Pleural Empyema Caused by Streptococcus intermedius and Fusobacterium nucleatum: A Distinct Entity of Pleural Infections

BACKGROUND

Many community-acquired pleural infections are caused by facultative and anaerobic bacteria from the human oral microbiota. The epidemiology, clinical characteristics, pathogenesis, and etiology of such infections are little studied. The aim of the present prospective multicenter cohort study was to provide a thorough microbiological and clinical characterization of such oral-type pleural infections and to improve our understanding of the underlying etiology and associated risk factors.

METHODS

Over a 2-year period, we included 77 patients with community-acquired pleural infection, whereof 63 (82%) represented oral-type pleural infections. Clinical and anamnestic data were systematically collected, and patients were offered a dental assessment by an oral surgeon. Microbial characterizations were done using next-generation sequencing. Obtained bacterial profiles were compared with microbiology data from previous investigations on odontogenic infections, bacteremia after extraction of infected teeth, and community-acquired brain abscesses.

RESULTS

From the oral-type pleural infections, we made 267 bacterial identifications representing 89 different species. Streptococcus intermedius and/or Fusobacterium nucleatum were identified as a dominant component in all infections. We found a high prevalence of dental infections among patients with oral-type pleural infection and demonstrate substantial similarities between the microbiology of such pleural infections and that of odontogenic infections, odontogenic bacteremia, and community-acquired brain abscesses.

CONCLUSIONS

Oral-type pleural infection is the most common type of community-acquired pleural infection. Current evidence supports hematogenous seeding of bacteria from a dental focus as the most important underlying etiology. Streptococcus intermedius and Fusobacterium nucleatum most likely represent key pathogens necessary for establishing the infection.

Osteomyelitt i underkjeven

BACKGROUND

Chronic non-bacterial osteomyelitis is an inflammatory bone disorder that may affect children and adolescents. Infections, malignancy and other differential diagnoses require consideration. Osteomyelitis of the jaw is a rare condition, but non-bacterial osteomyelitis is probably more common than previously thought, also in the mandible.

CASE PRESENTATION

We present four paediatric cases with osteomyelitis of the jaw with no obvious infection source or fever, but mandibular swelling and pain. All the patients were examined clinically, and X-ray, MRI and bone biopsies were performed. Therapeutic measures involved antibiotics, surgical debridement, use of NSAIDS and in one case peroral steroids.

INTERPRETATION

Even though all cases started with similar symptoms, the aetiology remained unclear and it was challenging to reach the final diagnosis. The possibility of chronic non-bacterial osteomyelitis was assessed late. The international nomenclature for osteomyelitis is not consistent, and it is in our opinion important to emphasise the aetiology of the condition to avoid terminology misinterpretations which may delay effective treatment.

Temporomandibular joint prosthesis in cancer reconstruction preceding radiation therapy

Total joint prostheses are a viable treatment option after removal of malignancies invading the temporomandibular joint, even when adjuvant radiation therapy is required.

Hormone spiral in treatment of progesterone-induced stomatitis

Hormonal changes in the menstrual cycle may cause autoimmune progesterone-induced stomatitis. This case illustrates that insertion of a hormone spiral can be a treatment option to reduce mucosal lesions and symptoms.

Multiple brain abscesses and ventriculitis secondary to chronic periodontitis

Chronic marginal periodontitis is a common oral disease, but can in rare cases cause severe intracranial infection. This case illustrates that poor dental status can be life threatening, in particular for immunocompromised patients.

Lymphatic growth factors are expressed in human gingiva and upregulated in gingival fibroblasts after stimulation

BACKGROUND

The lymphatic growth factors vascular endothelial growth factor (VEGF)-C and -D are important for maintenance and growth of lymphatic vessels (lymphangiogenesis), but their localization in human gingiva is unknown. This study investigated the expression of VEGF-C and -D in human gingiva and isolated human gingival fibroblasts (HGFs). In addition, the localization of their main receptor VEGFR-3 was explored.

METHODS

Non-inflamed gingiva from six donors was used for immunohistochemistry or isolation of HGFs. HGFs were stimulated with either E.coli lipopolysaccharide (LPS) or IL-6/soluble IL-6 receptor (sIL-6R) complex for 1, 6, and 24 hours. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to quantify the relative changes in gene expression of VEGF-A, -C, and -D and enzyme-linked immunosorbent assay (ELISA) for quantification of protein levels.

