Orofacial findings in chronic granulomatous disease: report of twelve patients and review of the literature.

BACKGROUND: Chronic granulomatous disease is an extremely rare primary immunodeficiency syndrome that can be associated with various oral complications. This can affect high number of patients. However, data on oral complications is sparse. Here we will review the literature and describe the orofacial findings in 12 patients. FINDINGS: The age range was 5-31 years. Oral findings were variable, and reflected a low level of oral hygiene. They included periodontitis, rampant caries, gingivitis, aphthous-like ulcers, and geographic tongue. One patient had white patches on the buccal mucosa similar to lichen planus. Another patient had a nodular dorsum of the tongue associated with fissured and geographic tongue. Biopsies from the latter two lesions revealed chronic non-specific mucositis. Panoramic radiographs showed extensive periodontitis in one patient and periapical lesions in another patient. CONCLUSION: Patients with chronic granulomatous disease may develop oral lesions reflecting susceptibility to infections and inflammation. It is also possible that social and genetic factors may influence the development of this complication. Therefore, oral hygiene must be kept at an optimum level to prevent infections that can be difficult to manage.

Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery-revisited.

OBJECTIVE: Earlier reports, including a preliminary study within our unit, have shown that the surgeon's experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paresthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are assessed in this study. STUDY DESIGN: This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients' demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of inferior alveolar and lingual nerves paresthesia at 1 month, 6 months, and 18 to 24 months postoperatively were also traced. RESULTS: At 1 month postoperatively, the incidence of IAN paresthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18 to 24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regard to inferior alveolar nerve paresthesia, risk factors included the patient's age (26-30 years), horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC), and treatment by trainee surgeons. With regard to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC, and treatment by trainee surgeons. CONCLUSION: One of the main risk factors of developing permanent sensory dysfunction in the distribution of these nerves is related to the surgical skills/experience of the operator. Other factors are associated with the type of impaction and the radiographic proximity of the tooth to the inferior alveolar nerve. Such long-term complications can affect the patient's quality of life; the impact on profession, education, and research is unknown.

In vitro examination of suspicious oral lesions using optical coherence tomography.

We compared findings of optical coherence tomography (OCT) with histopathological results of suspicious oral lesions to assess the feasibility of using OCT to identify malignant tissue. Thirty-four oral lesions from 27 patients had swept-source frequency-domain OCT. Four variables were assessed (changes in keratin, epithelial, and sub-epithelial layers, and identification of the basement membrane) and from this we calculated whether or not there were architectural changes. These data were then compared with histopathological results. Two clinicians, who were unaware of the clinical and histopathological diagnoses, decided whether biopsy was necessary. The basement membrane was recognised in only 15 oral lesions. OCT could identify diseased areas but could not provide a diagnosis or differentiate between lesions. The two clinicians, who recommended biopsy agreed in all cases. This pilot study confirms the feasibility of using OCT to identify architectural changes in malignant tissues.

Impact of educational posters on the lay knowledge of school teachers regarding emergency management of dental injuries.

The purpose of this study was to investigate the knowledge of school teachers about the emergency management of dental trauma, after an educational poster campaign. A total of 1000 questionnaires were sent to 100 schools in the area where the poster had been distributed. This was compared to another 100 schools (1000 questionnaires) in an area, Where the poster had not been distributed. The questionnaire surveyed demographic data, basic knowledge of emergency management of tooth fracture, luxation and avulsion injuries. A total of 511 questionnaires were returned (25.5%) and analyzed. Results showed differences between the two assessed areas. Teachers, who worked in the area with poster distribution, had better knowledge in handling tooth injuries. For the management of tooth fractures the portion of teachers, who knew the correct handling procedure, was 78.9% (area with poster campaign) vs 72.1% (area with no poster campaign), for the management of tooth luxation it was 87% vs 84% and for the management of tooth avulsion it was 71% vs 54%. In the area with the poster campaign 49% (n = 90 out of 185) of the teachers stated to have gained some knowledge about this topic beforehand. Out of these, 75 teachers (75/90 = 83%), had gained their information from the educational poster. Out of the 75 teachers, who had seen a poster on this topic, 68 (68/75 = 91%) would have managed such an emergency correctly. The present study shows the positive effect of educational poster campaigns. It therefore should encourage professionals in this field to embark on similar projects.

A comparison of health-related quality of life between Jordanian and British orthognathic patients.

