Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry

BACKGROUND: This article presents evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents. A guideline panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address clinical questions in relation to the efficacy, retention, and potential side effects of sealants to prevent dental caries; their efficacy compared with fluoride varnishes; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits and fissures of occlusal surfaces. TYPES OF STUDIES REVIEWED: This is an update of the ADA 2008 recommendations on the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars. The authors conducted a systematic search in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other sources to identify randomized controlled trials reporting on the effect of sealants (available on the US market) when applied to the occlusal surfaces of primary and permanent molars. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions. RESULTS: The guideline panel formulated 3 main recommendations. They concluded that sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes. They also concluded that sealants could minimize the progression of noncavitated occlusal carious lesions (also referred to as initial lesions) that receive a sealant. Finally, based on the available limited evidence, the panel was unable to provide specific recommendations on the relative merits of 1 type of sealant material over the others. CONCLUSIONS AND PRACTICAL IMPLICATIONS: These recommendations are designed to inform practitioners during the clinical decision-making process in relation to the prevention of occlusal carious lesions in children and adolescents. Clinicians are encouraged to discuss the information in this guideline with patients or the parents of patients. The authors recommend that clinicians reorient their efforts toward increasing the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.(AU)

U.S. Army dental emergency rates in Bosnia.

OBJECTIVE: Our objective is to report on overall dental emergency rates and rates by dental classification of a U.S. Army peacekeeping operation longer than 6 months in the year 2000. MATERIALS AND METHODS: This study was a retrospective cohort analysis of dental emergencies experienced by soldiers of the 3rd Armored Cavalry Regiment as a part of Stabilization Force VII. Before the deployment, all soldiers received dental examinations and the necessary dental treatment to make them class 1 or 2. A dental emergency was identified from field treatment records when a soldier presented to the clinic for a "sick call," emergency, or trauma visit. RESULTS: Retrospective review of the records identified 211 dental emergencies. Class 1 soldiers experienced 75 dental emergencies and class 2 soldiers experienced 136 emergencies. 3rd Armored Cavalry Regiment soldiers spent an average of 201.95 days deployed. The overall emergency rate was 156 dental emergencies per 1,000 soldiers per year. Class 1 and 2 rates were 121 and 185 dental emergencies per 1,000 troops per year, respectively. CONCLUSIONS: The results tend to confirm that dental emergencies continue to be a threat to overall readiness in deployed environments. Military planners need to ensure that the dental component of future forces are sufficient to care for the expected emergencies.

Herbal 'health' products: what family physicians need to know.

Patients who self-medicate with herbs for preventive and therapeutic purposes may assume that these products are safe because they are "natural," but some products cause adverse effects or have the potential to interact with prescription medications. The United States lacks a regulatory system for herbal products. Although only limited research on herbs has been published, St John's wort shows promise as a treatment for depression. Ginkgo biloba extract is possibly effective for cerebrovascular insufficiency and dementia. Feverfew is used extensively in Canada for migraine prophylaxis but needs more rigorous study. Ephedrine has been regulated by many states because its misuse has been associated with several deaths. Echinacea is being tried as an agent for immune stimulation, and garlic is under study for cholesterol-lowering properties, but both require more study. Physicians should educate themselves and their patients about the efficacy and adverse interactions of herbal agents and the limitations of our present knowledge of them.

Suspected lamotrigine-induced toxic epidermal necrolysis.

OBJECTIVE: To describe a patient who developed toxic epidermal necrolysis (TEN) possibly secondary to lamotrigine use. CASE SUMMARY: A 74-year-old white man with a history of probable complex partial seizures was admitted to the neurology service for a prolonged postictal state. His antiepileptic regimen was changed while he was in the hospital to include lamotrigine. After 19 days of hospitalization and 14 days of lamotrigine therapy, the patient became febrile. The next day he developed a rash which progressed within 4 days to TEN, diagnosed by skin biopsy. All suspected drugs were discontinued, including lamotrigine. The patient was treated with hydrotherapy in the burn unit. His symptoms improved and he was discharged from the hospital 26 days after the rash developed. DISCUSSION: During lamotrigine's premarketing clinical trials, the manufacturer reported several cases of Stevens-Johnson syndrome and TEN. There are several published case reports of lamotrigine-induced severe skin reactions. All of these reports included patients being treated with both valproic acid and lamotrigine. Our patient was exposed to phenytoin, carbamazepine, clindamycin, and lamotrigine, but not valproic acid. The patient reported prior use of phenytoin with no skin rash. Carbamazepine was the antiepileptic drug the patient was maintained on prior to his hospital admission, and the symptoms of TEN resolved while he was still receiving carbamazepine. The patient received only two doses of clindamycin, which makes this agent an unlikely cause of TEN. CONCLUSIONS: Because of the temporal relationship of the onset of the patient's rash and several drugs that are known to cause severe rashes, it is not certain which drug was the definite culprit. However, based on the evidence from the literature, lamotrigine appears to be the causative agent.

