Peripheral nervous system involvement in primary burning mouth syndrome--results of a pilot study

OBJECTIVE

The pathophysiology of primary burning mouth syndrome (BMS) has remained enigmatic, but recent studies suggest pathology within the nervous system at multiple levels. This study aimed to investigate in detail the contribution of either focal or generalized alterations within the peripheral nervous system (PNS) in the etiopathogenesis of BMS.

SUBJECTS AND METHODS

Intraepithelial nerve fiber density (IENFD) of tongue mucosa was assessed in 10 carefully characterized BMS, and the results were compared to 19 age- and gender-matched cadaver controls, 6 with lifetime diabetes. Extensive neurophysiologic and psychophysical examinations of the trigeminal system and distal extremities were performed to profile PNS function in BMS.

RESULTS

Patients with BMS had significantly fewer intraepithelial nerve fibers (0,27, s.e. 0,18 mm(-1); P = 0.0253) than non-diabetic controls (0,92, s.e. 0,15 mm(-1)). In the subepithelial space, the amount of nerve fibers did not differ between the groups. The majority (9/10) of patients with BMS showed neurophysiologic or psychophysical signs of a more generalized PNS dysfunction.

CONCLUSIONS

Our results in neurophysiologically optimally characterized BMS patients confirm that pure focal small fiber neuropathy of the oral mucosa has a role in the pathophysiology of primary BMS. Furthermore, BMS may be related to a more generalized, yet subclinical peripheral neuropathy.

Acoustic and neurophysiologic observations related to lingual nerve impairment

The purpose of this study was to determine the acoustic effects of lingual nerve impairment on speech. Neurophysiologic examination and thermal quantitative sensory testing (QST) were carried out to determine if the profile, type or severity of sensory nerve impairment had effects on the degree of speech changes. The study group consisted of 5 women and 5 men with lingual nerve damage following an oral and maxillofacial surgery procedure. Time interval between the examination and the nerve damage ranged from 1 month to 20 years. Formants and fundamental frequency and duration of vowel sounds were analyzed. The patients underwent sensory tests, blink reflex and thermal QST of the lingual nerve area. The lingual nerve impairment had effects on the central acoustic features of vowel sounds. A relationship was observed between warm detection threshold values and the magnitude of second formant changes in men. It is concluded that lingual nerve impairment has gender-specific effects on speech. The variability in the acoustic changes of vowel sounds between different patients indicates individual compensatory manners of speech production following lingual nerve impairment.

Interventions for the treatment of burning mouth syndrome

BACKGROUND

The complaint of a burning sensation in the mouth can be said to be a symptom of other disease or a syndrome in its own right of unknown aetiology. In patients where no underlying dental or medical causes are identified and no oral signs are found, the term burning mouth syndrome (BMS) should be used. The prominent feature is the symptom of burning pain which can be localised just to the tongue and/or lips but can be more widespread and involve the whole of the oral cavity. Reported prevalence rates in general populations vary from 0.7% to 15%. Many of these patients show evidence of anxiety, depression and personality disorders.

OBJECTIVES

The objectives of this review are to determine the effectiveness and safety of any intervention versus placebo for relief of symptoms and improvement in quality of life and to assess the quality of the studies.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register (20 October 2004), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004), MEDLINE (January 1966 to October 2004), EMBASE (January 1980 to October). Clinical Evidence Issue No. 10 2004, conference proceedings and bibliographies of identified publications were searched to identify the relevant literature, irrespective of language of publication.

SELECTION CRITERIA

Studies were selected if they met the following criteria: study design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) which compared a placebo against one or more treatments; participants - patients with burning mouth syndrome, that is, oral mucosal pain with no dental or medical cause for such symptoms; interventions - all treatments that were evaluated in placebo-controlled trials; primary outcome - relief of burning/discomfort.

DATA COLLECTION AND ANALYSIS

Articles were screened independently by two reviewers to confirm eligibility and extract data. The reviewers were not blinded to the identity of the studies. The quality of the included trials was assessed independently by two reviewers, with particular attention given to allocation concealment, blinding and the handling of withdrawals and drop outs. Due to both clinical and statistical heterogeneity statistical pooling of the data was inappropriate.

MAIN RESULTS

Nine trials were included in the review. The interventions examined were antidepressants (two trials), cognitive behavioural therapy (one trial), analgesics (one trial), hormone replacement therapy (one trial), alpha-lipoic acid (three trials) and anticonvulsants (one trial). Diagnostic criteria were not always clearly reported. Out of the nine trials included in the review, only three interventions demonstrated a reduction in BMS symptoms: alpha-lipoic acid (three trials), the anticonvulsant clonazepam (one trial) and cognitive behavioural therapy (one trial). Only two of these studies reported using blind outcome assessment. Although none of the other treatments examined in the included studies demonstrated a significant reduction in BMS symptoms, this may be due to methodological flaws in the trial design, or small sample size, rather than a true lack of effect.

AUTHORS' CONCLUSIONS

Given the chronic nature of BMS, the need to identify an effective mode of treatment for sufferers is vital. However, there is little research evidence that provides clear guidance for those treating patients with BMS. Further trials, of high methodological quality, need to be undertaken in order to establish effective forms of treatment for patients suffering from BMS.