The aim of this study was to assess health-related quality of life (HRQoL) in adult Jordanian patients referred for orthognathic treatment, and to compare this with previously published data from a British cohort. Thirty-eight Jordanians (21 females and 17 males; aged 16-31 years) who were about to commence a course of orthognathic treatment completed a generic HRQoL questionnaire [Short-Form 36 (SF-36)] and a condition-specific orthognathic quality-of-life questionnaire (OQoLQ). The questionnaires were completed prior to commencing any pre-surgical orthodontic treatment. The data were compared using the Mann-Whitney U-test for independent groups with non-normally distributed data. There were no statistically significant differences between the Jordanian males and females for any of the OQoLQ or SF-36 items; hence, the groups were combined for analysis. When comparing the OQoL data with that of the British sample, there was no statistically significant differences for three of the four domains: dentofacial aesthetics (P = 0.726), social aspects (P = 0.096), or the awareness of dentofacial aesthetics (P = 0.066). There was, however, a significant difference for oral function (P = 0.016), with the Jordanian group reporting a poorer quality of life (QoL) (mean value 10.9) than the British cohort (mean value 8.4). However, it is questionable whether this difference would be of clinical relevance. While it was not possible to directly compare the results of the SF-36 questionnaires with the same British cohort, Jordanian patients had generally lower scores, and therefore a poorer QoL, than reported in other studies. These differences may be cultural or may be due to differences in the health care system's criteria for funding, and this needs further investigation.

Management of deep-seated malformations with photodynamic therapy: a new guiding imaging modality.

Photodynamic therapy is an emerging technology and results from the interactions between a photosensitiser, oxygen and light. The delivery of light may either be by surface illumination or by interstitial application. We describe the first clinical application of ultrasound-guided interstitial photodynamic therapy (US-iPDT). A total of 23 treatments with meta-tetra-hydroxyphenyl chlorine (mTHPC) and ultrasound-guided interstitial photodynamic therapy were performed on 21 patients with various conditions at the Head & Neck Centre, University College London Hospital. The needles could be clearly identified during insertion in all 23 treatments, and it was possible to guide parallel needle insertions using ultrasound. Although the resolution of ultrasound is not as high as that of other imaging modalities [i.e. computed tomography (CT) and magnetic resonance imaging (MRI)] it was satisfactory in identifying the centre and the peripheries of the pathological lesions. Ultrasound is very easy to perform, non-invasive, relatively inexpensive, quick, convenient, non-ionising, suited to the imaging of soft tissues and does not cause any discomfort. Ultrasound can be used to guide 'real-time' photodynamic therapy in deep-seated tumours and other malformations and can augment the information from other imaging modalities without affecting the patient's treatment outcome.

Survey of maxillofacial 'out of hours' operating in the United Kingdom.

This survey looks at 'out of hours' maxillofacial operating in the United Kingdom during September 2006 and was sent out to all the maxillofacial consultants in the United Kingdom. Most respondents consider out of hours as '2200-0759'; however many hospitals now routinely work extended lists up to 2200 h. Since nearly 65% of respondents had no dedicated trauma list, the provision of theatre flexibility with prioritized trauma slots which would be used for other purposes depending upon the immediate departmental needs appears to be a viable compromise for the foreseeable future.

Willingness of Jordanian clinicians to treat a hepatitis B-infected patient.

OBJECTIVE: In the past, clinicians have sometimes been unwilling to provide care to patients known to be infected with hepatitis B virus (HBV). However, this lack of patient care should have lessened following the introduction of effective HBV vaccination for health care workers. The purpose of this study was to determine the willingness of clinicians in Jordan to provide care to HBV-infected patients. METHOD AND MATERIALS: A total of 290 general dental practices were randomly selected and surveyed for their willingness to provide treatment for toothache and routine dental care of individuals infected with HBV. RESULTS: Only 45% of the dental practices were willing to provide care to a person infected with HBV. The unwillingness to provide treatment did not seem to be influenced by financial factors. CONCLUSION: HBV-infected individuals will have difficulty obtaining dental health care in Jordan. There is a need for dental heath care workers in Jordan to be better informed and/or provide more effective treatment of HBV-infected individuals.

The effect of the new "24 hour alcohol licensing law" on the incidence of facial trauma in London.

On 24 November 2005 the new 2003 Licensing Act was implemented. It permits licensed premises to close at different times under English and Welsh law, rather than at 2300h as under the previous law. The aim of this study was to assess whether head and neck trauma secondary to alcohol-associated assaults had increased, decreased, or stayed the same since the introduction of the act. Data were collected from the Accident and Emergency Department, University College Hospital, attendance databases for two six-month periods: 24 November 2004 to 30 April 2005, and 24 November 2005 to 30 April 2006. There were 1102 attendances for head and neck trauma secondary to alcohol-associated assaults during the six months before the introduction of the 2003 Licensing Act and 730 such attendances during the similar period after the introduction of the law, with fewer cases in each corresponding month during the later period. There were more cases at weekends than on weekdays during both periods. There were fewer cases but more at weekends in 2005-6 than in 2004-5 (423, 58% compared with 584, 53%, respectively). Neither rainfall nor temperature had any influence on the results. The 2003 licensing Act seems to have reduced the number of attendances at the A&E department for head and neck trauma secondary to alcohol associated assaults.

