Impact of systemic diseases and tooth-based factors on outcome of root canal treatment

AIM

To investigate the impact of systemic health and tooth-based factors on the outcome of root canal treatment (RCT).

METHODOLOGY

The target population consisted of all patients receiving RCT at the Helsinki University Clinic in 2008-2011. The inclusion criteria were diagnosable pre- and postoperative (minimum 6 months after root filling) radiographs and adequate patient records of RCT available. Teeth extracted for nonendodontic reasons were excluded. Patient documents including digital radiographs of 640 permanent teeth in 504 patients were scrutinized. The radiographs were assessed by two examiners under standardized conditions. The Periapical Index was used to define radiographically 'healthy' and 'healing' cases as successful. Data included systemic health, technical quality of root fillings, type of restoration and level of alveolar bone loss. Statistical evaluation of differences between groups included chi-squared tests and Fisher's exact tests. Logistic regression modelling utilizing robust standard errors to allow for clustering within patients was applied to analyse factors related to the outcome of RCT.

RESULTS

The mean age of patients was 51.5 years (standard deviation (SD) 15.0; range 10-83), and 49% were female. In 41 cases (6%), the patient had diabetes mellitus (DM), in 132 (21%) cardiovascular disease and in 284 (44%) no systemic disease. The follow-up period was 6-71 months (mean 22.7). In the primary analyses, the success rate of RCT was 73.2% in DM patients and 85.6% in patients with no systemic disease (P = 0.043); other systemic diseases had no impact on success. In the multifactorial analysis, the impact of DM became nonsignificant and RCTs were more likely to succeed in the absence of apical periodontitis (AP; odds ratio (OR) = 4.4; P < 0.001), in teeth with optimal root filling quality (OR = 2.5; P < 0.001), in teeth restored with indirect restorations (OR = 3.7; P = 0.002) and in teeth with none/mild alveolar bone loss (OR = 2.4; P = 0.003).

CONCLUSIONS

DM diminished the success of RCT, especially in teeth with apical periodontitis. However, tooth-based factors had a more profound impact on the outcome of RCT. This should be considered in clinical decision-making and in assessment of RCT prognosis.

Priority criteria tool for elective specialist level adolescent psychiatric care predicts treatment received

BACKGROUND

Little validation data has so far been published on scoring systems and the literature on prioritization in psychiatry is especially meagre.

OBJECTIVE

To explore if the priority criteria score for elective specialist level adolescent psychiatric care in Finland is associated with treatment received and whether the association between the priority criteria scores and treatment given is similar among different subgroups.

METHODS

Adolescents currently in treatment contact in three adolescent psychiatric outpatient clinics (n = 450) were rated according to the criteria of the priority rating tool for specialist level adolescent psychiatric care and information about adolescent's age, sex, diagnosis, and treatments was gathered using a structured form.

RESULTS

When sex, age and psychiatric diagnosis were controlled for, the likelihood of receiving specific therapies and medications was significantly associated with the highest priority scores. Except for very frequent individual therapy, there were no differences in the probability of receiving any psychosocial treatment or medication between the sexes. Receiving individual therapy, lengthy treatment contacts and medications were more frequent among older adolescents. The rating tool worked best among adolescents with affective or anxious disorders and worst among those with conduct disorders.

CONCLUSION

The present study indicates that the structured tool used in Finland, originally modified from a Canadian priority rating tool for child and adolescent psychiatry, is able to identify adolescents requiring specified, multiple and lengthy treatments, indicating a need for specialist level services. The scoring system tested is a good candidate for a transparent prioritization tool for European adolescent psychiatric services.

Alexithymia and Depression: A Prospective Study of Patients With Major Depressive Disorder

The authors conducted a 12-month follow-up study to determine the association between alexithymia and depression in 116 outpatients with major depressive disorder (MDD) and 540 control subjects from the general population. Alexithymia was screened using the Toronto Alexithymia Scale (TAS-20), and depression was assessed using the Beck Depression Inventory (BDI). The results show that the severity of depression was significantly associated with alexithymia. In addition, the BDI scores increased or decreased proportionately with the change in TAS-20 score in both groups. These results lend further support to the idea that alexithymia may be a state-dependent phenomenon.