RESULTS

VEGF-C, -D and VEGFR-3 were seen in keratinocytes, blood vessels and in scattered single cells in gingiva. VEGFR-3 was also found in lymphatic vessels and VEGF-C in cells with fibroblastic appearance. Gene analysis showed no expression of VEGF-D in the HGFs, but showed constitutive expression of VEGF-C and -A. Stimulation of HGFs with LPS or IL-6/sIL-6R complex was followed by gene upregulation of VEGF-C and -A and increased protein levels in cell culture supernatant (P ≤0.05).

CONCLUSIONS

The localization of VEGF-C, -D, and VEGFR-3 expression imply that signaling via VEGFR-3 is linked to vascular homeostasis and keratinocyte function under normal conditions in gingiva. Inflammatory stimulation of HGFs upregulates VEGF-C and -A expression and may contribute to angiogenesis and lymphangiogenesis.

Temporomandibular joint function 10-15 years after mandibular setback surgery and six weeks of intermaxillary fixation

Intermaxillary fixation (IMF) is a classic method for immobilization of the mandible after mandibular fractures and corrective surgery. However, it has been suggested that IMF may be a risk for developing temporomandibular joint (TMJ)-related symptoms, especially when applied for longer periods.

Apnea-Hypopnea Index in Healthy Class III Patients Treated With Intraoral Vertical Ramus Osteotomy: A Prospective Cohort Study

PURPOSE

The study purpose was to assess whether mandibular setback surgery by intraoral vertical ramus osteotomy (IVRO) induces obstructive apnea and hypopnea in healthy Class III patients without a history of respiratory dysfunction. We hypothesized that the apnea-hypopnea index (AHI) would not exceed 5 events per hour after surgery.

PATIENTS AND METHODS

A prospective cohort study was conducted. The sample was composed of healthy Class III patients without a history of obstructive sleep apnea treated with isolated mandibular setback surgery by the IVRO procedure at a university hospital. In-home respiratory sleep recordings (Nox T3; Nox Medical, Reykjavik, Iceland) and self-administered questionnaires were obtained before and at least 3 months after surgery. The AHI was the primary outcome variable. Other study variables were as follows: peripheral capillary oxygen saturation, oxygen desaturation index, snore index, body mass index, Epworth Sleepiness Scale, and Oral Impact on Daily Performance index. Descriptive and bivariate statistics were computed, and the significance level was set at .05.

RESULTS

The sample was composed of 8 patients. The mean age at surgery was 23.2 years (range, 18.2 to 33.4 years). The mean amount of surgical setback was 4.3 mm (range, 2.5 to 7.4 mm). The mean body mass index was 24.2 kg/m² (standard error [SE], 1.3 kg/m²) and 23.9 kg/m² (SE, 1.4 kg/m²) at the presurgical and postsurgical sleep recordings, respectively. The mean AHI was 1.3 events per hour (SE, 0.3; range, 0.1 to 2.5) before surgery and 1.8 events per hour (SE, 0.4; range, 0.3 to 3.3) after surgery. No statistically significant changes in AHI (P = .412), peripheral capillary oxygen saturation (P = .443), oxygen desaturation index (P = .194), snore index (P = .363), or Epworth Sleepiness Scale (P = .812) were observed. The patients' self-reported oral health-related quality of life was statistically significantly improved after surgery (P = .034).

CONCLUSIONS

Mandibular setback surgery with the IVRO procedure in the range of 2.5 to 7.4 mm did not induce obstructive sleep apnea, measured as an AHI above 5 events per hour, in the 8 healthy, young adult Class III patients presented in this study. More studies including larger patient samples are needed.

Patient satisfaction and oral health-related quality of life 10-15 years after orthodontic-surgical treatment of mandibular prognathism

This study investigated 36 patients at 10-15 years after they had undergone mandibular setback surgery by intraoral vertical ramus osteotomy (IVRO) and subsequent intermaxillary fixation for 6 weeks. The patients completed a 37-item structured questionnaire to evaluate patient satisfaction and possible long-term effects of the treatment. Visual analogue scales were used to measure self-perceived changes in seven items concerning oral function and appearance. Oral health-related quality of life was assessed using the Oral Impacts on Daily Performance (OIDP) index. The main reasons for seeking treatment were to improve chewing function and appearance. The treatment had resulted in significant improvements regarding chewing function, appearance, bullying, and self-confidence in social settings (all P<0.05). All patients were either very satisfied (61%) or reasonably satisfied (39%) with the treatment result. The mean OIDP frequency score was 8.49 on a scale from 8 to 40. Seventy-four percent of the patients reported no oral impacts on quality of life. In conclusion, 10-15 years after combined orthodontic and IVRO surgical treatment of mandibular prognathism, the patients were satisfied, and oral health-related quality of life was reported to be good.

