Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better?

OBJECTIVE: To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes. BACKGROUND: Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH. METHODS: A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal. RESULTS: This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01). CONCLUSIONS: No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.

Changes in periodontal parameters of splinted versus non-splinted posterior teeth during ten years of supportive periodontal therapy - A retrospective evaluation.

OBJECTIVES: To compare periodontal parameters of splinted posterior teeth versus control teeth over ten years of supportive periodontal therapy (SPT) and to assess the survival rate of splints. MATERIAL AND METHODS: Retrospective data of 372 SPT-patients was screened for splints (composite/fiberglass-reinforced composite) in the posterior (molars/premolars) which were inserted at least ten years before due to increased tooth mobility. For each splinted tooth (test), a corresponding control tooth had to be present at the first SPT-session after splint insertion (T1). Data was assessed at T1 and ten years later (T2). Possible influencing covariates for splint survival (mobility degree/Eichner class) were tested by Cox regression. The change in clinical attachment level (ΔCAL), probing pocket depth (ΔPPD) and the testing of possible influencing covariates was analyzed by using mixed linear regression. RESULTS: Twenty-four patients (32 splints, 58 splinted teeth) were included. Ten test and two control teeth were lost. No differences were observed between ΔCAL and ΔPPD of test teeth compared to control teeth (ΔCAL -0.38 ± 1.90 vs. 0.20 ± 1.27 mm; ΔPPD -0.17 ± 1.18 vs. 0.10 ± 1.05 mm). Twenty-two splints fractured during the observation period (survival-rate: 31%). Mobility degree and Eichner class did not influence time until fracture. CONCLUSIONS: Splinting of periodontally compromised and mobile posterior teeth does not have any disadvantage regarding the clinical periodontal situation when regular SPT is applied. However, splint fractures occur very often. CLINICAL RELEVANCE: Splinting of posterior teeth is a treatment option in addition to active periodontal therapy when patients are disturbed by tooth mobility but splints have a high susceptibility to fracture.

Vital root resection with radicular retrograde partial pulpotomy in furcation-involved maxillary molars in patients with periodontitis: Technique description and case series considering clinical and economic aspects.

AIM: Conventional root resection in periodontally compromised furcation-involved maxillary molars requires preceding endodontic treatment and is therefore associated with loss of tooth vitality, higher invasiveness, treatment time and costs, and the risk of endodontic complications. Vital root resection (VRR) could overcome these disadvantages while establishing stable periodontal and endodontic conditions. This case series aimed to introduce the concept of one-stage VRR with radicular retrograde partial pulpotomy (VRRretro). SUMMARY: Seven vital maxillary molars with residual probing pocket depths (PPD) ≥ 6 mm and furcation ≥ class 2 of five patients with stage III/IV periodontitis were treated with VRRretro using mineral trioxide aggregate. Teeth with residual through-and-through furcations were additionally tunnelled. Follow-up up to 2.5 years postoperatively during supportive periodontal care included full periodontal status, percussion and thermal sensitivity testing. Periapical radiographs were obtained to rule out possible periradicular radiolucencies. All seven treated molars were in-situ at an average of 26.84 ± 5.37 months postoperatively and were clinically and radiographically inconspicuous independent of tooth position, the resected root, the need for tunnelling and the restorative status. The mean PPD on the seven treated molars was 4.02 ± 0.85 mm (6-10 mm) preoperatively and 2.62 ± 0.42 mm (3-4 mm) at the last follow-up. Clinical attachment level and bleeding on probing could also be decreased. The teeth showed no mobility over time and furcations class 2 were reduced to class 1 while the tunnelled furcations were accessible with interdental brushes. All molars reacted negatively to percussion and positively to thermal sensitivity testing. KEY LEARNING POINTS: In carefully selected cases considering patient- and tooth-related factors, VRRretro could be a promising treatment option to establish stable periodontal and endodontic conditions in furcation-involved maxillary molars while preserving tooth vitality.