National registry of patients with short bowel syndrome

In Sweden, with a population of 9 million, there are an estimated 400 people suffering from short bowel syndrome (SBS). These patients are dispersed throughout the country and are cared for mostly by ordinary health-care providers, who have limited experience with SBS. During the last decade the patients and their organizations have expressed increasing concerns about competent and equally distributed care. Against this background, the National Association of People with Stomach and Bowel Diseases, together with a faculty of experts in the field, created a web-based registry to facilitate follow-up and to improve quality of care of SBS patients. Their homepage, www.swegir.com/KTS, is based on the Swedish General Internet Registry administered by the Swedish Society of Surgery and Gastroenterology. Its homepage includes some information on SBS for the public, as well as links to a health manual on SBS and different associations. Behind a fire-wall, health professionals have access to an on-line registry for follow-up of patients with short bowel syndrome. In the future, on-line statistics regarding the number of complications, for example, will be available from the registry. Patients who would benefit from small bowel transplantation could also be identified.

Sensory regeneration following intraoperatively verified trigeminal nerve injury

OBJECTIVE

To follow recovery of sensory function mediated by both myelinated and unmyelinated axons in relation to the type of inferior alveolar nerve (IAN) injury.

METHODS

The authors assessed the function of afferent Abeta-, Adelta-, and C-fibers of the IAN using neurophysiologic (mental nerve blink reflex, sensory nerve conduction [NCS] of the IAN) and quantitative sensory tests (QST; cold, warm, heat pain, and tactile modalities). The tests were done 2 weeks, 1, 3, 6, and 12 months postoperatively and compared to the preoperative baseline in 20 patients undergoing mandibular bilateral sagittal split osteotomy. Nineteen patients underwent intraoperative monitoring.

RESULTS

In primarily demyelinating injuries (21/40 nerves), the sensory alteration and all tests normalized on the group level within the first 3 months. After partial axonal lesions (15/40 nerves), neurophysiologic and thermal QST results remained abnormal at 1-year control in a high proportion of the IAN distributions (up to 67%). At 1 year, the tactile QST was abnormal in 40%, but the NCS in 87% of the symptomatic IAN distributions. Neuropathic pain occurred in 5% of the patients, only after severe axonal damage.

CONCLUSIONS

Sensory nerve conduction and thermal quantitative sensory testing showed incomplete sensory regeneration at 1 year after axonal trigeminal nerve damage. Clinical examination with tactile quantitative sensory testing was less reliable in the follow-up of sensory recovery. Sensory Abeta-, Adelta-, and C-fibers recovered function at similar rates. The trigeminal nerve does not differ from other peripheral nerves as regards susceptibility to neuropathic pain.

Recovery of nerve injury after mandibular sagittal split osteotomy. Diagnostic value of clinical and electrophysiologic tests in the follow-up

The diagnostic value of several clinical, quantitative sensory tests (brush-stroke directional discrimination (BSD), touch detection threshold (TD), warm/cold (W/C) and sharp/blunt discrimination (S/B)), and electrophysiologic tests (mental nerve blink reflex (BR), nerve conduction study (NCS), cold (CDT), and warm (WDT) detection thresholds) in the recovery of inferior alveolar nerve (IAN) injury was evaluated in a prospective 1-year follow-up study of 20 patients after bilateral sagittal split osteotomy (BSSO). The subjective sensory alteration was assessed from patients' drawings. The predictive values of different tests at 2 weeks were determined in relation to the subjective sensory recovery at 12 months. The most pronounced recovery of the nerve damage occurred during the first 3 months according to all measures used. After 3 months, the electrophysiologic tests, especially the NCS, indicated significant further improvement. Except for the TD test, all other clinical test results were normal already at 3 months postoperatively. At early and late controls, the NCS and the thermal quantitative sensory testing could best verify the subjective sensory alteration, and most accurately assess the degree of thick and thin fibre dysfunction. At 1 year, the nerve dysfunction, as revealed by the NCS, corresponded with the figures of sensory alteration reported by the patients (35% R, 40% L). The W/C, BSD, S/B and WDT tests had the best early positive predictive values. Electrophysiologic tests had higher negative predictive values compared to clinical tests.

An evaluation of clinical and electrophysiologic tests in nerve injury diagnosis after mandibular sagittal split osteotomy

The yield of clinical sensory tests and electrophysiologic tests in the diagnostics of inferior alveolar nerve (IAN) damage after bilateral sagittal split osteotomy (BSSO) was studied. The diagnostic value of these tests was evaluated by comparing the test results to the degree of nerve damage at the end of the operation as documented by means of the intraoperative nerve conduction recording of the IAN. Twenty patients undergoing BSSO were analysed preoperatively and 2 weeks postoperatively. The frequency of the IAN disturbance ranged from 10% to 94% depending on the test method and the test site used. Of the clinical sensory tests, the touch detection threshold (TD) test was the most sensitive and clinically useful test. It also correlated best with the electrophysiologically verified intraoperative nerve damage (R = -0.603, P = 0.017 on the right, R = -0.626, P = 0.01 on the left). The blink reflex and quantitative cold detection threshold tests were almost as often abnormal as the TD-test, but nerve conduction study (NCS) was the most sensitive (88%) of all clinical and electrophysiologic tests. The frequency of abnormal findings in the electrophysiologic tests indicating IAN injury, 75% on the right side and 90% on the left side, corresponded exactly with the figures of subjective sensory alteration. Almost all electrophysiologic tests showed obvious associations with the objectively verified IAN damage. All tests, except the NCS, showed only moderate sensitivity. Specificity of the tests was generally high, the only exceptions being the TD test and the NCS. To increase the diagnostic accuracy of the testing and to detect different types of damage in different nerve fibre populations, a combination of different sensory and electrophysiologic tests is recommended.

