Alternative complete-arch cement-retained implant-supported fixed partial denture.

Early implant prostheses designs, which used screw-retained metal and acrylic resin structures, frequently left a space between the prosthesis and the soft tissue. Common deficiencies of this design included phonetic and esthetic problems and screw loosening. Cement-retained implant prostheses are also used in partially and completely edentulous patients, and are thought to have optimal occlusion and esthetics. Moreover, cement-retained prostheses may induce less stress on the implant, thereby maximizing the possibility of a passive fit. Porcelain fused to metal prostheses have been used mostly in partially edentulous situations. Recently, complete-arch porcelain fused to metal prostheses that replace hard and soft tissue have been used and, although this restoration can have excellent esthetics, there are disadvantages such as high cost, potential framework distortion during fabrication, and difficulty in repairing fractures of in-service porcelain. This article describes an alternative technique for the fabrication of a complete-arch, cement-retained, metal-acrylic resin implant-supported fixed partial denture. When compared with porcelain fused to metal complete-arch restorations, this prostheses is esthetic, has excellent retention and stability, yet is relatively inexpensive to fabricate, and requires less laboratory skill.

Procedure to prevent cast breakage during separation from elastomeric impressions.

This article describes a quick and simple procedure for removing dental stone casts from elastomeric impressions. Frequently, dental stone casts break at the time of separation because of the rigidity of the impression material. The materials used in this technique are inexpensive and easy to use. When this method is properly used, it simplifies the removal of the cast from the impression, decreasing the chance of fracture of the cast.

Alternative procedure for making a metal suprastructure in a milled bar implant-supported overdenture.

The predictability of implant-supported prostheses has been established. Although the original Brånemark design has been successfully used in the mandible, esthetic, speech, and hygiene-related problems have been reported in maxillary fixed prostheses. Implant-overdentures can overcome some of the problems encountered in maxillary fixed prostheses. Milled-bar implant-supported overdentures fabricated by electric discharge machining are characterized by stability similar to a fixed prostheses and are removable for hygiene procedures. However, the procedure is costly and requires highly trained technicians. An alternative procedure to produce an accurately fitting metal suprastructure is presented. This procedure does not require additional technical skills and uses instruments and materials that are readily available and relatively inexpensive. The use of simple and easy to replace attachments allows repairs to be performed in the dental office, thus reducing maintenance cost. The overall result is a prosthesis that incorporates the features of a spark erosion overdenture at a fraction of the cost and that is available to a broader patient population.

A pseudoepidemic of Rhodotorula rubra: a marker for microbial contamination of the bronchoscope.

Rhodotorula rubra was isolated from bronchoscopy specimens from 11 patients. An investigation of the bronchoscopy equipment and the bronchoscopy suite revealed contamination of the suction channel with R rubra, as well as potentially pathogenic bacteria. Disinfection control methods included gas sterilization of the bronchoscope and the institution of an alcohol and air flush through the suction channel to allow complete drying of the scope between each patient use. We have had no further isolates of R rubra from bronchoscopy specimens since these measures were instituted, and repeat cultures from the suction channel have been negative.

Paternity by cardiac transplant recipients.

To assess whether children fathered by cardiac transplant recipients are at high risk of teratogenicity, cardiac transplant centers listed with the International Society for Heart and Lung Transplantation were surveyed. Paternities after transplantation by heart (n = 35) and heart-lung (n = 1) allograft recipients have resulted in 42 pregnancies (children's age 3.3 +/- 0.3 years). The fathers' age at conception was < 45 years in 40 (95%) and > 45 years in 2 (5%). Most fathers (86%) were enjoying an active and healthy lifestyle at the time of conception; one (2%) was on dialysis and listed for kidney transplantation due to nephrotic syndrome, 1 (2%) had asthma, 4 (10%) had allograft coronary disease (1 died while waiting for second heart transplant when the child was 2 months old), and 2 (5%) were retransplanted after the pregnancies. Immunosuppressive regimens were reported for 37 paternities; drug protocols at the time of conception were as follows: 25 (60%) CsA/prednisone/AZA, 6 (14%) CsA/prednisone, 4 (10%) CsA/AZA, and 2 (5%) AZA/prednisone. Twenty-six (62%) had received treatment for rejection episodes before conception; seven (17%) had received treatment for rejections since conception. Of the 42 children fathered by these recipients, 3 (7%) were preterm, 1 (2%) had a cleft palate and lip that have subsequently been corrected, 1 (2%) died from interruption of umbilical cord circulation at 24 weeks, and 1 (2%) whose father had familial cardiomyopathy was born with a cardiomyopathy that improved with time. Although the numbers are small, the available data suggest that paternity by cardiac transplant recipients may be safe.

Amelioration of weight gain after heart transplantation by corticosteroid-free maintenance immunosuppression. UTAH Cardiac Transplant Program.