Primary bronchogenic carcinoma in recipients of heart transplants.

With the exception of carcinomas of the skin and lip, carcinoma of the bronchus is the most common carcinoma that afflicts recipients of solid organ grafts. Of 859 tumors occurring in 830 recipients of thoracic organs reported to the Cincinnati Tumor Transplant Registry, 242 were carcinomas and 68 of these were bronchogenic carcinomas, which therefore made up 8% of the overall total. There are, however, relatively few reports of heart transplant patients with bronchogenic carcinoma in the literature. We present details of four patients who developed this malignancy out of a total of 196 patients who survived and have been followed up for more than 3 months at our center, an incidence of 2%. The mean period from the time of transplant to diagnosis of malignancy was 58 months (range 11-82 months). The histology was squamous or anaplastic in three cases, and adenocarcinoma in one. Immunosuppressive therapy was reduced in all cases. Resection was carried out in two patients (both of whom died 6 and 11 months later, respectively), resection was combined with chemotherapy and radiation in one patient (alive 15 months later), and therapy consisting of radiation alone was given to one patient (died within 1 month). We conclude that bronchogenic carcinoma is relatively common in patients with heart transplants and that it has a poor prognosis.

A suggested technique for "orthotopic" heart transplantation in a patient with situs inversus.

We describe a technique for "orthotopic" heart transplantation in a patient with situs inversus. The left atrial, aortic, and pulmonary artery anastomoses were performed directly, in the usual manner. The recipient's right atrium was converted into a tunnel, and the donor's right atrium was left intact. Anastomoses were therefore required between the 2 inferior venae cavae (by direct end-to-end anastomosis) and the 2 superior venae cavae (necessitating the insertion of a Dacron-graft). We suggest that even simpler techniques, perhaps not requiring the use of an artificial vascular prosthesis, are possible.

Donor organ availability.

As the results of organ transplantation show steady improvement, we have seen a marked increase in the number of potential organ recipients. During this time however, the number of donor organs becoming available has remained little changed. The reasons for this phenomenon and some potential solutions for improving the supply of donor organs are reviewed.

Histologic characteristics of Campylobacter pylori (Helicobacter pylori) mediated gastritis.

One hundred-nineteen specimens were reviewed to determine whether or not there were histologic changes specific for Campylobacter pylori (CP), (Helicobacter pylori) mediated gastritis. Hematoxylin and eosin (H&E), Brown-Hopp, and Wright-Giemsa stained sections were examined independently by two pathologists for (a) the presence of acute cryptitis, (b) percent and degree of crypt involvement, and (c) spectrum of inflammatory cells within the lamina propriae. The amount of mucus was quantified on the Periodic Acid Schift (PAS)-Alcian Blue stain sections. Changes in the character of the mucus were noted by using both the PAS-Alcian Blue and the High Iron Diamine-Alcian Blue. A positive specimen for Campylobacter pylori (CP+), (Helicobacter pylori) was defined as one in which curved or spiral shaped microbes were identified on Wright-Giemsa and Brown-Hopp stain. Seventy-eight specimens were CP+ and 41 CP-. Statistically significant histologic findings included the extent and degree of superficial cryptitis and the preponderance of plasma cells in CP+ cases. These findings confirm aspects seen in an animal model and suggest that there is an histologic pattern consistent with C. pylori (Helicobacter pylori) mediated gastritis.

Experience with cardiorespiratory support devices in patients undergoing heart and heart-lung transplantation.

During the 2-year period 1987 through 1988, 124 patients were assessed for heart or heart-lung transplantation. Sixty were accepted for heart transplantation, of whom 49 received transplants. Nine required pretransplant intra-aortic balloon pump support (+/- positive-pressure ventilation) for periods ranging from 2 to 15 days (mean 5 days). One patient was supported successfully by a pneumatic biventricular assist device for 70 days pretransplant. The 30-day survival in this group of 10 critically unstable patients was 100% and the 6-month survival 90% (one death). This experience compares well with survival rates of 100% at 30 days and 92% at 6 months in the 39 patients who required no form of pretransplant circulatory support. The biventricular assist device also has been used in 2 other patients; one did not survive to transplant and the other was deemed unsuitable by virtue of cerebral injury. Extracorporeal membrane oxygenation supported 2 posttransplant patients (one heart and one heart-lung) with grossly impaired pulmonary function for periods of 5 and 2 days respectively, but both died before lung function had recovered.

Improved cardiac allograft function following triiodothyronine therapy to both donor and recipient.