Risk factors of nerve injury during mandibular sagittal split osteotomy

There is little objective data about whether surgical technique or mandibular anatomy are a risk for inferior alveolar nerve (IAN) injury during bilateral sagittal split osteotomy (BSSO). Orthodromic sensory nerve action potentials (SNAPs) of the IAN were continuously recorded on both sides in 20 patients with mandibular retrognathia during BSSO operation. Changes in latency, amplitude, and sensory nerve conduction velocity (SNCV) at baseline and at different stages of the operation were analyzed. The SNAP latencies prolonged, the amplitudes diminished, and the SNCVs slowed down during BSSO (P = 0.0000 for all parameters). The most obvious changes occurred during surgical procedures on the medial side of the mandibular ramus. There was a clear tendency towards more disturbed IAN conduction with longer duration of these procedures (right side R = -0.529. P = 0.02; left side R = -0.605, P = 0.006). Exposure or manipulation of the IAN usually had no effect on nerve function, but the IAN conduction tended to be more disturbed in cases with nerve laceration. Low corpus height (R = 0.802, P = 0.001) and the location of the mandibular canal near the inferior border of the mandible (R = 0.52, P = 0.02) may increase the risk of IAN injury. There was no correlation between the age of the patients and the electrophysiological grade of nerve damage.

Integrative group therapy outcome related to psychosocial characteristics in patients with chronic pain

Previous observations stress the importance of patient characteristics as contributors to treatment outcome. In this study the outcome of integrative pain group therapy was investigated in relation to prior treatment psychosocial characteristics in pain clinic outpatients with chronic pain. The patients participated in 10 weekly sessions (2 1/2 hours) of integrative pain group therapy consisting of cognitive-behavioural strategies and light physical exercises. After the 12-month follow-up the modified method of cluster analysis was applied on the admittance data of the sample of 47 patients in order to divide the subjects into three homogenized subgroups (Interpersonally Distressed patients, Adaptive Copers and Dysfunctional patients) with varying prior treatment characteristics. The outcome of treatment was analysed by comparing the effect of intervention on the psychosocial functional profiles of the subgroups. The functional profiles were assessed by a six-scale self-report questionnaire describing the psychosocial components of three functional dimensions as recommended by the World Health Organization (1999). The results supported the previous conclusions that prior treatment functional profiles are important contributors to pain treatment outcome. However, the results also suggested that cluster analysis technique may be a very robust method to divide patients into 'homogenized' subgroups.

Interventions for the treatment of burning mouth syndrome

BACKGROUND

The complaint of a burning sensation in the mouth can be said to be a symptom of other disease or a syndrome in its own right of unknown aetiology. In patients where no underlying dental or medical causes are identified and no oral signs are found, the term burning mouth syndrome (BMS) should be used. The prominent feature is the symptom of burning pain which can be localised just to the tongue and/or lips but can be more widespread and involve the whole of the oral cavity. Reported prevalence rates in general populations vary from 0.7% to 15%. Many of these patients show evidence of anxiety, depression and personality disorders.

OBJECTIVES

The objectives of this review are to determine the effectiveness and safety of any intervention versus placebo for relief of symptoms and improvement in quality of life and to assess the quality of the studies.

SEARCH STRATEGY

Electronic databases (The Cochrane Library, the Cochrane Oral Health Group's Specialised Register, MEDLINE, EMBASE), Clinical Evidence Issue No. 3, conference proceedings and bibliographies of identified publications were searched to identify the relevant literature, irrespective of language of publication.

SELECTION CRITERIA

Studies were selected if they met the following criteria: study design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) which compared a placebo against one or more treatments; participants - patients with burning mouth syndrome, that is, oral mucosal pain with no dental or medical cause for such symptoms; interventions - all treatments that were evaluated in placebo-controlled trials; primary outcome - relief of burning/discomfort

DATA COLLECTION AND ANALYSIS

Articles were screened independently by two reviewers to confirm eligibility and extract data. The reviewers were not blinded to the identity of the studies. The quality of the included trials was assessed independently by two reviewers, with particular attention given to allocation concealment, blinding and the handling of withdrawals and drop-outs. Due to differences in patient type, treatment and outcome measures, statistical pooling of the data was inappropriate.

MAIN RESULTS

Six trials were included in the review. The interventions examined were antidepressants (two trials), cognitive behavioural therapy (one trial), analgesics (one trial), hormone replacement therapy (one trial) and vitamin complexes (one trial). The participants included in the six identified trials reported suffering from BMS from six months to 20 years. Diagnostic criteria were not always clearly reported. Out of the six trials included in the review, only two interventions demonstrated a reduction in BMS symptoms; vitamin complexes and cognitive behavioural therapy. Neither of these studies reported using blind outcome assessment. Although none of the other treatments examined in the included studies demonstrated a significant reduction in BMS symptoms, this may be due to methodological flaws in the trial design, or small sample size, rather than a true lack of effect.

REVIEWER'S CONCLUSIONS

Given the chronic nature of BMS, the need to identify an effective mode of treatment for sufferers is vital. However, there is little research evidence that provides clear guidance for those treating patients with BMS. Further trials, of high methodological quality, need to be undertaken in order to establish effective forms of treatment for patients suffering from BMS.