After heart transplantation, recipients frequently become obese. Although the cause is undoubtedly multifactorial, administration of corticosteroids may contribute to posttransplant obesity. To test this hypothesis, we retrospectively reviewed the change in body weight with respect to corticosteroid use after transplantation in all 110 recipients surviving 1 year in the UTAH Cardiac Transplant Program. Fifty-two recipients (47%, group 1) were unable to be withdrawn from maintenance corticosteroids, and 58 recipients (53%, group 2) were successfully withdrawn, the latter group requiring only cyclosporine and azathioprine long-term maintenance immunosuppression. The change in weight from the time of transplantation to 1 year after transplantation in group 1 was 8.7 +/- 1.1 kg; group 2 patients gained only 4.9 +/- 0.9 kg (p = 0.009). In conclusion, successful withdrawal of maintenance corticosteroids after heart transplantation decreased posttransplant weight gain, suggesting that posttransplant obesity is in part related to use of corticosteroids.

A randomized trial of the immunosuppressive efficacy of vincristine in cardiac transplantation.

We evaluated the efficacy of the addition of the lymphoblasticidal agent vincristine to standard immunosuppression in heart transplantation in a prospective randomized study of 92 patients (46 to receive and 46 to not receive vincristine) with a follow-up period of 12 months. Patients received either equine antithymocyte globulin for the first week or OKT3 monoclonal antibody (OKT3) for the first 10 or 14 days after transplantation. Six to eight doses of vincristine were given over 9-12 weeks, beginning 2 days after completion of ATG or OKT3. The number of rejection episodes in the first six months posttransplantation, the percentage of patients corticosteroid maintenance-free at one year, cumulative immunosuppressive drug doses, deaths, infections, and neuropathy were followed. The addition of vincristine resulted in more patients achieving corticosteroid maintenance-free status at one year (vincristine 68%, no vincristine 38%, P = 0.01). In comparing patients at relatively high risk for rejection (those younger than 55 years and all females) with those at relatively low risk (males older than 55 years), only the high-risk vincristine-treated patients showed significantly fewer rejection episodes and a higher corticosteroid maintenance status at one year (66% vs. 32%, P = 0.01). There were no significant differences in survival (vincristine 96%, no vincristine 98%), infection, or amounts of other immunosuppressive agents used. The major side effect was neuropathy, which occurred more frequently in the vincristine-treated group (43% vs. 18%, P less than .001). We conclude that vincristine acts as an immunosuppressive agent in cardiac transplantation, particularly in patients at higher risk for rejection.

Hypercholesterolemia after heart transplantation: amelioration by corticosteroid-free maintenance immunosuppression.

Most heart transplant recipients develop hypercholesterolemia, the cause of which is poorly understood. To test the hypothesis that corticosteroids contribute to the hypercholesterolemia, we reviewed 117 consecutive heart transplant recipients who survived more than 4 months, of whom 51 (44%) required and 66 (56%) did not require maintenance corticosteroids, chronic immunosuppression maintained with cyclosporine and azathioprine only. Fasting serum cholesterol levels were measured every 3 months and were found to be 21% to 26% lower during the first 18 months after heart transplantation in the group that did not require chronic corticosteroid administration (p less than 0.001). Beginning 3 months after transplantation, average serum cholesterol levels ranged from 199 +/- 8 mg/dl to 211 +/- 9 mg/dl in the corticosteroid-free group compared with 262 +/- 8 mg/dl to 272 +/- 8 mg/dl in patients requiring corticosteroid maintenance immunosuppression. Because serum cyclosporine levels did not differ between the groups, a contribution by cyclosporine to posttransplant hypercholesterolemia could not be substantiated. Although the hypercholesterolemia that occurs after heart transplantation is undoubtedly multifactorial, corticosteroid administration contributes importantly to its development.

Rejection prophylaxis with murine monoclonal CD-3 antibody (OKT3): considerations for early hospital discharge.

Murine monoclonal CD-3 antibody (OKT3) is a significant new addition to the immunosuppressant armamentarium for treatment of heart transplant rejection. In the Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program, Salt Lake City, a broad experience with OKT3 has been acquired. Fifteen patients were treated for refractory rejection, whereas 68 patients were treated for early rejection prophylaxis therapy utilizing either 10- or 14-day protocols. To facilitate early hospital discharge, 12 patients were able to complete OKT3 therapy as outpatients. A retrospective review of length of initial hospital stay and clinical results revealed that patients who received OKT3 had an average hospital stay (+ standard deviation) of 17.1 days, and their 12-month survival was 96%. Patients who received antithymocyte globulin and/or steroids had an average stay of 27.4 days (p less than 0.05) and a 12-month survival of 93%. In conclusion, the possibility for reduced hospital stay and consequent cost reduction exists with the use of OKT3, especially when completion of therapy can be managed in an outpatient setting.