The Revisions of the First Autobiography of AT Still, the Founder of Osteopathy, as a Step towards Integration in the American Healthcare System: A Comparative and Historiographic Review.

INTRODUCTION: Osteopathy was originally introduced in rural America in 1874 as a comprehensive therapeutic approach aimed at promoting health. This approach was distinct and often conflicting with conventional/allopathic therapeutic methods available at that time to fight disease. We argue that, in struggling to achieve recognition within the American healthcare system and within the educational academic field that was about to be structured, the American osteopathic profession tried to protect itself from the charges of sectarism by starting to embrace principles of the biomedical paradigm. METHODS: A comparative and historiographic review of the second version of the autobiography of AT Still (1908), the founder of osteopathy, against the first (1897) was chosen as an example of the adaptation of the American osteopathic profession to its evolving academic environment. RESULTS: Although there were only a few substantial variations, we argue that they aimed to dampen the non-biological components of osteopathy, namely, its philosophical, spiritual, religious, emotional, and Native American roots, in an effort to gain respect and recognition within the emerging gold standard of the Western medical system. The shift towards a distinct, fully integrated profession within regulated Western healthcare systems was perceived by many professionals as a threat to AT Still's original ideas, and the trend started when he was alive. CONCLUSION: Our findings suggest that a crucial conversation regarding the future of the professional identity must take place within the osteopathic community.

Remote assessment of dental records by using intraoral scan-based digital three-dimensional models in an elderly patient population - an exploratory study.

AIM: To assess the agreement rates of dental records derived from intraoral scan-based digital three-dimensional models (3DM) and 3DM + panoramic radiographs (3DM+PAN-X) compared to clinical findings. MATERIALS AND METHODS: Based on the 3DM/3DM+PAN-X of 50 patients undergoing supportive periodontal therapy (SPT), ten remote raters (inexperienced in using IOS or 3DM) assessed for each site of the dental scheme (32 sites) whether a tooth was missing (M), filled (F), restoration- and caries-free (H), replaced by an implant (I) or decayed (D). Remote records were compared to the clinical reference record of each patient at tooth-level. The clinical records were assessed by an experienced dentist who supplemented the clinical findings with information from available radiographs and the patient records to define the clinical reference record. RESULTS: The agreement-rates for 3DM/3DM+PAN-X at tooth-level are: M: 93%/94%, F: 84%/88%, H: 92%/92%, I: 65%/96%, D: 29%/29%. The overall agreement-rate is 88% for the 3DM-based dental records (14093 of 16000 entries true) and 91% for 3DM+PAN-X (14499 of 16000 entries true). Using 3DM for dental record assessment, posterior teeth had higher odds of correct findings compared to anterior teeth (upper jaw OR=2.34, lower jaw OR=1.27). CONCLUSIONS: The remote detection of healthy, missing and filled teeth and implants by raters inexperienced in using IOS or 3DM shows a high agreement-rate with the clinical findings. The additional evaluation of PAN-X increased the agreement-rate significantly for implants. Thus, the remote assessment of dental records using 3DM+PAN-X has a high accuracy when applied in SPT-patients with low caries activity.

Severe chronic obstructive pulmonary disease is associated with reduced oral health conditions.