Risk factors for post-orthognathic condylar resorption: a review.

AIMS: To evaluate the current evidence identifying risk factors for post-orthognathic mandibular condylar resorption. METHODS: Studies published between January 1980 and August 2006 related to post-orthognathic condylar resorption were identified by searching the following databases: PubMed, Medline, EMBASE, PsycInfo, DARE, CENTRAL, and the Cochrane database of systematic reviews. The following keywords were used to identify relevant publications: condylar resorption, progressive condylar resorption, condylar atrophy, dysfunctional remodeling, and condylysis. A hand search of these papers was also carried out to identify additional articles. RESULTS: A number of methodological flaws are present within the current literature, including the comparison of nonmatched patient groups and poor imaging techniques, which makes evaluation difficult. Significant risk factors identified for condylar resorption include being female with mandibular retrognathia associated with an increased mandibular plane angle, the presence of pretreatment condylar atrophy, and undergoing posterior condylar displacement and upward and forward rotation of the mandible at the time of surgery. CONCLUSIONS: Better-controlled studies are required to fully understand the link between condylar resorption and orthognathic surgery. A number of risk factors have been identified within this article. It is important for orthodontists to consider these, particularly when consulting patients for treatment and identifying patients who may require closer postsurgical follow-up.

The application of photodynamic therapy in the head and neck.

UNLABELLED: Photodynamic therapy (PDT) is considered to be a minimally invasive treatment modality which shows great promise in premalignant and malignant conditions of the head and neck. This therapy can be applied before or after any of the conventional treatment modalities (ie surgery, radiotherapy or chemotherapy) and the treatment can be repeated as much as is needed at the same site. PDT uses photosensitizing drugs that are activated by exposure to light of a specific wavelength. Illumination of the suspected premalignant or malignant site by light at the activating wavelength results in cellular destruction by a non-free radical oxidative process. Most photosensitizers are administered systemically, although some can be applied topically in the treatment of skin cancer. Recent developments in photosensitizers and light delivery systems have substantially reduced treatment times and residual photosensitivity, while increasing the achievable depth of necrosis. Compared with standard approaches, PDT can achieve equivalent or greater efficacy in the treatment of premalignant and malignant lesions in the head and neck, with greatly reduced morbidity and disfigurement. The technique is simple, can commonly be carried out in outpatient clinics, and is highly acceptable to patients. It can be repeated to debulk large tumours progressively, and it can also be applied through interstitial light delivery to large solid tumours. CLINICAL RELEVANCE: Photodynamic therapy is now shown to achieve equivalent or greater efficacy than standard treatment of premalignant and malignant lesions in the head and neck, with greatly reduced morbidity and disfigurement.

Effect of dental implant cross-sectional design on cortical bone structure using finite element analysis.

PURPOSE: This finite element analysis investigation evaluated the effect of different implant cross-sectional designs on bone stress levels under different loading patterns. MATERIALS AND METHODS: Finite element analysis program was used to construct four different three-dimensional models describing 4x10-mm implants in blocks of cortical and trabecular bone. A 5-mm-long abutment was modeled above each implant. The implant in model 1 was unthreaded, while in model 2 the implant was circularly threaded. The third implant in model 3 had the cross-sectional shape as a 16-sided star-shaped design. The implant in model 4 was constructed unthreaded, with a diameter of 4.5 mm. Vertical and horizontal loads of 100 N each were applied on the top middle node of each implant assembly. All nodes at the bottom surface of the bone models were restrained. RESULTS: By comparing models 1, 2, and 3, the lowest bone stress values under vertical and horizontal forces were observed around the unthreaded implant in model 1 (8.92 and 94.52 MPa, respectively). The highest stress value under vertical loading was shown around the threaded implant in model 2 (10.07 MPa), whereas the highest stress value under horizontal loading was observed around the star-shaped implant in model 3 (108.40 MPa). Model 4, with a wider unthreaded design, had stress values under vertical and horizontal loading of 7.32 and 71.35 MPa, respectively. CONCLUSIONS: It was concluded that the unthreaded implant design produced the least bone stress. An increase in implant diameter could produce marked reduction in stress value in the bone around the neck of the implant.

Optical diagnostic techniques in the head and neck.

UNLABELLED: The aim of this review article is to compare findings from recent prospective studies on microendoscopy, fluorescence spectroscopy (FS) and elastic scattering spectroscopy (ESS) with histopathology on formalin-fixed surgical specimens, to assess if those techniques can be used as an adjunct or alternative to histopathology in defining tissue involvement. CLINICAL RELEVANCE: These are non-invasive techniques to aid diagnosis, treatment and follow-up, used to guide the more acurate delivery of treatment, eg photodynamic therapy specifically to abnormal areas.

