European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction of the incidence of postherpetic neuralgia and other complications. The guideline development followed a structured and predefined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this first part of the guideline, diagnostic means have been evaluated. The expert panel formally consented recommendations for the management of patients with (suspected) HZ, referring to the assessment of HZ patients, considering various specific clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

[Dental focus examination: a proposal for a more nuanced approach]. / Odontogeen focusonderzoek: een voorstel voor een meer genuanceerde benadering.

Oral and maxillofacial surgeons and hospital dentists are often requested to perform a dental focus examination in patients (to be) admitted in a hospital and for whom the state of their teeth is of importance for a medical treatment or situation. The main reasons for a dental focus examination include unexplained fever, heart surgery, chemotherapy, organ or artificial joint transplants, use of oral or intravenous bisphosphonates and radiotherapy of the head and neck. In daily practice, there is a need for a clear algorithm which is easy to apply for the diagnosis and treatment of dentalfoci for the various medical indications. The medical conditions described above have in common that subclinical infections can lead to complications under exceptional conditions. The influence and the nature of the development ofa dental infection varies in each of the situations mentioned. This has consequences for the need to eliminate dentalfoci. The diagnosis and treatment of dental foci in relation to various medical situations therefore requires a nuanced approach.

[Wasp and bee stings]. / Wespen en bijensteken zijn niet altijd zo onschuldig onschudig als wordt gedacht.

Occasionally a dentist is confronted with a painful, red facial swelling which has suddenly appeared, with no signs of a dental cause. In addition to the other possible causes, one should consider the possibility of an insect bite, especially in the summer months. The consequences of an insect bite or sting are often underestimated. Hymenopterae (wasps and honeybees) stings are not generally serious in nature, but can result in severe systemic medical complications, such as an allergic reaction. Dentists who are confronted with a patient with an insect bite or sting must provide the patient with adequate information and if necessary take measures in order to prevent further complications.

[A patient with Noonan syndrome]. / Een patiënt met het syndroom van Noonan.

Noonan syndrome is a relatively common autosomal dominant genetic disorder which is characterised by typical facial features, congenital heart diseases and small stature. In 50% of the cases the syndrome is caused by a mutation on the PTPN11-gen. The expression of symptoms associated with Noonan syndrome can be very mild in nature and facial features usually become less pronounced with age, which can sometimes make a correct diagnosis more difficult. Despite a wide range of associated symptoms most adults with Noonan syndrome can be self-sustaining, with a good quality of life. It is important that the dentist is well-informed about this syndrome due to the heart diseases and bleeding disorders which can be present with these patients and may influence a dentist's choice of therapy when invasive treatment is indicated.

Coronoid process hyperplasia: a systematic review of the literature from 1995.

The objective of this study was to review the literature and compare different surgical methods for the management of coronoid process hyperplasia. A literature search was performed for publications since 1995. Case characteristics were extracted (age, sex, duration of symptoms, form, maximal mouth opening and treatment) and entered into a database for analysis. The data were split into two groups (coronoidectomy and coronoidotomy). Maximal mouth opening measurements before and after surgery were analyzed with several statistical tests. 61 cases were entered into the database. The mean age was 23 years and mean duration of symptoms 7 years. The bilateral form occurred 4.1 times more frequently than the unilateral form. The male-female ratio was 3.3 to 1. In 94% of the cases the approach was intra-oral. 84% of the cases received a coronoidectomy. Statistical analysis showed that the preoperative and postoperative differences between the groups were significant. The results were not significant when corrected for the preoperative difference. Postoperative therapy was not comparable due to heterogeneity. Cases that received a coronoidotomy had slightly better postoperative results.

[Automutilation of the palate in a psychiatric patient]. / Automutilatie van het palatum bij een psychiatrische patiënt.

A 46-year-old man with a history of alcohol abuse was referred to an oral and maxillofacial surgeon with a large necrotic wound with raised edges on the palate. After history taking, radiography and clinical assessment, together with a psychiatrist, the lesion was diagnosed as an automutilation resulting from a period of alcohol abstinence. After a period of care in a medical centre, the lesion improved quickly. Following this treatment, the patient was admitted to a psychiatric treatment centre for supplemental treatment of his addiction problems.

An atypical presentation of a solitary bone cyst of the mandibular ramus: a case report.

This report describes a large solitary bone cyst involving the mandibular ramus, presenting with a history of recurrent hypoaesthesia of the lower lip and a multilocular, multilobular radiological aspect with cortical expansion and possibly cortical perforation.

[Tooth development disturbances following haematopoietic stem cell transplantation]. / Langetermijneffecten op de gebitsontwikkeling na stamceltransplantatie.