OBJECTIVES: This study aimed to investigate the association of explicitly severe chronic obstructive pulmonary disease (COPD) with oral conditions considering in-depth shared risk factors. METHODS: A case-control study was conducted with 104 participants, 52 with severe COPD and 52 matched controls without COPD. Dental and periodontal status were clinically assessed and oral health-related quality of life (OHRQoL) by OHIP-G14-questionnaire. RESULTS: Between COPD- and control-group, there were no statistically significant differences regarding age (66.02 ± 7.30), sex (female: 52 [50%]), smoking history (44.69 ± 23.23 pack years) and number of systemic diseases (2.60 ± 1.38). COPD patients demonstrated significantly fewer remaining teeth (12.58 ± 9.67 vs. 18.85 ± 6.24, p < 0.001) besides higher DMFT (decayed, missing and filled teeth) index (21.12 ± 5.83 vs. 19.10 ± 3.91, p = 0.036). They had significantly greater probing pocket depths (PPD: 3.24 mm ± 0.71 mm vs. 2.7 mm ± 0.37 mm, p < 0.001) and bleeding on probing (BOP: 34.52% ± 22.03% vs. 22.85% ± 17.94%, p = 0.003) compared to controls, but showed no significant difference in clinical attachment level or staging of periodontitis. The OHIP-G14 sum score was significantly higher in COPD patients (7.40 ± 7.28 vs. 3.63 ± 4.85, p = 0.002). Common risk factors such as educational status, physical activity, dentist visit frequency, oral hygiene regimens and dietary habits were less favourable in patients with COPD. CONCLUSIONS: COPD was significantly associated with higher tooth loss, PPD, BOP and DMFT besides lower OHRQoL.

Oral health conditions in patients under antiresorptive therapy are comparable to unexposed during supportive periodontal care.

OBJECTIVES: To investigate oral health and oral health-related quality of life (OHRQoL) of patients under antiresorptive therapy (ART) during supportive periodontal care (SPC) considering history of medication-related osteonecrosis of the jaw (MRONJ). MATERIALS AND METHODS: In this cross-sectional study, 100 patients (50 receiving ART (exposed) and 50 without ART (unexposed)) in regular SPC were enrolled for a clinical oral examination and the evaluation of OHRQoL using the OHIP-G14-questionnaire. History of MRONJ was assessed by anamnesis and reviewing patient records. RESULTS: There were no statistically significant group differences in age (exposed: 70.00 ± 9.07 versus unexposed: 71.02 ± 8.22 years), sex, distribution of systemic diseases and duration of SPC (on average 8.61 ± 5.73 years). Number of teeth (21.02 ± 5.84 versus 21.40 ± 5.42), DMFT (18.38 ± 3.85 versus 17.96 ± 4.08), probing pocket depth (2.31 ± 0.20 versus 2.38 ± 0.26), clinical attachment level (3.25 ± 0.76 versus 3.46 ± 0.58) and bleeding on probing (15.07 ± 11.53 versus 15.77 ± 13.08) were also not significantly different. The OHIP-G14 sum-score was significantly higher in exposed participants (6.10 ± 6.76 versus 3.62 ± 5.22, p = 0.043). History of MRONJ was prevalent in 8% of patients under ART. Periodontal/peri-implant-related MRONJ were reported in three participants with cancer (n = 1 before and n = 2 after active periodontal therapy). History of MRONJ due to endodontic/restorative reasons was reported in one patient with osteoporosis. CONCLUSIONS: Patients under ART in SPC demonstrated similar clinical periodontal and dental status but lower OHRQoL compared to unexposed (not statistically significant). Patient awareness of the MRONJ-risk and appropriate preventive measures should be ensured. CLINICAL RELEVANCE: SPC in osteoporotic patients under ART appeared safe regarding MRONJ, but further investigations on the MRONJ-risk in patients with different risk-profiles are necessary. STUDY REGISTRATION: clinicaltrials.gov (#NCT04192188).

Fascial Nomenclature: Update 2022.

The connective tissue or fascia plays key roles in maintaining bodily function and health. The fascia is made up of solid and fluid portions, which interpenetrate and interact with each other, forming a polymorphic three-dimensional network. In the vast panorama of literature there is no univocal thought on the nomenclature and terminology that best represents the concept of fascia. The Foundation of Osteopathic Research and Clinical Endorsement (FORCE) organization brings together various scientific figures in a multidisciplinary perspective. FORCE tries to find a common nomenclature that can be shared, starting from the scientific notions currently available. Knowledge of the fascial continuum should always be at the service of the clinician and never become an exclusive for the presence of copyright, or commodified for the gain of a few. FORCE is a non-profit organization serving all professionals who deal with patient health. The article reviews the concepts of fascia, including some science subjects rarely considered, to gain an understanding of the broader fascial topic, and proposing new concepts, such as the holographic fascia.