Bisphosphonate associated osteomyelitis of the jaw in patients with bony exposure: prevention, a new way of thinking

Objective

There is strong evidence of a link between the use of systemic bisphosphonates (BPs) and osteonecrosis of the jaw, especially in cancer patients. Among risk factors for BRONJ, tooth extraction and immune suppressive drugs seem to have significant role on bone healing. Therefore, the importance of these parameters in development of BRONJ was reviewed in this retrospective study in two maxillofacial surgery units.

Material and Methods

From 2007 to 2012, 46 patients on bisphosphonate who had developed oral bony lesions participated in this study. The pharmacological exposure, comorbidities, maxillofacial findings, types of treatment and outcome data were collected from clinical and radiological records.

Results

The most frequently used BP was alendronate (67%). Tooth extraction was reported in 61% of patients with BRONJ. Systemic corticosteroids were prescribed in 35 cases (76%) as an adjuvant for BP. Patients on corticosteroids had a lower probability of bony lesion healing (p<0.05) than patients without corticosteroids. Of the 46 patients who underwent conservative treatments, only ten were completely healed (21%).

Conclusions

Beside tooth extraction, corticosteroids were shown to be an implant risk factor for low rate of bone healing and hence the development of BRONJ. The outcome of conservative treatment was uncertain and this emphasizes the importance of prevention.

European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study

OBJECTIVE

The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year.

STUDY DESIGN

The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years.

RESULTS

The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures.

CONCLUSIONS

Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site.

Vascular endothelial growth factors signalling in normal human dental pulp: a study of gene and protein expression

In the well-vascularized dental pulp vascular endothelial growth factor A (VEGF-A) is expressed. Vascular endothelial growth factor A is a member of the VEGF family, which includes VEGFs-B, -C, and -D. The latter three have not been investigated in the pulp. Vascular endothelial growth factors C and D are the only ligands for vascular endothelial growth factor receptor (VEGFR)-3, which is usually expressed in lymphatic endothelium. They can also activate VEGFR-2, the main angiogenic receptor. We aimed to study VEGFs signalling in human dental pulp at the gene level and to identify the cellular source for protein expression using immunolabelling. All VEGFs (-A, -B, -C, and -D) were expressed in the pulp and may exert both autocrine and paracrine effects in blood vessels and immune cells found to be equipped with VEGFRs-2 and -3. Lymphatic vessel endothelial hyaluronan receptor-positive macrophages, known to be involved in angiogenesis, were found in the pulp, whereas lymphatic vessels were not detected. Twenty-six of 84 VEGF signalling genes, including VEGFR-3, were expressed at a significantly higher level in the pulp than in the control periodontal ligament. In conclusion, the normal human pulp represents a tissue with relatively high VEGF signalling involving both immune responses and vascular activity.

Misinterpretation of histopathological results as an important risk factor for unneeded surgery - case report of a "near miss" event in a pregnant woman

The oral cavity may exhibit a vast number of pathologic conditions, often dealt with by different medical disciplines. Combined with a substantial variation in clinical appearance, an accurate diagnosis may provide difficult to establish in selected cases. Histopathological investigations are therefore mandatory for correct diagnosis and adequate treatment. We describe a common, truly benign condition in the oral cavity, which due to histopathological misinterpretation was planned for major surgery and subsequent chemotherapy. This was avoided by spontaneous regression of the lesion. The case illustrates that uncritical trust in laboratory diagnostic tests may lead to severe mistreatment.

Coordination of trigeminal axon navigation and patterning with tooth organ formation: epithelial-mesenchymal interactions, and epithelial Wnt4 and Tgfbeta1 regulate semaphorin 3a expression in the dental mesenchyme

During development, trigeminal nerve fibers navigate and establish their axonal projections to the developing tooth in a highly spatiotemporally controlled manner. By analyzing Sema3a and its receptor Npn1 knockout mouse embryos, we found that Sema3a regulates dental trigeminal axon navigation and patterning, as well as the timing of the first mandibular molar innervation, and that the effects of Sema3a appear to be mediated by Npn1 present in the axons. By performing tissue recombinant experiments and analyzing the effects of signaling molecules, we found that early oral and dental epithelia, which instruct tooth formation, and epithelial Wnt4 induce Sema3a expression in the presumptive dental mesenchyme before the arrival of the first dental nerve fibers. Later, at the bud stage, epithelial Wnt4 and Tgfbeta1 regulate Sema3a expression in the dental mesenchyme. In addition, Wnt4 stimulates mesenchymal expression of Msx1 transcription factor, which is essential for tooth formation, and Tgfbeta1 proliferation of the dental mesenchymal cells. Thus, epithelial-mesenchymal interactions control Sema3a expression and may coordinate axon navigation and patterning with tooth formation. Moreover, our results suggest that the odontogenic epithelium possesses the instructive information to control the formation of tooth nerve supply.