Forty children treated with allogenic haematopoietic stem cell transplantation for haematological malignancies, were examined at least 2 years after transplantation. The researchers collected information concerning subjective oral symptoms, the results of a panoramic radiograph and the findings of an oral examination. Nearly all children had tooth development disturbances, including missing teeth, shortened roots, and arrested root development. The study group showed a significantly higher prevalence of missing teeth than the standard values for first and second premolars in both maxilla and mandible, as well as for second molars in the mandible. Children younger than 3 years of age at the start of the treatment missed significantly more teeth than older children. The mean root-crown length ratios of several tooth types were lower when compared with a control group of healthy Finnish children. The mean dental age was higher than the mean chronological age due to early final apical root formation.

Sclerostin in mineralized matrices and van Buchem disease.

Sclerostin is an inhibitor of bone formation expressed by osteocytes. We hypothesized that sclerostin is expressed by cells of the same origin and also embedded within mineralized matrices. In this study, we analyzed (a) sclerostin expression using immunohistochemistry, (b) whether the genomic defect in individuals with van Buchem disease (VBD) was associated with the absence of sclerostin expression, and (c) whether this was associated with hypercementosis. Sclerostin was expressed by cementocytes in mouse and human teeth and by mineralized hypertrophic chondrocytes in the human growth plate. In individuals with VBD, sclerostin expression was absent or strongly decreased in osteocytes and cementocytes. This was associated with increased bone formation, but no overt changes in cementum thickness. In conclusion, sclerostin is expressed by all 3 terminally differentiated cell types embedded within mineralized matrices: osteocytes, cementocytes, and hypertrophic chondrocytes.

[Haematopoietic stem cell transplantation and oral complications]. / Hematopoëtische stamceltransplantaties en orale problemen.

New haematopoietic stem cell transplantation procedures make the treatment available to patients who previously did not qualify, such as the elderly. In addition, the spectrum of oral complications associated with haematopoietic stem cell transplantation has altered as a result of the recent developments. This article is a review of the main principles of haematopoietic stem cell transplantation and provides information on oral complications which may develop, such as mucositis, infections, bleeding, graft-versus-host disease, xerostomia, hyposalivation, altered taste, secondary tumors, osteoporosis, osteonecrosis and growing and developing disturbancies. Finally, the role of dental care providers in cases of haematopoietic stem cell transplantation is addressed.

Long-term adverse effects of hematopoietic stem cell transplantation on dental development in children.

PURPOSE: The purpose of this study was to assess late effects of cytotoxic therapy with hematopoietic stem cell transplantation (HCT) on dental development in survivors of childhood cancer. MATERIALS AND METHODS: Forty children who underwent allogeneic HCT for a variety of hematological malignancies were evaluated at a minimum of 2 years after transplantation. We obtained information on oral symptoms, exposed panoramic radiographs (PRG), and performed an oral examination. PRGs were scored for agenesis and root and/or crown abnormalities. The root-crown ratio was calculated, and dental age was assessed using Demirjian' s method. MAIN RESULTS: The studied group showed a significantly higher prevalence of tooth agenesis compared to normative data for first and second premolars in both the maxilla and mandible, as well as the second molars in the mandible (all p values <0.001). Children who were <3 years old at the time of cancer treatment had significantly more missing teeth than older children, F(2,37) = 7.58, p < 0.002. Root-crown ratios were lower in the study sample than those from normative data. In addition, the mean dental age was higher (as a result of earlier apical root closure) than the mean chronological age, t(28) = 2.47, p < 0.020. CONCLUSIONS: Nearly all children examined had dental development disturbances, including agenesis, short roots, and arrested root development. An oral/dental evaluation and preventative oral supportive care regimens should be part of programs monitoring late effects in long-term survivors of childhood cancer.

Mycobacterium chelonae keratitis in a patient with Sjögren's syndrome.

PURPOSE: In this report a case of Mycobacterium chelonae keratitis in a patient without any previously described risk factors is described. The only risk factor found was a rheumatoid arthritis related Sjogren''s syndrome. METHODS: Case report. RESULTS: A 60-year-old woman was referred to the hospital with an infectious keratitis of the left eye of 3 months duration, unresponsive to empirical therapy with ofloxacin and tobramycin drops. Her medical history included a longstanding rheumatoid arthritis and a secondary ocular surface syndrome. Upon arrival the left eye showed diffuse corneal edema and centrally several large infiltrates with fluffy edges, surrounded by several smaller satellite infiltrates. The cornea was scraped for culture and grew M chelonae and sensitivity testing showed sensitivity to ciprofloxacin, clofazimine, and clarithromycin. Systemically, ciprofloxacin 750 mg and clarithromycin 500 mg twice daily were prescribed orally. Topical therapy consisted of topical erythromycin 10 mg/mL and ofloxacin 3 mg/mL every 2 hours. Treatment was continued for a total of 10 months during which the infiltrates cleared completely, but the central cornea remained scarred. CONCLUSIONS: M chelonae can be a cause of infectious keratitis in patients without known risk factors for rapidly growing mycobacterium keratitis. Especially in the case of ocular infections that show no response to regular antibacterial treatment, mycobacterial infection should be considered. Good communication between the ophthalmologist and the microbiologist is crucial for a rapid diagnosis.