Remote assessment of DMFT and number of implants with intraoral digital photography in an elderly patient population - a comparative study.

OBJECTIVES: This comparative study aimed to evaluate intraoral digital photography (IODP) as assessment-tool for DMFT and number of implants (IMPL) compared to clinical diagnosis (CLIN) in an elderly population with high restorative status. Secondary research questions were whether an additional evaluation of panoramic radiographs (PAN-X) or raters' clinical experience influence the agreement. METHODS: Fifty patients (70.98±7.60 years) were enrolled for standardized CLIN and IODP. The clinical reference examiner and ten blinded raters evaluated the photographs without and with a PAN-X regarding DMFT and IMPL. CLIN were used as reference standard and differences to IODP and IODP-PAN-X findings were analysed descriptively. To assess intra-rater agreement, pairwise Gwet's AC1s of the three diagnostic methods CLIN, IODP and IODP+PAN-X were calculated. RESULTS: Compared to a DMFT of 22.10±3.75 (CLIN), blinded raters evaluated a DMFT of 21.54±3.40 (IODP) and 22.12±3.45 (IODP+PAN-X). Mean values for "Decayed" were 0.18±0.52 (CLIN), 0.45±0.46 (IODP) and 0.48±0.47 (IODP-PAN-X), while 11.02±5.97 (CLIN), 10.66±5.78 (IODP) and 10.93±5.91 (IODP+PAN-X) were determined for "Missing" and 10.90±5.61 (CLIN), 10.43±4.85 (IODP) and 10.71±5.11 (IODP+PAN-X) for "Filled". IMPL were 0.78±2.04 (CLIN), 0.58±1.43 (IODP), 0.78±2.04 (IODP+PAN-X). Gwet's AC1 using the mode of the blinded raters' assessment of "Decayed", "Missing" and IMPL compared to CLIN ranged from 0.81 to 0.89 (IODP) and 0.87 to 1.00 (IODP+PAN-X), while for "Filled" and DMFT they were 0.29 and 0.36 (IODP) as well as 0.33 and 0.36 (IODP+PAN-X), respectively. Clinical experience did not influence the agreement. CONCLUSIONS: Assessment of "Decayed", "Missing" and IMPL by IODP showed almost perfect agreement, whereas of "Filled" and DMFT revealed fair to moderate agreement with clinical findings. Additional PAN-X-evaluation increased agreement compared to IODP-diagnostics alone. IODP for the assessment of DMFT and IMPL might be a suitable method in large-scale epidemiological studies, considering high agreement in total values and miscellaneous agreement at patient-level.

Impact of the COVID-19 pandemic on oral health and psychosocial factors.

The objective of this study was to investigate oral health-related quality of life (OHRQoL) in times of the COVID-19 pandemic and to examine a possible association to psychosocial factors like psychological stress and symptoms of depression and anxiety disorders. Secondary research questions were whether people changed oral hygiene regimens during the COVID-19 pandemic and to what extent dental symptoms existed and developed compared to pre-pandemic. For this cross-sectional study a survey has been conceptualized to determine OHRQoL, stress, depression and anxiety and their specific confounders in a German cohort. Validated questionnaires as OHIP-G14, PHQ-Stress and PHQ-4 have been implemented. Altogether 1178 participants completed the survey between May and August 2020. The overall OHIP-G14 sum score of 4.8 ± 7.5 indicated good OHRQoL. 21% of the participants (n = 248) reported toothache, 23% (n = 270) mucosal problems, 31% (n = 356) hypersensitivity of the teeth and 27% (n = 305) myofacial pain. The PHQ-Stress score (4.5 ± 3.5) demonstrated a mild severity of stress. Depression and anxiety level has been mild to moderate (PHQ-4 score: 2.4 ± 2.6). 38% of the participants stated subjectively greater emotional burden compared to pre-pandemic. Statistically significant differences exist for OHRQoL, stress, anxiety and depression levels between participants with greater, equal or less emotional burden compared to pre-pandemic. COVID-19 history and aggravated levels of depression, anxiety, and stress seem to associate with lower OHRQoL. Psychosocial consequences during pandemic times and their association to oral health should be further investigated.

