa of three different thicknesses. Ten pig maxillae were used, and the palatal area was chosen as the test region. To simulate different mucosa thicknesses, connective tissue grafts, 0.5 mm and 1.0 mm thick, were harvested from three additional jaws. Defined mucosa thicknesses were created by placing the grafts under a palatal mucosa flap. Four different test specimens (titanium, titanium veneered with feldspathic ceramic, zirconia, and zirconia veneered with feldspathic ceramic) were placed under the mucosa, and the color of the tissue was evaluated with a spectrophotometer for three different soft tissue thicknesses (1.5, 2.0, and 3.0 mm). The color was compared to mucosa without test specimens, and the color difference (DeltaE) was calculated. All restorative materials induced overall color changes (DeltaE), which diminished with increases in soft tissue thickness. Titanium induced the most prominent color change. Zirconia did not induce visible color changes in 2.0-mm-thick and 3.0-mm-thick mucosa, regardless of whether it was veneered. However, with a mucosa thickness of 3.0 mm, no change in color could be distinguished by the human eye on any specimen. Mucosa thickness is a crucial factor in terms of discoloration caused by different restorative materials. In patients with thinner mucosa, zirconia will show the least color change.

Periurethral mass formations following bulking agent injection for the treatment of urinary incontinence

PURPOSE

Durasphere is gaining popularity as a bulking agent for treating women with stress urinary incontinence. We present a series of patients with periurethral mass formation following Durasphere injection.

MATERIALS AND METHODS

The charts of 135 women with a mean age of 69.4 years (range 46 to 83) who underwent Durasphere periurethral injections were retrospectively reviewed. Patients who had a periurethral mass were identified and their clinical data were collected and analyzed.

RESULTS

Four patients (2.9%) were diagnosed with periurethral mass formation 12 to 18 months (average 14.7) following a Durasphere injection. Clinical presentation varied, including irritative voiding symptoms, pelvic pain and urinary incontinence. All patients were found to have a tender and tense periurethral mass. A radiopaque mass was revealed during videourodynamic study in 1 patient. Incision, and transvaginal and endoscopic drainage or transvaginal excision were used to treat these masses. Intraoperative and pathological findings as well as operative outcomes are presented.

CONCLUSIONS

Irritative or obstructing voiding symptoms, pelvic pain or a periurethral mass in patients with a history of Durasphere or other periurethral bulking agent injection should alert the physician to the possibility of periurethral mass formation. The true incidence of this late complication remains to be determined.

Safety of carbon bead injection for incontinence in patients taking warfarin

OBJECTIVES

To determine the safety of the use of Durasphere in patients receiving warfarin anticoagulation.

METHODS

This case series included patients requiring long-term anticoagulation who also had intrinsic sphincteric deficiency or mixed urinary incontinence, and bladder outlets without hypermobility. All patients, with the exception of the 1 man in the study, were treated under local anesthesia with periurethral carbon bead injections, while receiving therapeutic doses of warfarin.

RESULTS

Between 1999 and 2004, 20 such patients received carbon bead injections, on 36 different occasions, during therapeutic warfarin administration. Two complications related to the anticoagulation were encountered, one minor complication of a small periurethral hematoma and the other more severe, with a patient developing urinary retention and intravesical hemorrhage.

CONCLUSIONS

In most cases, the injection of carbon beads under local anesthesia in patients receiving therapeutic warfarin anticoagulation can be safely performed without reversal of the anticoagulation.

Urethral prolapse after durasphere injection

Urethral prolapse is an uncommon condition among adult patients. We report a case of adult female patient with urethral prolapse after Durasphere injection. The patient was successfully treated with excision of the prolapsed urethra and Durasphere mass, and fibrin glue injection to support the remaining part of urethra.

Advancements in minimally invasive treatments for female stress urinary incontinence: Radiofrequency and bulking agents

Continuous advancements in materials technology have provided the possibility that multiple new urethral bulking agents will be available soon. Experience continues to accrue in clinical trials for urethral bulking with these agents. Parallel use for the indication of pediatric vesicourethral reflux also has provided evidence of biologic activity related to these compounds. All of the agents closest to complete analysis are synthetic and represent a variety of material types and characteristics. As these materials evolve, understanding of the preferential injection technique is being gained. Delivery methods and sites may prove to alter the biologic activity of these compounds substantially. Emphasis on other minimally invasive options for the surgical treatment of stress incontinence also has resulted in the development of radiofrequency vesicourethral suspension. Improved understanding of thermal application to tissue, acute and chronic tissue response to this application, and accumulating human experience with this method of therapy has provided an acceptable tolerability profile for this therapy. This profile may provide application of this method of therapy to an in-office treatment setting, precluding hospitalization and substantially decreasing convalescence times.