Brain death is associated with neuroendocrine changes, in particular with a significant reduction of plasma-free triiodothyronine (T3) that results in impaired aerobic metabolism. Myocardial energy stores are reduced and tissue lactate increased. Cardiac function deteriorates. Similar metabolic changes are seen in patients undergoing open-heart surgery on cardiopulmonary bypass, including those undergoing heart transplantation. Therapy with T3 leads to a reversal of these metabolic changes, resulting in improved cardiac function. One hundred and sixteen consecutive potential donors have been so treated, as have 70 of the recipients. Immediate posttransplant cardiac function was good in all but 3, and these hearts recovered to normal within a maximum of 24 hr of mechanical support. In 2 small randomized trials in patients undergoing myocardial revascularization on cardiopulmonary bypass, postoperative T3 therapy was associated with a reduced need for inotropic support and diuretic therapy in the first study and improved cardiac output in the second study.

Triiodothyronine as an inotropic agent after open heart surgery.

Two small, randomized, blind clinical trials comparing the administration of triiodothyronine with that of placebo have been carried out in patients undergoing myocardial revascularization. In patients with a left ventricular ejection fraction of less than 30% (study I), triiodothyronine administration at the end of operation and during the initial 24 hours after operation was associated with a significantly reduced need for conventional inotropic agents (p less than 0.02) and diuretics (p less than 0.02). In patients with a left ventricular ejection fraction of greater than 40% (study II), triiodothyronine administration resulted in significantly improved stroke volume (p less than 0.01) and cardiac output (p less than 0.02) and reduced systemic (p less than 0.01) and pulmonary (p less than 0.05) vascular resistances. There were no adverse reactions to triiodothyronine in the dosages that were used. Triiodothyronine appears to be beneficial to all patients undergoing open heart surgery.

Experience with endomyocardial biopsy in 23 patients with heart transplants.

In the 33-month period April 1985 to December 1987, endomyocardial biopsy was performed 314 times in 23 patients with orthotopic (21) or heterotopic (2) heart transplants at Baptist Medical Center. The technique is described. Adequate tissue was obtained in 99% of cases and there was only one complication from the procedure. Mild to severe acute rejection was seen in 105 specimens (33%). The histopathological interpretation has proved invaluable in the care of patients with heart transplants.

Hypothermic ischemic arrest versus hypothermic potassium cardioplegia in human beings.

To determine if the addition of potassium enhances the myocardial protective effect of intracoronary perfusion hypothermia during aortic cross-clamping, 50 patients undergoing aortocoronary bypass grafting were studied in a randomized, prospective, double-blind fashion. Twenty-six patients received a cold crystalloid solution infused with a handheld syringe into the root of the cross-clamped aorta every 20 minutes, and 24 patients received the same solution but with 25 mEq/L of potassium chloride added, infused in a similar manner. Both groups were analyzed by mortality, rate of perioperative myocardial infarction (electrocardiographic changes, MB-CPK enzyme release, and preoperative and postoperative gated cardiac blood pool scans), intraoperative hemodynamic changes, intraoperative lactate determinations, postoperative arrhythmias, and requirement for pressor or intraaortic balloon pump support. One patient in the potassium cardioplegia group died (massive pulmonary embolism), and none in the hypothermic perfusion group died. Possible perioperative myocardial infarction was diagnosed by more than one marker in 4 of 26 patients in the hypothermic perfusion group and 5 of 24 patients in the potassium group (p = 0.61). There were no differences between the two groups in terms of hemodynamic changes, lactate production, postoperative arrhythmias, or the need for postoperative hemodynamic support. This study in human beings could not demonstrate a specific protective effect of potassium, beyond that afforded by myocardial perfusion hypothermia and wash-out. The data suggest that myocardial hypothermia, achieved through cold intracoronary arterial perfusion, may be the most important beneficial component of so-called cardioplegia for attaining effective intraoperative myocardial preservation in human beings.

Increase in free cholesterol content of the adrenal cortex after stress: radioautographic and biochemical study.

The purpose of this investigation was to quantify free cholesterol biochemically and in radioautographs of 3H-digitonin cholesterol complex in fasciculata cells of control and stressed rat adrenal cortex. Stress was induced by ether, laparotomy, and adrenal and intestinal handling. Control rats were anesthetized with nembutal. All animals were killed ten minutes from the beginning of anesthesia. The adrenals were excised and either fixed in glutaraldehyde containing 3H-digitonin or homogenized for biochemical determination of free cholesterol. The plasma corticosterone level of each animal was measured. The fixed adrenals were processed, using different methods of dehydration and embedment, for light and electron microscopic radioautography. The mean number of silver grains (mean) per unit area of zona fasciculata was counted from light microscopic radioautographs. Crystals of cholesterol-digitonide complex were more numerous in stressed fasciculata cells, particularly over SER. Silver grains were localized over or close to the crystals. The mean for stressed rats was significantly higher than control values, indicating more free cholesterol in fasiculata cells of stressed rats. The results were not affected by either the method of dehydration or the type of embedding medium used. The morphologic results were substantiated by biochemical findings of increase in free cholesterol in adrenals of stressed rats. Plasma corticosterone was significantly high in stressed rats. The increase in free cholesterol in stimulated fasciculata cells is consistent with a previously reported increase in cholesterol esterase activity after ACTH stimulation.