A pessimistic attitude towards the future and low psychosocial functioning predict psychiatric diagnosis among treatment-seeking adolescents

OBJECTIVE

The objective was to study factors associated with psychiatric diagnosis among adolescents (n = 164) seeking psychiatric care for mental symptoms.

METHOD

Psychiatric diagnosis was confirmed by a structured diagnostic interview. Psychosocial functioning was assessed with the Global Assessment of Functioning Scale, and the Beck Depression Inventory and Offer Self-Image Questionnaire were also used. Background data were gathered.

RESULTS

A majority (76%) of the adolescents met DSM-III-R criteria for psychiatric diagnosis. The self-image was more negative and the Beck score was higher among these adolescents than the others. All who had attempted suicide had a psychiatric disorder. Those diagnosed as having a psychiatric disorder consumed alcohol in order to get drunk more often than others. Continual conflicts with parents and smoking were not associated with the existence of a psychiatric disorder. In logistic regression analysis, low psychosocial functioning (OR = 3.9) and an uncertain or pessimistic attitude towards the future (OR = 9.1) proved to be independent risk factors for psychiatric disorders.

CONCLUSIONS

Health service staff should be aware of factors associated with psychiatric disorders in adolescents so that they can identify those at high risk.

Self-reported life satisfaction and recovery from depression in a 1-year prospective study

OBJECTIVE

To study the relationship of a self-rated four-item life satisfaction scale (LS) to the self-rated 21-item Beck Depression Inventory (BDI) and the 17-item Hamilton Rating Scale for Depression (HAMD) and to study LS changes during recovery from depression.

METHOD

A 1-year prospective study on 188 depressive patients receiving standard psychiatric outpatient treatment; 137 of the patients had major depression.

RESULTS

LS correlated strongly with BDI and HAMD. It explained 46.6%) of the variation in BDI at baseline and 66.2% at 12 months. LS improved substantially during recovery. The main recovery occurred during the first 6 months, the change in the LS score explaining 46.5% of the change in the BDI score (P < 0.001).

CONCLUSION

Life satisfaction is strongly affected in depression, but it improves concurrently with recovery from depression. LS scale may prove useful in screening for those whose subjective wellbeing deserves attention and in assessing alleviation from depression.

An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii

OBJECTIVES

Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii.

METHODS

Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses.

RESULTS

Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women.

CONCLUSIONS

Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.

An international comparison of cancer survival: relatively poor areas of Toronto, Ontario and three US metropolitan areas

BACKGROUND

This study of cancer survival compared adults in Toronto, Ontario and three US metropolitan areas: Seattle, Washington; San Francisco, California; and Hartford, Connecticut. It examined whether socioeconomic status has a differential effect on cancer survival in Canada and the United States.

METHODS

The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology and End

RESULTS

(SEER) programme provided a total of 23,437 and 37,329 population-based primary malignant cancer cases for the Toronto and US samples, respectively (1986-1988, followed until 1994). Census-based measures of socioeconomic status were used to ecologically control absolute income status.

RESULTS

Among residents of low-income areas, persons in Toronto experienced a 5 year survival advantage for 13 of 15 cancer sites [minimally one gender significant at 95 per cent confidence interval (CI)]. An aggregate 35 per cent survival advantage among the Canadian cohort was demonstrated (survival rate ratio (SRR) = 1.35, 95 per cent CI= 1.30-1.40), and this effect was even larger among younger patients not yet eligible for Medicare coverage in the United States (SRR = 1.46, 95 per cent CI = 1.40-1.52).

CONCLUSION

Systematically replicating a previous Toronto-Detroit comparison, this study's observed consistent pattern of Canadian survival advantage across various cancer sites suggests that their more equitable access to preventive and therapeutic health care services may be responsible for the difference.

Effects of therapeutic touch on biochemical and mood indicators in women

Previous research has shown therapeutic touch (TT) to be effective in reducing anxiety and discomfort and promoting relaxation. The present investigation experimentally evaluated the effects of TT on biochemical indicators and moods in a sample of 41 healthy female volunteers. Participants were randomly assigned to either an experimental group who received TT or to a control group who did not receive TT. Pretest and posttest urine samples were collected, and personality and mood inventories were administered across three consecutive monthly sessions. Results indicated that mood disturbance in the experimental group decreased significantly over the course of the three sessions, while the control group increased in mood disturbance over time. Specifically, experimental group participants showed significant reductions in tension, confusion, and anxiety and a significant increase in vigor across sessions. Analyses of the biochemical data indicated that TT produced a significant decrease in levels of nitric oxide in the experimental group by the third TT session. The results of the present investigation have important implications for reducing symptom distress in cancer patients undergoing chemotherapy.

