Does articaine, rather than lidocaine, increase the risk of nerve damage when administered for inferior alveolar nerve blocks in patients undergoing local anaesthesia for dental treatment? A mini systematic review of the literature.

Aims: This mini systematic review seeks to analyse the available literature and determine if a 4% articaine solution poses a greater risk of inferior alveolar and/or lingual nerve damage compared to that of 2% lidocaine, when administered for an inferior alveolar nerve block. Results: After a mini systematic review of the published literature, seven suitable studies were identified: one double-blind random controlled trial (DBRCT) and six retrospective cohort studies. The DBRCT and two of the cohort studies concluded that 4% articaine poses no greater risk of nerve damage. The remaining four cohort studies suggested that caution should be exhibited when using a 4% local anaesthetic solution rather than a 2% solution. However, these studies also concluded that no evidence exists to explain the reasons for their results. Discussion and conclusion: The included articles present no conclusive evidence to suggest that 4% articaine causes more nerve damage than 2% lidocaine, although some authors advise caution when using this agent. All studies conclude that further quality research is required, and it is therefore suggested that dental practitioners exhibit caution when choosing to use 4% articaine in an inferior alveolar nerve block until further scientific research has been performed.

In their own words: investigating the preparedness of final year dental students in the UK for independent general dental practice.

Introduction: There is relatively little data on the preparedness of UK dental graduates for independent general dental practice. Two recent studies have indicated that graduates appear well prepared, but although quantifying the level of preparedness, they provide limited understanding of the underlying factors contributing to preparedness. This study aims to more deeply understand the contributing factors leading to assertions of graduate preparedness using focus groups of final year dental students, and semi-structured interviews of senior faculty members. Materials and methods: Three UK dental schools were visited in order to conduct both study elements. Focus groups and semi-structured interviews were audio recorded and fully transcribed. Thematic analysis of the transcripts resulted in the production of a thematic matrix. Results: The major categories of the thematic matrix were classified as extrinsic; including the role of educators and features of the course, and intrinsic; relating to fear of the unknown, the development of adult learning abilities and less easily identifiable attributes in the development of competence, which became known as 'bricks and mortar'. Discussion: Students felt that the most important factor affecting their preparation was clinical exposure. Outreach placements were felt to be particularly useful, the simulation of general dental practice being highly valued by final year students. The interaction with educators was also felt to be a key influence on preparedness, with the involvement of general practitioners in dental school teaching felt to be helpful, perhaps giving students an extended exposure to general practice. Conclusion: It is hoped that the rich data derived from this study may allow an invaluable insight into factors contributing to preparedness of new dental graduates, which may then be considered in the light of any proposed changes in the curricula or syllabi.

How prepared are foundation dentists in England and Wales for independent general dental practice?

Introduction The Graduate Assessment of Preparedness for Practice (GAPP) questionnaire has been shown to be valid and reliable in assessing the preparedness of foundation dentists (FDs) for independent general dental practice (GDP). In this study it is used to establish preparedness at six weeks of dental foundation training (DFT) across England and Wales.Method GAPP questionnaires were sent to all FDs and ESs in England and Wales in mid-September 2012. Part 1 of the GAPP questionnaire collected the descriptive data of respondents. Part 2 comprised 34 'competence areas' designed to reflect the breadth of Preparing for Practice allowing respondents a 7-category Likert style response. Part 3 comprised open questions designed to allow respondents to expand on their views. Quantitative categorical data from Part 2 was analysed using IBM SPSS (version 20). Median scores were analysed and mean rank scores were generated in order to compare FD and ES responses. Part 2 results were cross-tabulated with the Part 1 descriptors and analysed using the Mann Whitney U and Kruskal Wallis H non-parametric tests. Mean rank scores were considered to be statistically significant if P ≤0.05. Part 3 data was analysed thematically using NVivo (version 10).Results FDs and ESs felt that FDs were generally well prepared for independent GDP, although FDs rated their preparedness significantly higher than ESs in all areas. FDs who graduated from 4-year courses felt significantly more prepared across most of the curriculum than those from 5-year courses, and graduates from outside the UK felt less prepared for GDP than those from a UK school.Conclusions FDs appear to be well prepared for independent GDP at six weeks of DFT. FDs rated their preparedness significantly higher than ESs across the curriculum. Coupled with the finding that the more experienced ESs felt their FDs were less well prepared, that may indicate FDs potentially overstate their level of preparedness. FDs who completed 4-year courses were generally more prepared across a range of curricular areas, some of which may reflect differences in the courses they completed, while others may relate to the individual being a graduate on entry to the course. Distribution of questionnaires through DFT schemes has resulted in a large number of respondents which may allow valuable generalisations to be made about the preparedness of graduates entering DFT in the UK.