The acute effects of alcohol on auditory thresholds.

BACKGROUND: There is very little knowledge about alcohol-induced hearing loss. Alcohol consumption and tolerance to loud noise is a well observed phenomenon as seen in the Western world where parties get noisier by the hour as the evening matures. This leads to increase in the referrals to the "hearing aid clinic" and the diagnosis of "cocktail party deafness" which may not necessarily be only due to presbyacusis or noise-induced hearing loss. METHODS: 30 healthy volunteers were recruited for this trial which took place in a controlled acoustic environment. Each of the individuals was required to consume a pre-set amount of alcohol and the hearing was tested (using full pure tone audiogram) pre- and post- alcohol consumption over a broad range of 6 frequencies. Volunteers who achieve a minimum breath alcohol threshold level of 30 u/l had to have second audiogram testing. All the volunteers underwent timed psychometric and visuo-spatial skills tests to detect the effect of alcohol on the decision-making and psychomotor co-ordination. RESULTS: Our results showed that there was a positive association between increasing breath alcohol concentration and the magnitude of the increase in hearing threshold for most hearing frequencies. This was calculated by using the Pearson Regression Coefficient Ratio which was up to 0.6 for hearing at 1000 Hz. Over 90% of subjects had raised auditory thresholds in three or more frequencies; this was more marked in the lower frequencies. CONCLUSION: Alcohol specifically blunts lower frequencies affecting the mostly 1000 Hz, which is the most crucial frequency for speech discrimination. In conclusion alcohol does appear to affect auditory thresholds with some frequencies being more affected than others.

The role of surgical audit in improving patient management; nasal haemorrhage: an audit study.

BACKGROUND: Nasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified. The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit. Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care. METHODS: Retrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March). Prospective: 60 consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent. New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use. RESULTS: Previously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days. In the prospective audit the total number of admissions was significantly reduced, by over 70%, (chi2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (chi2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (chi2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over pound 50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work. CONCLUSION: Exclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care.

Recent technological developments: in situ histopathological interrogation of surgical tissues and resection margins.

OBJECTIVES: The tumour margin is an important surgical concept significantly affecting patient morbidity and mortality. We aimed in this prospective study to apply the microendoscope on tissue margins from patients undergoing surgery for oral cancer in vivo and ex vivo and compare it to the gold standard "paraffin wax", inter-observer agreement was measured; also to present the surgical pathologist with a practical guide to the every day use of the microendoscope both in the clinical and surgical fields. MATERIALS AND METHODS: Forty patients undergoing resection of oral squamous cell carcinoma were recruited. The surgical margin was first marked by the operator followed by microendoscopic assessment. Biopsies were taken from areas suggestive of close or positive margins after microendoscopic examination. These histological samples were later scrutinized formally and the resection margins revisited accordingly when necessary. RESULTS: Using the microendoscope we report our experience in the determination of surgical margins at operation and later comparison with frozen section and paraffin section margins "gold standard". We were able to obtain a sensitivity of 95% and a specificity of 90%. Inter-observer Kappa scores comparing the microendoscope with formal histological analysis of normal and abnormal mucosa were 0.85. CONCLUSION: The advantage of this technique is that a large area of mucosa can be sampled and any histomorphological changes can be visualized in real time allowing the operator to make important informed decisions with regards the intra-operative resection margin at the time of the surgery.

Psycho-education programme for temporomandibular disorders: a pilot study.

BACKGROUND: Temporomandibular disorders (TMDs) are by far the most predominant condition affecting the temporomandibular joint (TMJ), however many patients have mild self-limiting symptoms and should not be referred for specialist care. The aim of this pilot study was to develop a simple, cost-effective management programme for TMDs using CD-ROM. 41 patients (age 18-70) participated in this study, patients were divided into three groups: the 1st group were involved in an attention placebo CD-ROM (contain anatomical information about the temporomandibular system), the 2nd group received information on CD-ROM designed to increase their control and self efficacy, while the 3rd group received the same programme of the 2nd group added to it an introduction to self-relaxing techniques followed by audio tape of progressive muscle relaxation exercises. Each of the groups was asked to complete a number of questionnaires on the day of initial consultation and six weeks afterwards. RESULTS: The two experimental groups (2nd & 3rd) were equally effective in reducing pain, disability and distress, and both were more effective than the attention placebo group (1st), however the experimental groups appeared to have improved at follow-up relative to the placebo-group in terms of disability, pain and depressed mood. CONCLUSION: This pilot study demonstrates the feasibility and acceptability of the design. A full, randomized, controlled trial is required to confirm the efficacy of the interventions developed here.