Association between socioeconomic status and cancer incidence in Toronto, Ontario: possible confounding of cancer mortality by incidence and survival

OBJECTIVE

To observe the association between socioeconomic status (SES) and cancer incidence in a cohort of Canadians.

DESIGN

Cases of primary malignant cancer (83,666) that arose in metropolitan Toronto, Ont., from 1986 to 1993 were ascertained by the Ontario Cancer Registry and linked by residence at the time of diagnosis to a census-based measure of SES. Socioeconomic quintile areas were then compared by cancer incidence.

RESULTS

Significant associations between SES and cancer incidence in the hypothesized direction--greater incidence in low-income areas--were observed for 15 of 23 cancer sites.

CONCLUSIONS

These findings, together with the recently observed consistent pattern of significant associations between SES and cancer survival in the United States and the equally consistent pattern of nonsignificant associations in Canada, support the notion that differences in cancer incidence alone explain the observed cancer mortality differentials by SES in Canada. The cancer mortality differential by SES observed in the United States is probably a function of differences in both incidence and length of survival, whereas in Canada such mortality differentials are more likely to be merely a function of differences in incidence by SES. This pattern of associations primarily implicates differences in the 2 health care systems; specifically, the more egalitarian access to preventive, investigative and therapeutic services available in the single-payer Canadian system.

Body image and psychopathology in adolescence: a controlled clinical study

The aim of this study was to investigate mentally disturbed adolescents' problems of acknowledging and accepting the physical changes and sexual maturation of their bodies, in comparison with healthy adolescents. The study sample consisted of 60 adolescents (30 boys and 30 girls), 15-18 years of age, who had been referred for psychiatric examination, and 60 healthy controls, matched on the basis of age, sex, place of residence and level of education. The study methods were the self-rated questionnaire and psychiatric in-depth interview modified on the basis of the diagnostic profile of adolescents. Mentally disturbed adolescents had more negative attitudes towards developmental body changes than healthy adolescents. They were unable to describe the physical changes they had undergone. Healthy adolescents were more aware of developing sexual characteristics. On discriminant analysis, independent background variables explaining problems relating to sexual maturation in mentally disturbed adolescents were found to be a lack of or low number of peer relationships, and long-term stress. In the healthy adolescents, independent variables associated with problems in sexual maturation were found to be a lack of or low number of peer relationships and a single-parent home. We conclude that adolescents with psychiatric problems seem to have a poorer capacity to process mentally the ongoing bodily and sexual maturation of their bodies than matched healthy controls.

Breast irradiation in women with early stage invasive breast cancer following breast conservation surgery. Provincial Breast Disease Site Group

GUIDELINE QUESTIONS

1) Should breast irradiation be given to women with early stage invasive breast cancer (stage I and II) following breast conservation surgery (lumpectomy with clear resection margins and axillary dissection)? 2) Is there an optimal schedule for breast irradiation? 3) What is a reasonable interval between definitive surgery and the start of breast irradiation? 4) Are there patients who can be spared breast irradiation after lumpectomy?

OBJECTIVE

To make recommendations about the use of breast irradiation in women with early stage invasive breast cancer following breast conservation surgery.

OUTCOMES

Local control is the primary endpoint of interest. Survival, quality of life (addressed through the adverse effects of radiotherapy) and cosmesis are also considered.

PERSPECTIVE (VALUES)

Evidence was selected and reviewed by 6 members of the Breast Disease Site Group (Breast DSG) of the Ontario Cancer Treatment Practice Guidelines Initiative. Earlier drafts of the evidence-based recommendation were reviewed, discussed and approved by the Breast DSG, which comprises medical oncologists, radiation oncologists, surgeons, epidemiologists, pathologists and a medical sociologist. There was no participation by a community representative in the development of this guideline.

QUALITY OF EVIDENCE

There are 5 randomized controlled trials (RCTs) and 1 meta-analysis comparing breast irradiation with no breast irradiation following breast conservation surgery; 6 randomized trials comparing breast conservation surgery plus breast irradiation with mastectomy are also included, as well as several retrospective studies.