The development and piloting of the graduate assessment of preparedness for practice (GAPP) questionnaire.

Introduction Most new dental graduates in the UK begin their professional career following a year in dental foundation training (DFT). There has been little investigation of how prepared they feel for independent general dental practice across all four domains of the General Dental Council's curriculum 'Preparing for practice'. This paper describes the development of the Graduate Assessment of Preparedness for Practice (GAPP) questionnaire to address this.Methodology The GAPP questionnaire was developed and piloted using a cohort of educational supervisors (ESs) and foundation dentists (FDs). The questionnaire comprised three parts, the first of which collected respondent demographic data. The second was based on Preparing for practice and was used to develop 34 'competence areas' and required a tick-box response on a 7-category Likert Scale. The third comprised free text questions in order to further explore the subject's responses.Results Pilot feedback was positive, the statements were felt to be clear and unambiguous, allowing them sufficient scope to state their position. The pilot study informed small cosmetic changes to the GAPP questionnaire and inclusion of a 'comments' column for respondents to qualify their responses. The pilot results indicated that both FDs and their ESs felt that at ten months of DFT, the FDs were very well prepared for independent general dental practice.Discussion The paper describes the important considerations relating to the reliability and validity of the GAPP questionnaire.Conclusions GAPP appears to be a suitable questionnaire to measure preparedness of new graduates with a degree of reliability and validity. The instrument is designed to be simple to complete and provides a useful analytical instrument for both self-assessment of competence and for wider use within dental education.

The efficacy and safety of fasciectomy and fasciotomy for Dupuytren's contracture in European patients: a structured review of published studies.

A structured review of published papers was done to assess the efficacy and safety of fasciectomy and fasciotomy in European patients with Dupuytren's contracture. The outcomes varied across 48 studies. For fasciectomy, outcomes and results were as follows: the proportions of patients with a 100% correction in contracture angle ranged from 61 to 97%, the mean improvement in contracture angle ranged from 58 to 79%, and cases judged excellent/good ranged from 63 to 90%. Fasciotomy had similar outcomes, with a mean improvement in contracture angle ranging from 46 to 88%. Immediate failures upon recovery were reported for both procedures. The average recurrence rates were 39% after a fasciectomy and 62% after a fasciotomy at a median time of about 4 years. Overall, about 20% of fasciectomy and fasciotomy patients experienced an adverse event. In summary, postoperative outcomes were successful, but surgical complications were common and recurrence of a contracture was likely within a few years.

Paracetamol overdose as a result of dental pain requiring medical treatment - two case reports.

Two cases of unintentional paracetamol overdose are presented. Over a one month period these patients presented to an Accident and Emergency (A&E) department with symptoms of paracetamol toxicity, following the ingestion of large quantities of analgesia for the self treatment of dental pain. In one case the patient had no access to a dentist. Both patients required admission under the care of the medical on-call team and required anti-toxicity treatment to prevent permanent liver injury. Subsequent referrals were made to the oral and maxillofacial surgery team who provided emergency dental treatment and advice on further dental care. This paper highlights the significant signs and symptoms of paracetamol overdose about which dental practitioners should be aware. It also describes the management principles required to prevent potentially life threatening liver damage. Discussion is also made of the potential impact on patients struggling to cope with pulpal pain without access to a general dental practitioner.

Serum levels of insulin-like growth factors (IGFs) and their binding proteins (IGFBPs), -1, -2, -3, in oral cancer.

INTRODUCTION: Insulin-like growth factor (IGF) possesses mitogenic properties promoting cellular proliferation and inhibiting cellular apoptosis. Reported evidence suggests that cancer (non-oral) is associated with high circulating levels of IGF-1 and low levels of IGFBP-3. AIMS: This study measured circulating levels of IFG-1 and IGFBPs -1, -2 and -3 in oral cancer patients. METHODOLOGY: Blood was collected from surgical patients and controls. Samples were assayed for IGF-1 and IGFBPs -1, -2, -3, using commercially available enzyme-linked immunosorbant assays (ELISA; R&D Systems Europe, Oxon, UK). RESULTS: Twenty-seven oral cancer and 31 age- and sex-matched patients were recruited. Mean IGF-1 and IGFBP-3 levels were significantly lower in cancer patients than controls (85.3 ng/ml and 2008 ng/ml versus 191 ng/ml and 2935 ng/ml, P<0.001). In contrast, levels of IGFBPs 1 and 2 were significantly higher in cancer patients than in controls. No significant association was demonstrated with tumour size or nodal metastases. DISCUSSION: This study has shown that in contrast to other cancers, circulating levels of IGF-1 and IGFBP-3 may both be lowered in patients with head and neck cancer.