Fatigue performance and cyto-toxicity of low rigidity titanium alloy, Ti-29Nb-13Ta-4.6Zr

A beta type titanium alloy, Ti-29Nb-13Ta-4.6Zr, was newly designed and developed for biomedical applications. The new alloy contains non-toxic elements such as Nb, Ta, and Zr. In the present study, phases that appeared in the new alloy through various aging treatments were characterized by hardness tests and microstructural observations in order to identify the phase transformation. Fatigue properties of the new alloy were investigated. Young's modulus and cyto-toxicity of the new alloy were also evaluated. Precipitated phases distribute homogeneously over the whole specimen, and they are alpha phase, a small amount of omega phase, and beta phase when the new alloys are subjected to aging treatment at 673K for 259.2ks after solution treatment at 1063K for 3.6ks. The fatigue strength of the new alloy subjected to aging at 673K for 259.2ks after solution treatment at 1063K for 3.6ks is much better than when subjected to other aging treatments. In this case, the fatigue limit is around 700MPa. Young's modulus of the new alloy is much smaller than that of Ti-6Al-4V ELI. The cyto-toxicity of the new alloy is equivalent to that of pure Ti. Therefore, it is proposed that the new alloy, Ti-29Nb-13Ta-4.6Zr, will be of considerable use in biomedical applications.

Endoscopic evacuation of Durasphere

Durasphere is a urethral bulking agent used to treat stress urinary incontinence secondary to intrinsic sphincter deficiency. Although rare, chronic outlet obstruction and urinary retention are possible complications of this "permanent" bulking agent. We describe the endoscopic evacuation of Durasphere causing bladder outlet obstruction 1 year after being injected.

Particle migration after transurethral injection of carbon coated beads for stress urinary incontinence

PURPOSE

Despite 20 years of experience with injectable bulking agents for stress urinary incontinence results are rather disappointing. The satisfying initial results of collagen injection are rapidly decreasing with time, whereas synthetic bulking agents have shown problems with migration and biocompatibility. The ideal bulking agent would be permanent with a good clinical long-term success rate. We report our experience with Durasphere (Carbon Medical Technologies, Inc., St. Paul, Minnesota), a new injectable bulking agent containing carbon coated beads.

MATERIALS AND METHODS

Seven men and 13 women with a mean age of 62.5 years underwent transurethral submucosal injection. The 13 female patients had been diagnosed with type III stress urinary incontinence and each had undergone at least 1 unsuccessful previous operation for urinary incontinence. There were iatrogenic and traumatic sphincter lesions in 6 and 1 of the male patients, respectively. Mean volume injected per treatment was 6.0 cc. Mean followup was 10 months.

RESULTS

After 6 months 76.9% of the female patients were improved but after 12 months the success rate decreased to 33%. In the male patients after 6 months the success rate was 66%, which decreased to 33% after 12 months. At the 6-month followup we observed significant migration of the carbon coated beads into the local and distant lymph nodes as well as into the urethral mucosa.

CONCLUSIONS

Due to limited success and proved particle migration, carbon coated beads do not show any improvement over existing bulking materials. The clinical effect of bead migration must be determined before extended use of this substance.

A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere

OBJECTIVES

To assess the safety and effectiveness of Durasphere compared with bovine collagen in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

METHODS

This multicenter, randomized, controlled, double-blind trial was composed of 355 women diagnosed with SUI due to ISD and used a standardized pad test and the Stamey continence grade as the primary endpoints. The participants' ages ranged from 26 to 84 years. All patients had an abdominal leak point pressure of less than 90 cm H(2)O (average 51).

RESULTS

At 12 months after the first injection, the two materials were equivalent with respect to the improvement in continence grade and pad weight testing. Less Durasphere was injected to obtain comparable clinical results (Durasphere 4.83 mL versus bovine collagen 6.23 mL, P <0.001). When examined 1 year after the date of the last treatment, 49 (80.3%) of the 61 women treated with Durasphere showed improvement of 1 continence grade or more compared with 47 (69.1%) of 68 women treated with bovine collagen (P value for difference = 0.162). Although the adverse events reported for both groups were similar, the Durasphere group had an increased short-term risk of urgency and urinary retention.

CONCLUSIONS

The use of Durasphere for the treatment of SUI due to ISD was equally effective as bovine collagen and used less material. The U.S. Food and Drug Administration granted market approval for Durasphere on September 13, 1999. The product design and initial clinical data suggest the potential for greater durability of the clinical benefit, with the possibility of a permanent solution for SUI due to ISD in some patients.