BENEFITS

All of the 5 RCTs showed a significant decrease in local recurrence rates among patients receiving radiotherapy. In the 4 trials with a median follow-up of 5 years or longer, the relative risk reduction with breast irradiation ranged from 69% to 88%. The absolute differences ranged from 16% (p < 0.001) to 25% (p < 0.001). Despite the effect on local recurrence, no difference in survival was detected in any of the 5 trials. Most of the patients with local recurrence in these trials underwent mastectomy.

HARMS

Major adverse effects of breast irradiation occur very infrequently.

PRACTICE GUIDELINE

Women with early stage invasive breast cancer (stage I and II) who have undergone breast conservation surgery should be offered postoperative breast irradiation. The optimal fractionation schedule for breast irradiation has not been established, and the role of boost irradiation is unclear. Outside of a clinical trial, 2 commonly used fractionation schedules are suggested: 50 Gy in 25 fractions to the whole breast, or 40 Gy in 16 fractions to the whole breast with a local boost to the primary site of 12.5 Gy in 5 fractions. Shorter schedules (e.g., 40 or 44 Gy in 16 fractions) have also been used routinely in some centres. The enrollment of patients in ongoing clinical trials is encouraged. Women who have undergone breast conservation surgery should receive local breast irradiation as soon as possible after wound healing. A safe interval between surgery and the start of radiotherapy is unknown, but it is reasonable to start breast irradiation within 12 weeks after definitive surgery. For women who are candidates for chemotherapy, the optimal sequencing of chemotherapy and breast irradiation is unknown. It is reasonable to start radiotherapy after the completion of chemotherapy, or concurrently if anthracycline-containing regimens are not used. For further information, please refer to Ontario Cancer Treatment Practice Guidelines Initiative's practice guideline "Surgical Management of Early Stage Invasive Breast Cancer (stage I and II)."

An international comparison of cancer survival: Toronto, Ontario, and Detroit, Michigan, metropolitan areas

OBJECTIVES

This study examined whether socioeconomic status has a differential effect on the survival of adults diagnosed with cancer in Canada and the United States.

METHODS

The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program provided a total of 58,202 and 76,055 population-based primary malignant cancer cases for Toronto, Ontario, and Detroit, Mich, respectively. Socioeconomic data for each person's residence at time of diagnosis were taken from population censuses.

RESULTS

In the US cohort, there was a significant association between socioeconomic status and survival for 12 of the 15 most common cancer sites; in the Canadian cohort, there was no such association for 12 of the 15 sites. Among residents of low-income areas, persons in Toronto experienced a survival advantage for 13 of 15 cancer sites at 1- and 5-year follow-up. No such between-country differentials were observed in the middle- or high-income groups.

CONCLUSIONS

The consistent pattern of a survival advantage in Canada observed across various cancer sites and follow-up periods suggests that Canada's more equitable access to preventive and therapeutic health care services is responsible for the difference.

The role of prophylactic brain irradiation in limited stage small cell lung cancer: clinical, neuropsychologic, and CT sequelae

Ninety-four patients with limited stage small cell lung cancer treated between 1981 and 1985 with a regimen including prophylactic brain irradiation (PBI) after combination chemotherapy were assessed for compliance with PBI, brain relapse, and neurologic morbidity. Seventy-seven percent of patients had PBI and of these, 22% developed brain metastases after a median time of 11 months post treatment. The brain was the apparent unique initial site of relapse in 10% of PBI cases but more commonly brain relapse was preceded or accompanied by failure at other sites, especially the chest. Brain metastases were the greatest cause of morbidity in 50% of PBI failures. Twelve of 14 PBI patients alive 2 years after treatment had oncologic, neurologic, and neuropsychological evaluation, and brain CT. All long-term survivors were capable of self care and none fulfilled diagnostic criteria for dementia, with three borderline cases. One third had pretreatment neurologic dysfunction and two thirds post treatment neurologic symptoms, most commonly recent memory loss. Fifty percent had subtle motor findings. Intellectual functioning was at the 38th percentile with most patients having an unskilled occupational history. Neuropsychologic impairment ratings were borderline in three cases and definitely impaired in seven cases. CT scans showed brain atrophy in all cases with mild progression in those having a pre-treatment baseline. Periventricular and subcortical low density lesions identical to the CT appearance of subcortical arteriosclerotic encephalopathy were seen in 82% of posttreatment CT studies, and lacunar infarcts in 54%. Neuropsychologic impairment scores and the extent of CT periventricular low density lesions were strongly associated (rank correlation 0.7, p less than .05). Overall, PBI after intensive combination chemotherapy did not induce gross dementia or neurologic dysfunction but its risk/benefit ratio is not overwhelmingly favorable, with failure to prevent brain relapse in 1/5 patients and subtle but detectable motor findings and neuropsychologic impairment in the majority.