Expression of ephrin-A ligands and EphA receptors in the developing mouse tooth and its supporting tissues

Ephrins are cell-membrane-bound ligands for Eph receptor tyrosine kinases and regulate a variety of developmental processes. In order to investigate the potential roles of the ephrin-Eph system in tooth formation, we studied the cellular mRNA expression of Ephrin-A1-A5 and EphA2, EphA3, EphA4, EphA7, and EphA8 receptors during embryonic histomorphogenesis of the mouse first molar (embryonic days 11.5-18.5). Ephrin-A1, ephrin-A5, EphA2, EphA3, EphA4, and EphA7 were expressed in the tooth germ at the epithelial thickening stage, and later, ephrin-A1, ephrin-A5, EphA2, EphA4, and EphA7 showed distinct expression patterns in the enamel organ undergoing epithelial folding morphogenesis. Prior to birth, ephrin-A1, ephrin-A5, EphA2, and EphA4 transcripts were present in the cuspal area of the dental papilla including the preodontoblasts. In addition, ephrin-A1 and ephrin-A5 were seen in the forming blood vessels and alveolar bone, respectively. In contrast, ephrin-A2, ephrin-A3, and ephrin-A4 showed ubiquitous expression during odontogenesis, whereas EphA8 transcripts were not observed. During dental trigeminal axon pathfinding (embryonic days 12.5-13.5), ephrin-A2, ephrin-A4, and ephrin-A5 were evenly distributed in the trigeminal ganglion, whereas EphA7 was expressed in a subset of ganglion cells. These results suggest regulatory roles for ephrin-A/EphA signaling in the formation of the tooth organ proper and its supporting tissues.

Developmentally regulated expression of Netrin-1 and -3 in the embryonic mouse molar tooth germ

The Netrins form a small, conserved family of laminin-related signaling proteins regulating axon guidance in the developing nervous system. Here, we analyzed the roles of Netrin-1 and -3 in trigeminal axon guidance to the first lower molar of the embryonic mouse. Netrin-1 showed a restricted epithelial expression domain buccal to the tooth germ, toward which the pioneer tooth axons initially appear to navigate. Later, before birth, transcripts were colocalized with nerve fibers around the bell stage tooth germ. Analysis of Netrin-1-deficient mice, however, did not reveal any obvious disturbances in the axon growth or pattern of tooth innervation. In contrast, Netrin-3 showed a prominent, distinct expression in the axon pathway and target field mesenchyme around the tooth. Hence, it is possible that Netrin-3 may regulate pioneer axon growth toward and within the embryonic tooth target field.

Identification of a novel putative signaling center, the tertiary enamel knot in the postnatal mouse molar tooth

The final shape of the molar tooth crown is thought to be regulated by the transient epithelial signaling centers in the cusp tips, the secondary enamel knots (SEKs), which are believed to disappear after initiation of the cusp growth. We investigated the developmental fate of the signaling center using the recently characterized Slit1 enamel knot marker as a lineage tracer during morphogenesis of the first molar and crown calcification in the mouse. In situ hybridization analysis showed that after Fgf4 downregulation in the SEK, Slit1 expression persisted in the deep compartment of the knot. After the histological disappearance of the SEK, Slit1 expression was evident in a novel epithelial cell cluster, which we call the tertiary enamel knot (TEK) next to the enamel-free area (EFA)-epithelium at the cusp tips. In embryonic tooth, Slit1 was also observed in the stratum intermedium (SI) and stellate reticulum cells between the parallel SEKs correlating to the area where the inner enamel epithelium cells do not proliferate. After birth, the expression of Slit1 persisted in the SI cells of the transverse connecting lophs of the parallel cusps above the EFA-cells. These results demonstrate the presence of a novel putative signaling center, the TEK, in the calcifying tooth. Moreover, our results suggest that Slit1 signaling may be involved in the regulation of molar tooth shape by regulating epithelial cell proliferation and formation of EFA of the crown.