Intraoperative monitoring of the inferior alveolar nerve during mandibular sagittal-split osteotomy

In order to evaluate the risk of nerve injury and to prevent iatrogenic damage at different stages of bilateral sagittal-split osteotomy (BSSO) of the mandible, we monitored the function of the inferior alveolar nerve (IAN) continuously on both sides in 13 orthognathic patients undergoing BSSO. The IAN was stimulated at the mental foramen with two monopolar needle electrodes fixed to the dental splint, and the orthodromic sensory nerve action potentials (SNAP) of the IAN were recorded with a silver-wire electrode inserted near the oval foramen on each side. The latencies, amplitudes, and sensory nerve conduction velocities at baseline, after medial opening, sawing, splitting, eventual manipulation, and fixation of the mandible were analyzed. The monitoring method functioned technically well in 25 of 26 nerves. Both the surgical technique and the duration of medial opening had conspicuous effects on the function of the IAN, which led us to modify the medial approach. When finer instruments were used for retraction and the duration of medial opening was shortened to less than 10 min, the SNAP of the IAN was always preserved at this stage. Monitoring of the IAN also prevented nerve injury during splitting and fixation. This technique for intraoperative monitoring of the IAN seems to be a feasible and promising tool for objective evaluation of intraoperative events and for prevention of nerve injury during BSSO.

Piperacillin/tazobactam compared with cefuroxime/ metronidazole in the treatment of intra-abdominal infections

OBJECTIVE

To assess the effect of piperacillin/tazobactam compared with cefuroxime/metronidazole in the treatment of patients with intra-abdominal infections.

DESIGN

Randomised open study.

SETTING

16 Swedish and 6 Norwegian hospitals.

SUBJECTS

269 patients with intra-abdominal infections were randomised and treated with at least one dose of each study drug. 205 patients, 105 treated with piperacillin/tazobactam and 100 with cefuroxime, were clinically evaluable for follow up (had been given the full course of treatment).

INTERVENTION

Patients were given piperacillin 4g/tazobactam 0.5 g every 8 hours or cefuroxime 1.5 g every 8 hours plus metronidazole 1.5 g every 24 hours. Each patient was to be treated for a minimum of 3 days and not more than 10 days.

MAIN OUTCOME MEASURES

Clinical evaluation of infection at the end of and 4-6 weeks after treatment. Evaluation of safety and tolerance to the drugs and bacteriological susceptibility to the treatment drugs.

RESULTS

In the intention to treat analysis treatment was equally successful for piperacillin/ tazobactam (103/140, 74%) and the cefuroxime/metronidazole groups (90/129, 70%) (p = 0.6). Corresponding figures for the clinically evaluable group were 102/105 (97%) and 94/100 (94%) for piperacillin/tazobactam and cefuroxime/metronidazole groups, respectively, at the end of treatment. At late follow up, 92/105 (88%) and 83/100 (83%) in the two groups, respectively, remained free of infection. The side effects of the treatment were mild and evenly distributed between the two groups. Most pathogens were susceptible to the drugs in both treatment groups.

CONCLUSION

Both piperacillin/tazobactam and cefuroxime/metronidazole are well suited to the treatment of patients with intra-abdominal infections, and we found no significant difference between the two. The drugs were safe and well tolerated in the regimens used.

Trazodone in burning mouth pain: a placebo-controlled, double-blind study

AIMS

An 8-week parallel, placebo-controlled, double-blind trial evaluated the efficacy of the antidepressant trazodone in the treatment of chronic burning mouth pain.

METHODS

Thirty-seven carefully selected women aged 39 to 71 (mean 58.6 years) were randomized to receive either 200 mg of trazodone or a placebo in a similar manner. Pain and pain-related symptoms were evaluated on a visual analogue scale and other measures at 0, 2, 4, and 8 weeks.

RESULTS

There were no significant differences between the groups in treatment effects for pain or pain-related symptoms. Seven patients in the trazodone group and 2 in the placebo group failed to complete the trial because of side effects. The most common side effects were dizziness and drowsiness.

CONCLUSION

In this controlled trial, trazodone failed to relieve burning mouth pain.

Electrophysiological testing of the trigeminofacial system: aid in the diagnosis of atypical facial pain

The aim of this study was to evaluate the yield of objective electrophysiological testing of the trigeminofacial system in atypical facial pain (AFP). In addition to the clinical neurological examination, two brainstem reflexes covering both the peripheral parts and the central connections of the trigeminal and the facial nerves, the blink and jaw reflexes (BR and JR), were recorded in 17 AFP patients. The control group consisted of 18 healthy volunteers with no history of facial pain or chronic headache. The AFP patients could be divided into three distinct groups on the basis of the clinical and electrophysiological findings. (1) Major trigeminal neuropathy. Four patients had clinical and electrophysiological signs of trigeminal neuropathy (three patients with an afferent pattern of abnormal BR, and one with absent JR on the clinically affected side) despite normal findings in the MRI-scans of the brain. Thus, electrophysiological testing may be more sensitive than MRI in demonstrating pathology in some of the AFP patients. (2) Minor trigeminal neuropathy. Seven patients had signs of increased excitability of the BR in the form of uni- or bilaterally abnormal (diminished or absent) habituation of the R2 component of the BR; two of these patients also showed clinical signs of trigeminal dysfunction, but the MRI-scans were all normal. This deficient habituation of the BR indicates increased excitability of the BR at brainstem level in nearly 50% of our AFP patients. (3) 'Idiopathic', no signs of trigeminal neuropathy. Five patients had normal findings both in the brainstem reflex recordings and in the clinical examinations. Additionally, one patient had abnormal BAEP and EEG recordings. On the group level, the AFP patients had significantly higher thresholds of the tactile R1 component of the BR than the control subjects. Electrophysiological testing may offer a valuable tool for both the clinical evaluation, and the scientific study of AFP.

Lansoprazole and omeprazole in the prevention of relapse of reflux oesophagitis: a long-term comparative study

BACKGROUND

Proton pump inhibitors are superior to H2-receptor antagonists in the prevention of relapse of oesophagitis, but few data directly compare the relative efficacies of lansoprazole and omeprazole in preventing oesophagitis relapse over a prolonged period.