Benign cellular responses in rats to different wear particles in intra-articular and intramedullary environments

We examined the cellular responses to various particles injected into the knees and the intramedullary femoral cavities of rats in the presence of polymethylmethacrylate (PMMA) plugs. The intra-articular particles were mainly ingested by synovial fibroblasts. Increased numbers of macrophages were not detected and there was only a slight increase in synovial thickness. Cellular responses in the intramedullary space were similarly mild and bone resorption around the PMMA plug did not occur. Bone formation was inhibited only by polyethylene particles. In contrast to current views, our study shows that wear particles per se do not initiate bone resorption.

Radio-opaque agents in bone cement increase bone resorption

A heavy infiltrate of foreign-body macrophages is commonly seen in the fibrous membrane which surrounds an aseptically loose cemented implant. This is in response to particles of polymethylmethacrylate (PMMA) bone cement and other biomaterials. We have previously shown that monocytes and macrophages responding to particles of bone cement are capable of differentiating into osteoclastic cells which resorb bone. To determine whether the radio-opaque additives barium sulphate (BaSO4) and zirconium dioxide (ZrO2) influence this process, particles of PMMA with and without these agents were added to mouse monocytes and cocultured with osteoblast-like cells on bone slices. Osteoclast differentiation, as shown by the presence of the osteoclast-associated enzyme tartrate-resistant acid phosphatase (TRAP) and lacunar bone resorption, was observed in all cocultures. The addition of PMMA alone to these cocultures caused no increase in TRAP expression or bone resorption relative to control cocultures. Adding PMMA particles containing BaSO4 or ZrO2, however, caused an increase in TRAP expression and a highly significant increase in bone resorption. Particles containing BaSO4 were associated with 50% more bone resorption than those containing ZrO2. Our results suggest that radio-opaque agents in bone cement may contribute to the bone resorption of aseptic loosening by enhancing macrophage-osteoclast differentiation, and that PMMA containing BaSO4 is likely to be associated with more osteolysis than that containing ZrO2.

Ceramic-ceramic and metal-polyethylene total hip replacements: comparison of pseudomembranes after loosening

We made a semiquantitative study of the comparative histology of pseudomembranes from 12 loose cemented ceramic-ceramic and 18 metal-polyethylene total hip replacements. We found no significant difference in cellular reaction between the two groups, but there was a major difference in the origin of the particulate debris. In the metal-polyethylene group, polyethylene of articular origin was predominant, while in the ceramic-ceramic group the cellular reaction appeared to be a response to zirconia ceramic particles used to opacify cement used for fixation. Isolation and characterisation of the debris showed that the zirconia particles formed the greatest proportion (76%) in ceramic-ceramic hips, while alumina debris of articular origin formed only 12%. Our study has indicated that aseptic loosening of ceramic cups is not due to a response to debris generated at the articular interface, but to mechanical factors which lead to fragmentation of the cement.

Absence of skin sensitivity to oxides of aluminium, silicon, titanium or zirconium in patients with Crohn's disease

BACKGROUND

Some metallic compounds, especially of zirconium, can cause cell mediated granulomatous inflammation of the skin. Pigment granules containing compounds of aluminium, silicon, and titanium have been observed within macrophages in the wall of the small intestine in health and in Crohn's disease. Zirconium compounds can be ingested in toothpaste.

AIM

To determine in a pilot study if granulomatous sensitivity can be detected to compounds of these metals or silicon after injection into the skin of patients with Crohn's disease.

SUBJECTS

Eight patients with Crohn's disease known to have had granulomata in the intestine and not currently treated with corticosteroids, and two healthy controls.

METHOD

Two intradermal injections each of 0.1 ml of a 0.02% suspension of one of the compounds made in the abdominal wall of each subject. The site was marked and full thickness skin biopsy performed six weeks later.

RESULT

A foreign body granuloma was observed on histological examination of two biopsy specimens but no evidence of a cell mediated response in any subject.

CONCLUSION

No support was found for the hypothesis that Crohn's disease is due to a specific sensitivity to ingested metallic or silicon compounds.

Evaluating the antagonistic wear of restorative materials when placed against human enamel

Several clinical and laboratory studies have reported data on the nature of tooth wear against restorative materials (that is, amalgam, gold, glass ceramic and various composite resin systems). Several antagonistic substrates are known to cause various in vitro wear rates when placed in opposition to enamel. In this study, the authors evaluated 10 commercially available posterior composite resin systems and a gold alloy control. The findings showed that posterior composite resins containing zirconium silicate or quartz fillers caused greater antagonistic enamel wear than did microfilled or barium silicate-filled composite resins.