Simplifying the assessment of the recovery from surgical injury to the lingual nerve.

OBJECTIVE: To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome. METHOD: A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months. RESULTS: The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice. CONCLUSIONS: The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

N-linked sialyated sugar receptors support haematopoietic cell-osteoblast adhesions.

Haematopoietic progenitor cells proliferate and develop predominantly when they adhere to bone marrow stromal cells such as osteoblasts. Therefore, changes in adhesion may be a common mechanism by which stem cells survive, mature and properly traffic between the bone marrow and the circulation. To characterize these adhesion molecules, we reduced the bone marrow cavity to a simple adhesion assay between KG1a (a CD34+ haematopoietic cell line) and osteosarcoma monolayers (MG-63 or SaOS-2). The data demonstrated that adhesion was mediated by cell-to-cell rather than cell-to-matrix contact, was sensitive to trypsin, calcium chelators and glycosylation inhibitors. Selective pretreatment attributed the constitutive binding to N-linked glycans on KG1a. When carboprocessing was inhibited later at the high mannose intermediate (via deoxymannojirimycin), adhesion was retained. Surprisingly, binding of KG1a to SaOS-2 increased past constitutive levels as doses of tunicamycin or deoxymannojirimycin dropped. Selective pretreatment suggested that this 'inducible' binding resides with molecule(s) on SaOS-2. If the terminal sialic acid was digested (via neuraminidase), this induced response was duplicated. These data, verified in primary cells, suggest that the initial tethering between blood and bone cells in this model is probably due to heavily glycosylated, rapidly processed protein(s) on both cell types.

Simultaneous occurrence of sublingual dermoid cyst and oral alimentary tract cyst in an infant: a case report and review of the literature.

The simultaneous occurrence of sublingual dermoid cyst and oral alimentary tract cyst is very rare. A literature search revealed only two previous cases and one other, where a dermoid cyst was associated with a gastrointestinal microcyst in its cyst wall. We report a case of a six-week-old Caucasian boy, who presented with swelling of the tongue and floor of mouth, which interfered with his normal feeding and swallowing. The swelling was rapidly increasing in size and had become an airway threat. Magnetic resonance imaging (MRI) scans revealed the presence of a lobulated lesion arising in the region of the floor of the mouth on the left and a further lobule which actually invaded the soft tissues of the inferior aspect of the tongue. These two cystic lesions were excised surgically via an intraoral approach and the infant made a complete recovery postoperatively, with resumption of normal feeding and swallowing. The differential diagnoses and approach to sublingual swellings are discussed and the importance of prompt treatment is emphasized.

Temporomandibular joint synovial fluid sampling: estimation of dilution factor using calcium ion concentration.

Saline aspirates have been commonly used in the biochemical investigations of temporomandibular joint (TMJ) pathology. However, due to presence of adhesions in the diseased temporomandibular joint, full equilibration between the injected saline and the synovial fluid may not be achieved in all cases. We measured calcium ion concentration in the saline aspirates and the plasma to assess the degree of dilution of the synovial fluid by the injected media. Saline aspirates obtained prior to the arthroscopic examination of 17 patients with painful TMJs not responding to 3 months of conservative treatment were analysed for their calcium content by a highly sensitive spectrophotometric autoanalyser. In 10 patients with unilateral symptoms, the contralateral asymptomatic side was used as a control. Using a concentration volume equation the amount of the synovial fluid in the saline aspirates was calculated. The yield of the saline aspirates was variable ranging from 330 to 1000 microl. The mean calcium level was 0.787 mg/dl in the symptomatic group (C.I. 95% 0.337-1.237 mg/dl) and 0.512 mg/dl (C.I. 95% 0.235-0.797) in the asymptomatic group. Using a Student t-test there was no significant difference between the two groups. Furthermore, there was no demonstrable correlation between the volume of the aspirate and its synovial fluid content. This study confirms that the saline aspirate may not be a representative sample of the TMJ synovial fluid, and that expression of the results of the biochemical assays per volume of the aspirate may be misleading.

The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer.