METHODS

Patients with healed Grade II, III or IV oesophagitis were treated with lansoprazole 30 mg o.d. or omeprazole 20 mg o.d. for 48 weeks. Endoscopy and symptom assessment were performed after 12. 24 and 48 weeks of treatment and an additional symptom assessment 36 weeks after starting treatment.

RESULTS

Intention-to-treat analysis included 248 patients (lansoprazole n = 126, omeprazole n = 122). Comparison of time to endoscopic and/or symptomatic relapse revealed no difference between the treatments. There was no significant difference between treatments with respect to the proportion of patients in whom endoscopic and/or symptomatic relapse was reported (lansoprazole 12/126 (9.5%), omeprazole 11/122 (9.0%)). No difference between the treatments in either the number or severity of adverse events was reported.

CONCLUSIONS

Continuous treatment with either lansoprazole 30 mg or omeprazole 20 mg is effective in preventing the relapse of oesophagitis over a 48-week period in a majority of patients. Both treatments exhibit a similar side-effect profile.

Expectations and perceptions regarding treatment: a prospective study of patients undergoing orthognathic surgery

One hundred consecutive patients undergoing orthognathic surgical treatment were interviewed concerning their problems before surgery, motives for seeking treatment, and the effects of treatment 1 year after surgery. Comparison with other studies was undertaken using questionnaires validated in such studies. Before surgery, problems relating to function were most significant, followed by esthetic concerns and, to a far lesser extent, social interaction-type problems. Motives for seeking treatment also related mostly to functional issues. Such issues were considered best resolved through treatment. The finding that functional issues were of greater significance to patients than esthetic concerns differs from findings in most previous studies. The difference may at least partly be explained by sociocultural differences.

Role of acid secretory response to sham feeding in predicting recurrent ulceration after proximal gastric vagotomy

The completeness of vagal denervation in determining the long-term outcome of patients with duodenal ulcer disease after proximal gastric vagotomy (PGV) was studied by examining the relationship between the postoperative acid secretory response to sham feeding ('chew and spit' technique) and the subsequent ulcer recurrence rate during a mean follow-up of 7.5 (range 5-15) years. The cumulative recurrence rate of 98 patients analysed prospectively was 11 per cent. Of 22 patients who had incomplete vagotomy as suggested by the sham feeding response, five had a later relapse. This compares with only an 8 per cent relapse rate among those with a secretory response suggesting complete vagotomy. Four patients suffered from a relapse more than 5 years after operation but none had undergone incomplete vagotomy. However, in seven patients with an early postoperative relapse (within 5 years) five had had incomplete vagal denervation (P < 0.05). In this latter group the median time elapsed from surgery until the first recurrence was only 1 year. It is concluded that the early postoperative acid secretory response to a sham feeding stimulus is clinically useful as it allows prediction of the risk of early relapse after PGV. This test may be helpful for the validation of new techniques of vagotomy.

Effect of 7 years' daily oral administration of omeprazole to beagle dogs

Ten beagle dogs were given omeprazole orally at a dose of 0.17 mg/kg (0.5 mumol/kg) daily for 7 years. Six dogs served as controls. Regularly evaluated criteria were clinical signs, body weight, food consumption, rectal temperature, electrocardiography, hematology, blood chemistry, urinalysis, ophthalmoscopy, gastroscopic examination including gastric mucosal biopsy sampling for histological evaluation, pharmacokinetics of omeprazole, and plasma gastrin levels. After approximately 5 years, a quantitative gastric acid secretion test was performed. No treatment-related adverse clinical signs or effects were observed in the dogs, and all animals survived to term. The annual gastroscopy with histological examinations of gastric mucosa did not show any treatment-related changes. At all investigations and in all dogs, the parietal cells were morphologically normal, and there were no changes of pattern or any increase in the number of argyrophil enterochromaffin-like cells compared to the control animals. In the plasma samples collected 24 h after dosing, there were no significant differences in either basal or meal-stimulated gastrin levels between the controls and the omeprazole-treated animals. Peak plasma concentration of omeprazole occurred within 2 h of dosing. The area under the concentration curve (AUC) was not affected by dosing over 7 years and was in good agreement with the AUC in humans given a dose of 20 mg omeprazole daily. Acid secretion tests after 5 years of treatment showed that the mean inhibition of acid secretion by omeprazole 4-7 h after dosing was as expected--about 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical detection of androgen receptors in human oral mucosa

Oral mucosal biopsies from 11 healthy volunteers, 7 women and 4 men, were analysed for the localization of androgen, oestrogen and progesterone receptors. The samples were dissected as quickly as possible and immediately frozen in liquid nitrogen to be stored at -70 degrees C. Only androgen receptors could be detected by the methods used. These were mainly located in the nuclei of basal epithelial cells, and to some extent in the nuclei of fibroblasts and endothelial cells. Failure in the localization of oestrogen and progesterone receptors might have been due either to low numbers of receptors or to the insensitivity of antibodies used. The method is thus suitable only for detecting androgen receptors.

Resolution of oral lichenoid lesions after replacement of amalgam restorations in patients allergic to mercury compounds

The significance of contact allergy in patients with various oral symptoms was studied. Positive patch-test reactions to mercury compounds were found in 21/91 patients. Of these, 18 had lichenoid lesions in oral mucosa in close contact to amalgam fillings, and three patients with contact allergy had neither amalgam fillings in their teeth nor visible oral lesions. Amalgam replacement was carried out in 15/18 symptomatic patients. The fillings were replaced with gold in three cases, composite resin fillings in six, glass ionomer in three and both gold and composite materials in three cases. In 10 patients there was complete replacement and in five it was restricted to the fillings adjacent to the mucosal lesions. After a mean follow-up period of 3.2 years a complete cure was seen in seven patients, each of whom had had all their fillings changed. A marked improvement occurred in six patients, and there was no change in two.