The impact of splinting timepoint of mobile mandibular incisors on the outcome of periodontal treatment-preliminary observations from a randomized clinical trial.

OBJECTIVES: To compare the outcome of periodontal parameters in mobile mandibular incisors which were splinted before or after full-mouth disinfection (FMD). MATERIALS AND METHODS: Thirty-four periodontitis patients with ≥ 1 mobile mandibular incisor (mobility degree II/III, clinical attachment loss (CAL) ≥ 5 mm, relative bone loss ≥ 50%) were randomly allocated to group A or B. Patients received periodontal treatment (PT) including splinting of teeth 33-43 before (A) or after FMD (B). Patient (age/sex/smoking status/systemic diseases/number of teeth) and tooth-related parameters (mean probing pocket depth (PPD)/CAL/oral hygiene indices; for the overall dentition and region 33-43) were assessed prior to PT and 12 months after FMD by a blinded examiner. Therapy-related information was added (group/antibiotic therapy/surgical intervention). RESULTS: Twenty-six patients (A: 12; B:14) were re-examined. Two patients of group B did not need splinting after FMD because of reduction in mobility after FMD. Regression analysis revealed a positive association of antibiotic therapy with CAL_overall, PPD_overall, and PPD_33-43 (p ≤ 0.01). There is a trend toward a higher reduction of periodontal parameters at teeth 33-43 in group A (PPD_33-43: - 0.91 vs. - 0.27 mm; CAL_33-43: - 1.02 vs. - 0.47 mm). CONCLUSIONS: Teeth splinted before or after FMD show a significant improvement in periodontal parameters 12 months after FMD. Splinting after FMD offered the option to detect reduction in mobility. CLINICAL RELEVANCE: Despite a higher, but not statistically significant, improvement in periodontal parameters on teeth splinted before FMD, the results do not indicate which timepoint of splinting is more beneficial. The decision for the therapeutic procedure should therefore be made individually.

The impact of splinting mobile mandibular incisors on Oral Health-Related Quality of Life-Preliminary observations from a randomized clinical trial.

AIM: To compare the Oral Health-Related Quality of Life (OHRQoL) of patients with mobile mandibular incisors before and after full-mouth disinfection (FMD) with and without splinting. MATERIAL AND METHODS: Thirty-four periodontitis patients with ≥1 mobile mandibular incisor (degree II/III) were randomly allocated to the test or control group. All patients received FMD and the test group additional splinting of teeth 33-43. OHRQoL was assessed before (BL) and 3 months after FMD (RE) using the Oral Health Impact Profile (OHIP)-14. Data were compared within and between the groups (Wilcoxon test/Mann-Whitney U test). RESULTS: Twenty-eight patients (13 test group/15 control group) were re-evaluated. FMD led to a reduction of the mean probing pocket depth (PPD; in mm) (test group: BL-PPD 3.89 ± 1.03, RE-PPD 2.82 ± 0.53; control group: BL-PPD 3.58 ± 0.66, RE-PPD 2.77 ± 0.59; each p ≤ .001), the mean clinical attachment level (CAL; in mm) (test group: BL-CAL 5.22 ± 1.38, RE-CAL 4.79 ± 0.85; control group: BL-CAL 4.58 ± 1.10, RE-CAL 4.41 ± 0.96; each p ≤ .05), and the mean OHIP-14 summary scores (test group: BL-OHIP 21.7 ± 11.06, RE-OHIP 9.9 ± 8.96, p = .0046; control group: BL-OHIP 16.8 ± 8.27, RE-OHIP 11.7 ± 8.55; p = .0217). The reduction of the OHIP-G14 scores was considerably higher in the test group but statistically not significant (p = .080). CONCLUSIONS: The results show a positive impact of non-surgical periodontal treatment on OHRQoL and a possible tendency for further improvement by splinting mobile mandibular incisors.