[Diagnosing and treatment of dental foci in Dutch medical centres]. / Odontogeen focusonderzoek in een selectie van Nederlandse medische centra.

Although not scientifically proven, dental foci are believed to result in severe local or systemic disease. Eradicating dental foci in order to prevent possible interference with a medical treatment may be important in specific patient groups. To gain insight in the number of dental focus examinations, the medical evidence, the number of potential foci determined, as well as the treatment eradicating the focus, all dental focus examinations in 16 Dutch hospitals were registered during 3 months. A total number of 470 examinations were performed. Scheduled heart(valve)surgery and radiotherapy of the head and neck were the main reasons for a dental focus examination. Dental foci were found and treated in more than 50% of the patients examined. There was a significant difference between dentate and edentulous patients in the percentage of patients diagnosed and treated for a dental focus. More than 80% of dentate and less than 20% of edentulous patients were treated.

A successful alternative: repair of a penetrating limbal wound by lamellar keratoplasty.

PURPOSE: To report repair of a penetrating limbal wound by lamellar keratoplasty 1 year post-traumatically. METHOD: Interventional case report. RESULTS: A 5-year-old boy had a self-inflicted injury leading to a limbal penetrating wound. The wound closed spontaneously by prolapsed subconjunctival uveal tissue and no intervention was planned. One year later surgical closure of the defect was necessary, as the amount of prolapsed tissue had increased. After excising the prolapsed tissue the wound was closed with a lamellar corneal graft, resulting in a quiet and stable anterior segment and a best-corrected visual acuity of 20/16. CONCLUSIONS: Lamellar keratoplasty can be a useful technique to repair a limbal penetrating wound. Corneal allografts have adequate tensile strength, low immunogenicity, and are easy to obtain.

Growth characteristics of large mandibular ameloblastomas: report of 5 cases with implications for the approach to surgery.

The aim of this study was to establish surgical guidelines based on the growth pattern of ameloblastomas in relation to the possible infiltration of the cortical bone, the inferior alveolar nerve, the periosteal layer and the surrounding soft tissues. Five male patients with voluminous mandibular ameloblastomas were treated by means of radical surgery. Ameloblastomas showed an invasive growth pattern in the cancellous bone with small tumour nests at a maximum distance of 5mm away from the bulk of the tumour. Expansive and invasive growth in the Haversian canals was observed. There was no invasion of the inferior alveolar nerve. The mucoperiosteal layer was invaded but not perforated. No invasion was observed in the surrounding soft tissues of the periosteum and in the skin tissue. A local resection with a surgical margin of spongious bone of 1cm is suggested. When the tumour is radiologically closer than 1cm to the inferior border of the mandible, a continuity resection is mandatory. A conservative approach concerning the inferior alveolar nerve is suggested. Removal of an excess of perimandibular soft tissue is not indicated. The overlying attached mucosal surface should however be excised together with the underlying bone.

Limited regression of central giant cell granuloma by interferon alpha after failed calcitonin therapy: a report of 2 cases.

Central giant cell granuloma (CGCG) is a benign lesion of the jaws with a sometimes locally aggressive behaviour. The most common therapy is surgical curettage which has a high recurrence rate, especially in lesions with aggressive signs and symptoms (i.e. pain, paresthesia, root-resorption and rapid growth). Alternative therapies such as interferon alpha (INFalpha) or calcitonin are described in the literature. In this study 2 patients with an aggressive CGCG are presented who were treated with INF mono-therapy. INF mono-therapy was capable of terminating the rapid growth of the lesion in both patients and induced a partial reduction. Total resolution, however, was not obtained and alternative treatment is still necessary.

[Using corticosteroids to prevent postoperative oedema]. / Gebruik van corticosteroïden ter preventie van postoperatief oedeem.

Corticosteroids are produced in the adrenal gland cortex and are subdivided in mineralocorticosteroids and glucocorticosteroids. Usually, corticosteroids are prescribed as drugs to replace natural corticosteroids in case of insufficient functioning adrenal glands and in numerous diseases because of their anti-inflammatory and immunosuppressive effects. Based on literature data, it was concluded in this article that corticosteroids are never indicated as a preventive measure in regular dentistry and oral and maxillofacial surgery. Only in cases of major elective oral and maxillofacial surgery, prescription of corticosteroids may be considered.