Medetomidine premedication in dental surgery--a double-blind cross-over study with a new alpha 2-adrenoceptor agonist

A single 50-micrograms dose of medetomidine, a highly selective alpha 2-adrenoceptor agonist, was administered intravenously as premedication 30 min before surgical third molar extraction under local anaesthesia to ten healthy male subjects in a double-blind, placebo-controlled, cross-over study. Blood pressure, heart rate, plasma catecholamines and cortisol were measured as indicators of operation-related stress. Apprehension and pain were assessed with repeated Visual Analogue Scales. The dental surgeon rated the overall effectiveness of the premedications, and the patients reported their subjective preference. Drug-induced sedation was determined with the Critical Flicker Frequency (CFF) test. The dental surgeon rated medetomidine as significantly more effective premedication than saline placebo. Apprehension was significantly reduced by medetomidine. The patients clearly preferred medetomidine premedication. Blood pressure was lower in the medetomidine session, whereas no significant differences were seen in heart rate. Plasma noradrenaline was lower after medetomidine, but adrenaline and cortisol levels were not affected. In conclusion, medetomidine may offer a useful alternative to traditional premedications in out-patient surgery, and its clinical usefulness should also be studied in other anaesthetic paradigms.

Attenuation of gastric sham feeding response during reflex sympathetic activation in man

In six human volunteers we studied the effects of hypovolemia on the secretory activity of the gastric mucosa. The secretion of acid and HCO3 from the stomach was calculated from continuous measurements of pH and Pco2 in gastric effluent. Gastric secretion was stimulated by sham feeding (SF), and cardiac filling pressure was decreased by pooling blood in the lower extremities (lower body negative pressure (LBNP]. LBNP at -20 mmHg had no significant effects on systemic arterial pressure or heart rate but increased plasma norepinephrine concentration by 48 +/- 6% (p less than 0.001). Both the acid and the alkaline responses to SF were significantly attenuated during LBNP (-38 +/- 8%, p less than 0.01, and -55 +/- 14%, p less than 0.05, respectively). Analysis of the relationship between acid and HCO3 secretion in individual experiments suggested a relatively more pronounced inhibition of HCO3 secretion. The results imply that a decreased responsiveness of the gastric mucosa may be one component of the cardiovascular reflex adaptation to hypovolemia. A downregulation of active secretion will lead to smaller metabolic demands from the secreting cells and may thereby help to maintain a vasoconstriction in the gastric mucosa.

Simultaneous measurement of gastric acid and bicarbonate secretion in man

Experiments were performed to validate the computerized pH/PCO2 technique for measurement of HCO3 secretion at a physiologic pH in the human stomach. In bench-side experiments the system detected 103 +/- 2% (mean +/- SE, n = 66) of boluses or infusions of NaHCO3. The standard curve was linear in the physiologic concentration range, and in the pH interval from 1.8 to 6.9 the recovery rate of added HCO3 was independent of the pH of the aspirate. In vivo the recovery rate of an exogenous NaHCO3 infusion (240 mumol/15 min) was 95 +/- 5% (n = 9), and there was no significant correlation between basal gastric pH and recovery rate. The results support that our computerized gastric perfusion method can be used for quantification of gastric bicarbonate secretion also at a physiologic acid pH.

Propofol infusion for sedation in outpatient oral surgery. A comparison with diazepam

An infusion of propofol was compared with intravenous boluses of diazepam as sedation for minor oral surgery under local anaesthesia in 12 healthy patients who had elective bilateral surgical extraction of lower third molars; the patients served as their own controls. Plasma catecholamine, vasopressin and cortisol concentrations were determined from repeated blood samples. The total administered dose of propofol was 3.93 (SD 1.34) mg/kg and of diazepam 0.28 (SD 0.07) mg/kg. No cardiovascular depression or airway problems occurred. Other side effects were also rare but some discomfort on injection was frequent with propofol. Recovery times were faster after propofol than after diazepam as assessed by the Maddox wing and visual analogue scales. Propofol also provided better amnesia compared to diazepam at the time of the extraction of the teeth. Eight of the 12 patients subjectively preferred propofol sedation. There was no hormonal stress response in either group.

A comparison of two sedative premedications for minor oral surgery under local anaesthesia

Two commonly used drug combinations were studied as premedications before surgical 3rd molar removal under local anaesthesia. The study was randomized, crossover and double-blind in 12 patients. Our routine premedication for lengthy operations, consisting of diazepam 10 mg p.o. plus i.m. scopolamine 0.006 mg/kg and morphine 0.2 mg/kg, was compared with a combination of diazepam 10 mg p.o. plus metoprolol 50 mg p.o. The latter combination was expected to cause fewer central nervous system side effects and be more suitable for out-patient surgery. Drug levels in blood, physiological and biochemical indicators of operation-related stress, CNS side effects, and the patients' subjective preferences were monitored. Both combinations were equally accepted by the patients, but the diazepam/scopolamine/morphine combination caused clearly more side effects after discharge than diazepam/metoprolol. The operation-related haemodynamic changes and plasma catecholamine responses were similar after both premedications.