Management of seminoma with bulky abdominal disease

Thirty-three cases of seminoma with palpable abdominal disease were treated at the Cancer Control Agency of B.C. between 1948 and 1983. Twenty-three had disease confined to the abdomen (Stage IIB), eight had simultaneous involvement of mediastinal and supraclavicular nodes (Stage IIIB) and two had bone or pulmonary metastases (Stage IV). Five and 10-year disease-specific actuarial survivals for the whole group were 87% and 81%, respectively. Corresponding relapse-free survival was 64%. Of the twenty-three IIB cases, 15 had primary treatment with abdominal radiation only, and eight had prophylactic mediastinal/supraclavicular radiation. Although relapse in IIB was more common in the group receiving abdominal radiation only, survival was unchanged. For the entire IIB group, 5- and 10-year disease-specific actuarial survivals were 91% and 84%, respectively, and corresponding relapse-free survival was 74%. The eight IIIB patients were treated primarily with radiation. Four patients relapsed, all in extranodal sites. Two of these died of disease. Both Stage IV patients required radiation and chemotherapy for long-term disease control. Stage IIB disease can be treated primarily with abdominal radiation, but radiation alone is inadequate when bulky abdominal disease is associated with supradiaphragmatic lymphatic spread or hematogenous metastases.

Well-differentiated squamous cell carcinoma of the thymus

Images

Laser treatment of obstructive endobronchial tumors: factors which determine response

To investigate whether computerized tomography (CT) and radionuclide quantitative ventilation-perfusion lung scan add any useful information to a carefully performed endoscopic examination in determining the response of patients with obstructive endobronchial tumors to laser treatment, the findings in 40 patients treated with photodynamic therapy (PDT) or the Nd:YAG laser were analysed. Endoscopic laser treatment was found to be most effective when the tumor was polypoid in appearance bronchoscopically, with little or no submucosal invasion or peribronchial extension seen on CT. When bronchoscopy and CT showed increasing submucosal and/or peribronchial disease, the immediate and long-term response to treatment was poorer. CT provided valuable information regarding the extent of the peribronchial involvement and airway distortion which were often underestimated by bronchoscopy alone. Reduction of regional perfusion out of proportion to ventilation on scintigraphy in the involved lung zone was found to be associated with extensive peribronchial involvement. We conclude that the addition of CT and radionuclide quantitative ventilation-perfusion lung scan to bronchoscopic examination is useful in predicting the response of patients with obstructive endobronchial tumors to laser treatment. Whether PDT or YAG laser is more effective in relieving endobronchial obstruction by tumor awaits a randomized controlled trial.

Alternating chemotherapy and thoracic radiotherapy with concurrent cisplatin-etoposide for limited-stage small-cell carcinoma of the lung

Seventy patients with limited-stage small-cell lung cancer (SCLC) were given six courses of chemotherapy alternating two drug combinations: a combination of cyclophosphamide, doxorubicin (Adriamycin [Adria Laboratories, Columbus OH]) and vincristine (CAV) was alternated with cisplatin and etoposide at 3-week intervals. Thoracic radiotherapy was administered concurrently with the first cisplatin-etoposide chemotherapy. Prophylactic cranial irradiation (PCI) was administered after the completion of all chemotherapy. No maintenance treatment was used. Seventy-six percent of patients achieved a complete clinical response. The median survival was 78 weeks and the 2-year survival rate was 32% with an average follow-up of 3 1/2 years. Seventeen percent are currently alive and disease free. Cisplatin and etoposide can be administered concurrently with thoracic irradiation with acceptable toxicity. Our results justify further clinical research using alternating chemotherapy and concurrent thoracic irradiation and cisplatin-etoposide chemotherapy.