Interstitial lung granulomas as a possible consequence of exposure to zirconium dust

A case of interstitial lung granulomas is described in a worker exposed to zirconium compounds. Chest X-rays revealed diffuse slight reticular interstitial radio-opacities (ILO classification, 1/0 s/t). Histological examination of transbronchial biopsy tissue revealed small interstitial nonconfluent granulomas with epithelioid and giant cells showing no central necrosis, with PAS-positive diastase-resistant small weakly birefringent particles in interstitial histiocytes. These histological and stain findings, which are characteristic of zirconium skin lesions and granulomas, suggest zirconium interstitial lung disease.

Evaluation of carcinogenicity and chronic toxicity associated with orthopedic implants in mice

The carcinogenicity and chronic toxicity of 316L stainless steel, nickel, Ti-6A1-4V, hydroxyapatite (HA)-coated Ti-6A1-4V, aluminum oxide containing yttrium oxide, and zirconium oxide containing yttrium oxide were evaluated by implanting solid rods of each material in the thigh muscle of C57BL/6N mice for 24 months. Nickel alloy showed high carcinogenic and toxic potencies, whereas other materials showed no evidence of them. Tumors retaining nickel alloys were malignant fibrous histiocytoma or fibrosarcoma. In some cases, lymphomata that seemed to develop spontaneously were found around the implants because lymphocytes were known to accumulate in chronic inflammatory lesions, and this phenomenon also might be applied to lymphoma.

Hypersensitivity pneumonitis and exposure to zirconium silicate in a young ceramic tile worker

We describe a nonsmoking ceramic tile worker 25 yr of age who developed a worsening dry cough and dyspnea after 3.5 yr as a sorter and glazer of tiles. Open lung biopsy revealed an intense granulomatous interstitial pneumonia with mild fibrosis, compatible with hypersensitivity pneumonitis, and numerous very small birefringent crystals around the terminal airways and occasionally in granulomas. Pulmonary particle analysis revealed an inhaled dust burden nearly 100-fold the normal background level, mainly consisting of clay minerals and zirconium silicate. The patient had no history or clinical or laboratory findings suggesting any organic etiologic agent. A sarcoid granulomatosis type of chronic pulmonary hypersensitivity reaction is known after long-term exposure to zirconium, but this case demonstrates that zirconium can also cause an acute and fulminant allergic alveolitislike hypersensitivity reaction.

Zirconium granuloma resulting from an aluminum zirconium complex: a previously unrecognized agent in the development of hypersensitivity granulomas

Zirconium compounds have been associated with the development of hypersensitivity granulomas. However, aluminum zirconium complexes have not previously been shown to induce sensitization. We present the clinical and histologic findings of a case in which a patient developed an acute hypersensitivity reaction to an aluminum zirconium complex.

Zirconium. An abnormal trace element in biology

The action of Zirconium (Zr) on biological systems presents an enigma. It is ubiquitous, being present in nature in amounts higher than most trace elements. It is taken up by plants from soil and water and accumulated in certain tissues. The entry into animal systems in vivo is related to the mode of exposure and the concentration in the surrounding environment. Retention is initially in soft tissues and then slowly in the bone. The metal is able to cross the blood brain-barrier and is deposited in the brain and the placental barrier to enter milk. The daily human uptake has been known to be as high as 125 mg. The level of toxicity has been found to be moderately low, both in histological and cytological studies. The toxic effects induced by very high concentrations are nonspecific in nature. Despite the presence and retention in relatively high quantities in biological systems, Zr has not yet been associated with any specific metabolic function. Very little information is available about its interaction with the compounds of the genetical systems, such as nucleic acids. Apparently, the metal is neither an essential nor toxic element in the conventional sense. However, the increasing exposure to this element through its increasing use in new materials and following radioactive fallout, has increased the importance of the study of its effects on living organisms. The tetravalent nature of the ionic state and the high stability of the compounds formed are important factors that need to be considered, as also the accumulation of this element in the brain, reminiscent of the relationship between Al3+ and Alzheimer's disease.

Zirconium compound-induced pulmonary fibrosis

Despite suspicion that inhalation of zirconium should be capable of causing human pulmonary disease, documentation of zirconium pneumoconiosis in humans has been lacking. We studied a likely case of zirconium compound-induced pulmonary fibrosis. The diagnosis was based on the following: (1) a history of gradual increase in symptoms and slowly progressing pulmonary fibrosis by chest roentgenogram compatible with a pneumoconiosis; (2) an appropriate history of exposure and a latency period of about 15 years before the onset of dyspnea and of roentgenographic changes; (3) analysis of open lung biopsy material revealing end-stage fibrosis and honeycombing, a moderate number of birefringent particles, and extremely high levels of a variety of zirconium compounds; and (4) no other potential cause of fibrosis. We conclude that zirconium should be considered a likely cause of pneumoconiosis and that appropriate precautions should be taken in the workplace.