Effect of elimination of occlusal interferences on signs and symptoms of craniomandibular disorder in young adults

Sixty-two dental students judged not to be in need of treatment for craniomandibular disorder (CMD) were randomly divided into two groups, one receiving occlusal adjustment and the other mock adjustment. A double-blind study design was applied. After 2 years of education in dentistry, including courses in stomatognathic physiology, the increase in the subjective symptoms of CMD was significantly greater in the placebo control group than in the treatment group. The difference between the groups in the increase of sites tender to palpation was less clear, showing only a trend. However, the increase was statistically significant within the placebo group but not within the treatment group. Prophylactic occlusal adjustment thus appears to be effective in reducing the occurrence of symptoms of CMD, and possibly also the occurrence of clinical signs.

Local dental anaesthesia with lidocaine and adrenaline. Effects on plasma catecholamines, heart rate and blood pressure

5 volunteers took part in this double-blind, cross-over study to evaluate the role of adrenaline 1:80,000 in lidocaine used in dental local anaesthesia on haemodynamics and the concentrations of catecholamines and their metabolites in plasma. The exogenous adrenaline statistically significantly elevated the heart rate (from 66 +/- 7 to 79 +/- 9 bpm), but did not affect systolic or diastolic blood pressure. Plasma adrenaline concentrations were increased more than 10-fold (from 0.02 +/- 0.02 to 1.0 +/- 0.3 nmol/l). We conclude that the adrenaline present in the local anaesthetic is a major source of adrenergic activation during minor oral surgery.

Reflex sympathetic activation in humans is accompanied by inhibition of gastric HCO3- secretion

The study was performed to determine whether the sympathetic nervous system contributes to the reflex control of gastric HCO3- secretion in humans. Gastric HCO3- secretion was registered by a computerized technique based on measurements of pH and PCO2 in gastric effluent. To minimize formation of CO2 in the stomach, subjects were pretreated with the H2-receptor blocker ranitidine. Compensations were made for HCO3- of nongastric origin. As indicators of cardiovascular sympathetic activity, we measured heart rate, forearm vascular resistance, and plasma catecholamine concentrations. In one series of experiments, peripheral sympathetic activity was enhanced by the application of a negative pressure around the lower part of the body (lower body negative pressure, LBNP), at a rate sufficient to induce a slight decrease in systemic arterial pressure. In another series of experiments, peripheral sympathetic activity was inhibited by elevation of the legs, a procedure that simulates volume loading by redistributing blood volume toward the central circulation. LBNP at -20 mmHg decreased systolic pressure and pulse pressure and significantly increased heart rate, forearm vascular resistance, and plasma catecholamine levels. All these effects were observed in the first 15-min period of LBNP and were well maintained throughout the 45-min observation period. LBNP also inhibited basal gastric HCO3- secretion rate in seven of eight individuals, but this response was slower in onset with a latency of at least 15 min. Elevation of the legs increased pulse pressure and decreased forearm vascular resistance. Catecholamines were not measured in these experiments. Gastric HCO3- secretion tended to increase, but the magnitude of the response was highly variable.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between reduction of gastric acid secretion and plasma gastrin concentration during omeprazole treatment

We have studied the relationship between reduction of gastric acid secretion and fasting plasma gastrin concentrations during once daily omeprazole treatment. Healthy subjects were given omeprazole for 5 days in daily doses of 5, 10, 20, 40, or 80 mg. Acid secretion and fasting gastrin concentration were measured 6 h (maximal omeprazole effect) and 24 h (minimal omeprazole effect) after the fifth omeprazole dose. Omeprazole in doses lower than 20 mg daily did not suppress pentagastrin-stimulated acid secretion in all subjects 6 h after dosing on the 5th day. Doses of 20-80 mg omeprazole, however, significantly reduced acid secretion 24 h after the fifth dose, the range being 36-76%. A relationship between degree of acid inhibition and fasting gastrin concentration was observed. However, acid secretion needed to be reduced by more than 80% before gastrin levels were clearly affected. This degree of acid inhibition was only achieved 6 h after administration of omeprazole in doses of 20 mg and higher. The inhibitory effect of omeprazole on acid secretion decreased 24 h after dosing. Thus, fasting gastrin concentrations were moderately increased in the beginning and normalized at the end of each 24-h period during treatment with daily doses of 20-80 mg omeprazole.

Comparative potency of carbachol, sham feeding, fundic distension and 16,16-dimethyl prostaglandin E2 as stimulants of human gastric bicarbonate secretion

Six healthy subjects in random order underwent gastric bicarbonate secretion investigations, including stimulation with increasing doses of the cholinergic agonist carbachol, sham feeding, fundic distension and gastric instillation of 16,16-dimethyl prostaglandin E2. Bicarbonate secretion was measured by a computer-based system which continuously recorded pH and PCO2 of the effluent in a high-volume gastric perfusion system. The peak 30 min gastric bicarbonate output in response to carbachol, 150 mg subcutaneously, was 114% (P less than 0.05). Vagal stimulation by sham feeding resulted in a corresponding increase of 112% (P less than 0.05), while fundic distension to a volume of 600 ml gave an increase of 114% (P less than 0.05). In comparison, the response to 80 micrograms 16,16-dimethyl prostaglandin E2 was much greater, the peak bicarbonate output being increased by 245% (P less than 0.05). Both sham feeding and fundic distension appear to be either submaximal stimuli of gastric bicarbonate secretion in man or may possess both stimulatory and inhibitory actions.