PURPOSE: To determine the effects of medial (inwards) and lateral (outwards) rotation of the head on the transverse diameter of the internal jugular vein. MATERIAL: The original study sample included 26 patients. Duplex ultrasound was used to measure the transverse diameter of the internal jugular vein at a fixed point on either side of the neck. Measurements were taken with the head central (neutral position), rotated laterally and medially. RESULTS: Using Student's t-test we found that lateral rotation of the head produced a reduction in the mean of the transverse diameters of the left and right ipsilateral vein from 6.9 mm to 5.4 mm (p < 0.03) and 5.9 mm to 5.0 mm (p = 0.2173) respectively. One patient excluded from the study because of previous neck surgery showed complete occlusion of the ipsilateral internal jugular vein on lateral rotation of the head. CONCLUSION: There is a possibility that patency of the vein could be compromised if the head is turned laterally. This situation may arise immediately after surgery in the ventilated and paralysed patient when the head may be unsupported. It could be of particular importance if the vein has been used as a recipient vein for free tissue transfer.

Effect of orthognathic surgery on the temporomandibular joint in patients with anterior open bite.

This study examined the prevalence of temporomandibular joint (TMJ) signs and symptoms in patients with anterior open bite. The influence of orthognathic surgery on the TMJ in these patients and the interaction of occlusal and psychologic variables on the presence and/or persistence of pain was studied. A retrospective survey of 83 patients with an anterior open bite who underwent orthognathic surgery was carried out. Records were examined for the prevalence of abnormal TMJ signs and symptoms, including pain. A survey was mailed to these patients that consisted of: (1) the TMJ Scale, (2) the Symptom Checklist 90 (SCL90), (3) the Spielberger State-Trait Anxiety Inventory (STAI), and (4) a visual analog scale on which patients indicated their degree of satisfaction with the procedure. Thirty-seven (42%) patients responded to the survey, and 13 (15%) also attended a clinical and radiographic examination. Multiple regression analysis was used for statistical analysis of the factors contributing to the presence and/or persistence of pain. In the preoperative group, the prevalence of pain was 32%, dysfunction 40%, and limitation of opening 7%. Age and gender were significantly associated with the presence of pain. The overall prevalence of abnormal TMJ signs and symptoms was not significantly different after orthognathic surgery. An abnormal psychologic profile was the most significant factor associated with the presence and/or persistence of pain. It is concluded that that the prevalence of temporomandibular disorders in anterior open bite patients increases with age, is significantly higher in females, and is not influenced by other occlusal variables. Furthermore, orthognathic surgery does not significantly influence temporomandibular disorders in patients with anterior open bite. Female patients, particularly those with an abnormal psychologic profile, are at a higher risk of persistent postoperative TMJ pain.

Facial features of widespread neuroblastoma: a case report.

A case report of stage IV neuroblastoma which presented with periorbital swelling and ecchymosis originally misdiagnosed as facial trauma. The child soon developed a sinister pancytopenia, which following extensive investigations was revealed to be due to an underlying neuroblastoma. Periorbital ecchymosis associated with neuroblastoma is termed 'raccoon eyes' and is a diagnostic trap for the unwary.

Soluble 2-substituted aminopyrido[2,3-d]pyrimidin-7-yl ureas. Structure-activity relationships against selected tyrosine kinases and exploration of in vitro and in vivo anticancer activity.

In continuing our search for medicinal agents to treat proliferative diseases, we have discovered 2-substituted aminopyrido[2,3-d]pyrimidin-7-yl ureas as a novel class of soluble, potent, broadly active tyrosine kinase (TK) inhibitors. An efficient route was developed that enabled the synthesis of a wide variety of analogues with substitution on several positions of the template. From the lead structure 1, several series of analogues were made that examined the C-6 aryl substituent, a variety of water solublizing substitutents at the C-2 position, and urea or other acyl functionality at the N-7 position. Compounds of this series were competitive with ATP and displayed submicromolar to low nanomolar potency against a panel of TKs, including receptor (platelet-derived growth factor, PDGFr; fibroblast growth factor, FGFr;) and nonreceptor (c-Src) classes. Several of the most potent compounds displayed submicromolar inhibition of PDGF-mediated receptor autophosphorylation in rat aortic vascular smooth muscle cells and low micromolar inhibition of cellular growth in five human tumor cell lines. One of the more thoroughly evaluated members, 32, with IC50 values of 0.21 microM (PDGFr), 0.049 microM (bFGFr), and 0.018 microM (c-Src), was evaluated in in vivo studies against a panel of five human tumor xenografts, with known and/or inferred dependence on the EGFr, PDGFr, and c-Src TKs. Compound 32 produced a tumor growth delay of 14 days against the Colo-205 colon xenograft model.