Mouse rudimentary diastema tooth primordia are devoid of peripheral nerve fibers

The tooth is a well-defined peripheral target organ for trigeminal nerve fibers. However, only limited information is available regarding pioneer axon guidance to the developing tooth target field. In rodents there is a toothless diastema region between incisors and molars that in the mouse maxilla contains three rudimentary tooth anlagen. Their development stop at the early bud stage when the primary nerve axons grow towards the developing first molar tooth germs. In order to provide background information for studies of regulatory mechanisms of pioneer axon guidance to the developing tooth germs, we investigated the distribution of nerve fibers in the mouse diastema tooth buds, and compared it to the axon growth to the maxillary and mandibular first molar tooth germs by immunohistochemical localization of peripherin and PGP9.5. Analysis of serial sections showed that trigeminal nerve fibers emerging from the trigeminal maxillary and mandibular nerve trunks started to grow towards the developing molar tooth germ at the early bud stage, and subsequently they diverged into buccal and lingual branches next to the condensed dental mesenchyme. During the cap stage, nerve fibers were observed around the tooth germ in the dental follicle region. In contrast, no nerve fibers were located in the vicinity of the diastema tooth primordia at any stage studied, nor did any nerve fibers appear to grow towards this region. Our results show that the development and subsequent disappearance of the diastema tooth primordia takes place without peripheral trigeminal innervation. The diastema tooth primordia may therefore be a useful model system for future studies on molecular regulatory mechanisms of pioneer axon guidance to the tooth germs, and possibly also for evolutionary studies of peripheral axon guidance mechanisms.

Slit1 is specifically expressed in the primary and secondary enamel knots during molar tooth cusp formation

The shape and diversity of the mammalian molar teeth is suggested to be regulated by the primary and secondary enamel knots, which are putative epithelial signaling centers of the tooth. In search of novel molecules involved in tooth morphogenesis, we analyzed mRNA expression of Slit1, -2 and -3, earlier characterized as secreted signals needed for axonal pathfinding and their two receptors Robo1 and -2 (Roundabout1 and -2) in the developing mouse first molar. In situ hybridization analysis showed that Slit1 mRNAs were expressed in the primary enamel knot of the bud and cap stage tooth germ and later the expression continued in the secondary enamel knots of the late cap and bell stage tooth. In contrast, expression of Slit2 and -3 as well Robo1, and -2 was largely restricted to mesenchymal tissue components of the tooth until the bell stage. At the late bud stage, however, Robo1 transcripts were evident in the primary enamel knot, and at the cap stage a pronounced expression was noted in the middle of the tooth germ covering the primary enamel knot and dental papilla mesenchyme. During the bell stage, Robo1 and Slit2 expression became restricted to the dental epithelia, while Slit3 continued in the dental mesenchyme. Prior to birth, Robo1 and -2 were co-localized in the predontoblasts. These results indicate that Slits and Robos display distinct, developmentally regulated expression patterns during tooth morphogenesis. In addition, our results show that Slit1 is the second known gene specifically located in the primary and secondary enamel knots.

Expression of class 3 semaphorins and neuropilin receptors in the developing mouse tooth

The semaphorins are a large family of secreted or cell-bound signals needed for the development of the nervous system. We compared mRNA expression of class 3 semaphorins (Sema3A, 3B, 3C and 3F) and their two receptors (Neuropilin-1 and -2) in the embryonic mouse first molar tooth germ (E10-18) by radioactive in situ hybridization. All genes showed distinct developmentally regulated expression patterns during tooth organogenesis. Interestingly, Sema3A and 3C were first detected in the early dental epithelium, and later both genes were present in the epithelial primary enamel knot, a putative signaling center of the embryonic tooth regulating tooth morphogenesis. Prior to birth, Sema3A was also observed in tooth-specific cells, preodontoblasts, which later differentiate into odontoblasts secreting dentin, and in the mesenchymal dental follicle cells surrounding the tooth germ. Sema3B appeared transiently in the dental mesenchyme in the bud and cap stage tooth while Sema3F was expressed in both epithelial and mesenchymal components of the tooth. Of note, Npn-1 expression pattern was largely complementary to that of Sema3A, and transcripts were restricted to the dental mesenchymal cells. Npn-1 expression was first seen in the developing dental follicle, and later transcripts also appeared in the dental papilla mesenchyme. In contrast, Npn-2 signal was seen in both epithelial and mesenchymal tissues such as in the primary enamel knot and preodontoblasts.