Synovial chondromatosis of the temporomandibular joint

An illustrative case of synovial chondromatosis in the temporomandibular joint (TMJ) region is presented, and 36 cases reported earlier are reviewed. The present patient, a 35-year-old woman, had been suffering from swelling and pain in the TMJ area as well as limited mandibular movements for 7 years. The condition had been treated with various conservative methods without any relief of the symptoms. Finally, radiological examination revealed calcified nodules within the joint space and a surgical exploration was performed. In all, 27 loose particles were removed from the joint in connection with the extirpation of the perforated and deformed disk. The result of surgical therapy has been favourable during the follow-up period of 18 months. Although synovial chondromatosis is rare in the TMJ, it should be kept in mind as one possible disease when treating patients suffering from symptoms similar to those of mandibular dysfunction syndrome.

A criterion for completeness of vagotomy based on basal and vagally stimulated gastric acid secretion after esophagectomy or proximal gastric vagotomy

The variation in basal acid secretion was determined in 10 patients after resection of the esophagus, an operation resulting in a total transection of all vagal nerves to the abdomen. After recording basal acid secretion over a 3-h period, a 15-min modified sham feeding procedure was performed, and the acid output was studied for an additional hour. The mean basal acid output +2 SD was 0.27 mmol/15 min. The difference between the highest and lowest recorded 15-min output--that is, the oscillation of basal acid output--was calculated for each patient. The mean oscillation of basal acid output +2 SD was 0.58 mmol/15 min. Vagal stimulation accomplished by sham feeding produced no significant increase in acid output above this level. The variation in basal acid secretion was also investigated in 20 duodenal ulcer patients after proximal gastric vagotomy. These patients were insulin-negative and remained asymptomatic during a 7- to 10-year follow-up study. Shortly after the vagotomy, measurement of basal acid secretion over 3 h showed a mean basal acid output +2 SD of 0.58 mmol/15 min. The mean oscillation of basal acid output +2 SD was 0.66 mmol/15 min. On the basis of the oscillation in basal acid secretion after complete vagotomy we propose a new criterion for completeness of vagotomy, namely a response to physiologic vagal stimulation which does not exceed the lowest basal level by more than 0.6 mmol/15 min.

Recurrence of keratocysts. A long-term follow-up study

The aim of the study was to investigate the recurrence rate of keratocysts based on a material with a follow-up of at least 5 years, and to evaluate the relationship between different features of these cysts and their recurrence. It was found that of 75 keratocysts with follow-up times ranging from 5 to 17 years (mean 8.3), 32 (43%) recurred. The cumulative recurrence rate of the 67 annually examined cysts increased from 3% after the 1st year following the operation to 37% after the 3rd year. Thereafter, no new recurrences were noted. Recurrence of keratocysts in patients with basal cell nevus syndrome occurred more frequently than that of patients without the syndrome. Keratocysts enucleated in one piece recurred significantly less often than cysts enucleated in several pieces. The recurrence rate of keratocysts with a clinically observable infection, with fistula or with a perforated bony wall was higher than that of keratocysts without these features. Recurrence was also found more frequently in cysts with multilocular radiographic appearance than in unilocular cysts. The size or the location of the keratocysts did not have an influence on the recurrence rate.

Simple bone cyst. Review of the literature and analysis of 23 cases

A retrospective study of 23 simple bone cysts including analysis of clinical, radiographical, histopathological features and follow-up information was made. The age of the patients varied from 8 to 59 years (mean 21.4 years). All lesions were found in the mandible, and 2 of them were radiologically multilocular. A loose connective tissue lining was found histologically in 8 out of 17 cysts with the biopsy specimens available. At follow-up, 2 failures of the primary surgical treatment were noted. The results emphasize that a proper follow-up is required after the treatment of simple bone cyst.

Gastric mucosal defence mechanisms: a brief review

In the stomach several mucosal defence mechanisms protect the stomach against hydrochloric acid and noxious agents. The pre-epithelial protection is made up by the mucus-bicarbonate barrier. Mucus and bicarbonate, secreted by mucus cells, create a pH gradient maintaining the epithelial cell surface at near neutral pH. In humans, secretion of bicarbonate is an active process and is activated by vagal stimulation and fundic distension. Several mechanisms at the epithelial cell level contribute to an intact mucosal barrier. Surfactants in apical cell membranes prevent water-soluble agents in the gastric lumen from reaching and damaging the epithelium. Nonprotein sulphydryls in the epithelium are capable of binding reactive free radicals. Rapid cell turn-over and the process of restitution contribute to an intact epithelial lining. In subepithelial protection, mucosal blood flow is essential in supplying the epithelium with nutrients and oxygen and for disposal of hydrogen ions and noxious agents permeating the mucosa. Prostaglandins may maintain blood flow and prevent vascular endothelial injury caused by ethanol. Several agents have been established as protective for the gastric mucosa. Prostaglandins possess direct cytoprotective actions, whilst sucralfate, aluminium containing antacids, carbenoxolone and bismuth are mild irritants that induce liberation of endogenous prostaglandins of the mucosa.

Antibiotic prophylaxis in high-risk gastric surgery. A prospective, randomized clinical comparison of cefuroxime and doxycycline

The efficacy of two antibiotics as prophylaxis in high-risk gastric surgery was evaluated in a prospective, randomized trial: 400 mg doxycycline in a single dose (98 patients) was compared with 1.5 g cefuroxime given twice with an 8-hour interval (101 patients). The two groups were comparable in regard to all relevant factors of importance for susceptibility to infection. The incidence of postoperative abdominal infection was 8.2% in the doxycycline group and 7.9% in the cefuroxime group. The most common extraabdominal infectious complications were in the lungs (20% of the patients in both groups). No subgroup of patients was identifiable in which one antibiotic was superior to the other. The efficacy of the two investigated prophylaxis regimens was apparently identical.