[Comparative animal experiments on tissue compatibility and measurement of radioactivity of various roentgen contrast media]

In a comparative study the tissue reaction of several X-ray contrast materials was examined by subcutaneous and intraperitoneal application on rats. There were tested Bariumsulphate (BaSO4) and three Zircondioxyde (ZrO2) samples of several manufactures (cubic and monocline ZrO2-Feldmühle; Optipur-Merck). In the histologic evaluation no inflammatory signs could be seen. In case of BaSO4 the tissue reaction was more distinct than in the ZrO2 samples. Within the tested ZrO2 samples the differences were small; the cubic ZrO2 showed the slightest, the monocline one the relatively strongest cellular reaction. We also measured the radioactive emission by the contrast media. Here the monocline and--first of all--the cubic ZrO2 showed an alarming radioactive emission (radium 3000-11,500 Bq/kg). Only the Optipur (Merck) was free of radiation and can so be recommended for human implantation. Also the BaSO4 had no measurable radioactive Emission. Therefore only these two X-ray contrast media can be recommended for human implantation.

IgM antibody production in mice intraperitoneally injected with zirconium oxychloride

The effect of zirconium (Zr) on the humoral immune response was studied by measuring the level of IgM-plaque forming cells (IgM-PFC) against sheep red blood cells (SRBC) in the spleen of C57 BL mice intraperitoneally injected with zirconium oxychloride. Two experiments, a single injection of zirconium oxychloride of 1/5, 1/10, 1/50, and 1/100 of the LD50 for intraperitoneal injection and continuous injection of 1/20, 1/40, and 1/80 of the LD50 every other day for two or four weeks in mice, were carried out. In the case of a single injection zirconium oxychloride was intraperitoneally injected on days -1, 0, +1, +2, and +3 in relation to SRBC immunisation. The following conclusions may be drawn from this study: (1) Zr was shown to have an adjuvant like activity in relation to the humoral immune response, at least to IgM antibody production; (2) this effect was recognised not only with a single injection with Zr but also after continuous injection; (3) a single injection of Zr was more effective when the mice were treated with Zr 24 hours before or after SRBC immunisation; and (4) with regard to an injected dose of Zr, it was shown that a lower dose (1/50, 1/100 of the LD50 for a single injection and 1/40, 1/80 of the LD50 for continuous injection) led to a more enhanced level of IgM-PFC than a higher dose (1/5, 1/10 of the LD50 for a single injection, and 1/20 of the LD50 for continuous injection).

Periorbital granuloma annulare

A 40-year-old woman had erythematous, papular lesions on both periorbital areas. Histologic examination disclosed the presence of palisading granulomatous lesions. To our knowledge, periorbital granuloma annulare is extremely rare. Our experience demonstrates the importance of obtaining biopsy specimens from periorbital papules and considering granuloma annulare in the differential diagnosis of such lesions.

Evaluation of an occupational respiratory exposure to a zirconium-containing dust

A group of handfinishers of zirconium metal reactor components questioned whether the dust to which they were exposed would cause chronic lung disease or cancer, or both. To investigate this possibility, the work environment was surveyed, and 32 male employees who had worked as handfinishers from one to seventeen years, were compared to a group of controls in reference to a respiratory questionnaire, chest x-ray findings, and expiratory lung function tests. The controls were matched to the handfinishers for age, sex, payroll status and smoking history. No significant differences were found between the exposed and the control groups. Results of earlier animal respiratory studies vary from no effect to definite pathology. Previous employee exposure studies are short-term and have methodological shortcomings. It would appear that lifetime animal respiratory studies and systematic epidemiological studies of employee populations with long-term inhalation exposure are needed to demonstrate unequivocally whether zirconium and zirconium compounds are harmful.

Lung tumors from PuO2-ZrO2 aerosol particles in Syrian hamsters

Syrian golden hamsters were given PuO2/ZrO2 particles via inhalation and/or Pu-laden ZrO2 ceramic 10-micron diameter microspheres lodged in the capillary bed of the lung. The mean initial lung burdens ranged from 8 nCi to 143 nCi for the six experimental groups of animals. Significant numbers of primary lung tumors (5-50% per group) were induced in those animals that received inhalation exposures. Additional alpha radiation administered via Pu-laden intravenous microspheres had little or no effect on tumorigenesis or the production of non-neoplastic, degenerative changes in the respiratory tract.