Japanese fermented soybean food as the major determinant of the large geographic difference in circulating levels of vitamin K2: possible implications for hip-fracture risk.

Increasing evidence indicates a significant role for vitamin K in bone metabolism and osteoporosis. In this study, we found a large geographic difference in serum vitamin K2 (menaquinone-7; MK-7) levels in postmenopausal women. Serum MK-7 concentrations were 5.26 +/- 6.13 ng/mL (mean +/- SD) in Japanese women in Tokyo, 1.22 +/- 1.85 in Japanese women in Hiroshima, and 0.37 +/- 0.20 in British women. We investigated the effect of Japanese fermented soybean food, natto, on serum vitamin K levels. Natto contains a large amount of MK-7 and is eaten frequently in eastern (Tokyo) but seldom in western (Hiroshima) Japan. Serum concentrations of MK-7 were significantly higher in frequent natto eaters, and natto intake resulted in a marked, sustained increase in serum MK-7 concentration. We analyzed the relation between the regional difference in natto intake and fracture incidence. A statistically significant inverse correlation was found between incidence of hip fractures in women and natto consumption in each prefecture throughout Japan. These findings indicate that the large geographic difference in MK-7 levels may be ascribed, at least in part, to natto intake and suggest the possibility that higher MK-7 level resulting from natto consumption may contribute to the relatively lower fracture risk in Japanese women.

Identification of the secreted macromolecular immunogens of Staphylococcus aureus by analysis of serum.

The ability of sera to recognise secreted macromolecules of Staphylococcus aureus was examined by ELISA and Western immunoblotting. Individual secreted proteins were also studied using both human sera and sera from rabbits immunised with secreted macromolecules. Patients sera showed a wide range of IgG antibody titres to secreted macromolecules and whole bacteria. Controls showed a significantly lower IgG response. Western immunoblotting revealed that a significant number of secreted proteins were recognised by circulating IgG antibodies. Surprisingly, both the sera from controls and from patients recognised similar macromolecules including a number of potential virulence factors. The major difference was in the IgG binding to a 16-kDa component, which was recognised by the majority of the sera from infected individuals, but only by a small number of sera from healthy controls. The higher incidence of antibodies recognising the 16 kDa component may be related to our earlier finding that the major bone resorbing component of S. aureus is a heterodimeric protein containing a 16-kDa subunit, the activity of which could be blocked by sera.

Functional differences between monocyte chemotactic protein-1 receptor A and monocyte chemotactic protein-1 receptor B expressed in a Jurkat T cell.

The monocyte chemotactic protein-1 (MCP-1) receptor (MCP-1R) is expressed on monocytes, a subpopulation of memory T lymphocytes, and basophils. Two alternatively spliced forms of MCP-1R, CCR2A and CCR2B, exist and differ only in their carboxyl-terminal tails. To determine whether CCR2A and CCR2B receptors function similarly, Jurkat T cells were stably transfected with plasmids encoding the human CCR2A or CCR2B gene. Nanomolar concentrations of MCP-1 induced chemotaxis in the CCR2B transfectants that express high, intermediate, and low levels of MCP-1R. Peak chemotactic activity was shifted to the right as receptor number decreased. Five-fold more MCP-1 was required to initiate chemotaxis of the CCR2A low transfectant, but the peak of chemotaxis was similar for the CCR2A and CCR2B transfectants expressing similar numbers of receptors. MCP-1-induced chemotaxis was sensitive to pertussis toxin, implying that both CCR2A and CCR2B are G(i)alpha protein coupled. MCP-1 induced a transient Ca(2+) flux in the CCR2B transfectant that was partially sensitive to pertussis toxin. In contrast, MCP-1 did not induce Ca(2+) flux in the CCR2A transfectant. Since MCP-1 can stimulate chemotaxis of the CCR2A transfectant without inducing Ca(2+) mobilization, Ca(2+) flux may not be required for MCP-1-induced chemotaxis in the Jurkat transfectants. These results indicate that functional differences exist between the CCR2A and CCR2B transfectants that can be attributed solely to differences in the carboxyl-terminal tail.

Modified apically repositioned flap in the treatment of unerupted maxillary central incisors.

The successful management of labially unerupted maxillary central incisors requires a coordinated surgical, orthodontic and general practitioner approach. The key to achieving maximal eruption of these teeth is their surgical exposure, central to which is the philosophy that the surgeon must provide a functional width of attached gingiva on the labial surface. This case describes the incorporation of palatal mucosa into an apically repositioned flap, resulting in the successful establishment of an attached gingival margin, where routine flap design would have seriously compromised the eventual outcome.