Changes of clinical parameters at implants: A retrospective comparison of implants versus natural teeth over 5 years of supportive periodontal therapy.

OBJECTIVES: To compare clinical parameters of implants versus natural teeth over a period of 5 years during supportive periodontal therapy (SPT). MATERIAL AND METHODS: A total of 421 SPT patients were screened for implants (I) and corresponding control teeth (C). Data (patient level [P ]: sex, age, smoking status, systemic diseases, adherence, oral hygiene indices, mean probing depth [PD]P , bleeding on probing [BOP]P , periodontal risk profile; implant/control tooth level [I/C ]: PDI/C , BOPI/C ; site level at implants [SITE ]: position, dental arch, aspect, BOPSITE ) were assessed at the first SPT session where the implant was probed (T1) and 5 years later (T2). The influence of patient and implant/control-related factors on PDI/C /BOPI/C was tested (linear mixed model) as well as the influence of site-specific factors on the PDSITE change (multilevel regression). RESULTS: A total of 70 patients (151 implants) were included. Mean PDI was 2.75 ± 0.85 mm (T1) and 2.87 ± 0.79 mm (T2). Mean PDC was 2.42 ± 0.66 mm (T1) and 2.49 ± 0.71 mm (T2). BOPI increased from 8.62 ± 15.01% (T1) to 24.06 ± 26.79% (T2) and BOPC from 9.97 ± 17.78% (T1) to 15.52 ± 22.69% (T2). The differences between implants and controls were significant for BOP (p = .0032). At T2, BOPI/C was associated with periodontal risk (p = .0351). The site-specific analysis revealed an association of BOPSITE at T1 with the progression of PDSITE (p = .0058). CONCLUSIONS: Probing depths of implants and controls seem to change similarly during SPT but retention of inflammation-free conditions at implants appears to be more difficult compared to natural teeth. Patients with a high-risk profile appear to have an increased susceptibility for BOP around implants, and BOP at implants seems to be a predictor for further PD increase.

Students' self-assessment of competencies in the phantom course of operative dentistry.

INTRODUCTION: The aim was to assess the competencies of undergraduate students in their roles of dental expert, scholar, communicator, collaborator, health advocate, manager and professional. MATERIALS AND METHODS: For this retrospective, pseudonymised observational study (pre-/post-testing), students in two cohorts in their first clinical semester in operative dentistry were asked to judge their competencies (1 = very good to 6 = insufficient) with a learning objective catalogue designed at the Goethe University Frankfurt (modelled after the National Competency-Based Learning Objective Catalogue Dentistry), at the beginning and end of their phantom course. In order to relate the students' subjective competency judgements to objective evidence of their skills, at the end of the semester their marks from the summative Objective Structured Practical Examination (OSPE) were compared with the subjective judgement of their exam performance before the final results were known. RESULTS: The reliability of the evaluation sheet was evaluated with Cronbach's alpha 0.98. The students judged their competencies as "sufficient" (4.23 ± 0.51) at the beginning and "satisfactory" (2.82 ± 0.43) at the end. A significant improvement in competencies was observed within all roles. The students' subjective judgement of the exam results (3.66 ± 0.62) was significantly correlated with the actual marks (3.69 ± 0.83) in the OSPE at 0.3547 (P = 0.0015). CONCLUSION: The evaluation instrument showed excellent reliability. The students judged that their competencies significantly increased during the semester. The triangulation with the actual marks in the context of an OSPE demonstrated a significant correlation with the students' exam judgements.