The Norwich Osteoarthritis of the Ankle MRI Score (NOAMS): a reliability study.

AIM: To define and test the inter- and intra-rater reliability of a grading system for staging osteoarthritis (OA) of the ankle with magnetic resonance imaging (MRI) (Norwich Osteoarthritis of the Ankle MRI Score, NOAMS). MATERIALS AND METHODS: The MRI features to be included in the score were defined by a multidisciplinary expert panel through a Delphi process. An anonymised randomised dataset of 50 MRI studies was created from patients with concurrent plain radiographs to include 10 ankles of each of the Kellgren-Lawrence grades 0 to 4. Two experienced musculoskeletal radiologists and two trainees scored each ankle MRI twice independently and blinded to the plain radiographs. RESULTS: The inter-rater kappa coefficient of agreement for cartilage disease was 0.88 (95% confidence interval [CI]: 0.85, 0.91) for experienced raters and 0.71 (95% CI: 0.67, 0.76) for trainees. Inter-rater agreement for subchondral bone marrow oedema and cysts varied from 0.73 to 0.82 for experienced raters and from 0.63 to 0.75 for trainees with lowest 95% CI of 0.48 and 0.63. When bone marrow lesions were combined into a total joint score the level of agreement increased to between 0.88 and 0.97 with lowest 95% CI of 0.86. Combining cartilage zone scores did not increase the reliability coefficients. CONCLUSION: An expert panel considered that cartilage degradation and subchondral bone marrow lesions were the most important features for staging the severity of ankle OA on MRI. Experienced observers can grade the severity of ankle OA on MRI with a clinically useful high degree of reproducibility.

Four-year experience of paediatric penetrating injuries: findings from a paediatric major trauma centre in the UK.

AIM: To review the experience of penetrating injury and its subsequent imaging and to discuss imaging strategies in overall trauma management in a paediatric major trauma centre. MATERIALS AND METHODS: A retrospective, single-centre study was conducted over a 4-year period (1/1/16-31/12/19) of children (<16 years old) presenting to the Emergency Department with penetrating trauma. Clinical, radiographic, and demographic data were analysed using descriptive statistics. RESULTS: Fifty-eight patients in >60 attendances were reviewed. Most (44/60, 73%) underwent some imaging, with almost half (28/60, 47%) having both computed tomography (CT) and radiography. Of cases with only a single injury site (35/60, 58%), CT was performed in 19/35 (54%) with 13/19 (68%) covering more than one body area. Of the multi-injury site cases (26/60, 42%), CT was performed in 16/25 (64%) with 14/16 (88%) involving multiple body areas. The most common injuries were solid-organ lacerations and soft-tissue and vascular injuries according to body site involved. CONCLUSION: Contrast-enhanced CT across multiple body parts should be performed for multiple stab wounds or visible injuries involving the torso. Isolated penetrating injuries may only require CT of a single body part unless the entry wound crosses body parts. An imaging algorithm is suggested, which may be applicable to other paediatric trauma units.

Systematic review and meta-analysis of the reliability and discriminative validity of cartilage compositional MRI in knee osteoarthritis.

OBJECTIVE: To assess reliability and discriminative validity of cartilage compositional magnetic resonance imaging (MRI) in knee osteoarthritis (OA). DESIGN: The study was carried out per PRISMA recommendations. We searched MEDLINE and EMBASE (1974 - present) for eligible studies. We performed qualitative synthesis of reliability data. Where data from at least two discrimination studies were available, we estimated pooled standardized mean difference (SMD) between subjects with and without OA. Discrimination analyses compared controls and subjects with mild OA (Kellgren-Lawrence (KL) grade 1-2), severe OA (KL grade 3-4) and OA not otherwise specified (NOS) where not possible to stratify. We assessed quality of the evidence using Quality Appraisal of Diagnostic Reliability (QAREL) and Quality Assessment of Diagnostic Accuracy (QUADAS-2) tools. RESULTS: Fifty-eight studies were included in the reliability analysis and 26 studies were included in the discrimination analysis, with data from a total of 2,007 knees. Intra-observer, inter-observer and test-retest reliability of compositional techniques were excellent with most intraclass correlation coefficients >0.8 and coefficients of variation <10%. T1rho and T2 relaxometry were significant discriminators between subjects with mild OA and controls, and between subjects with OA (NOS) and controls (P < 0.001). T1rho showed best discrimination for mild OA (SMD [95% CI] = 0.73 [0.40 to 1.06], P < 0.001) and OA (NOS) (0.60 [0.41 to 0.80], P < 0.001). Quality of evidence was moderate for both parts of the review. CONCLUSIONS: Cartilage compositional MRI techniques are reliable and, in the case of T1rho and T2 relaxometry, can discriminate between subjects with OA and controls.

Incorporating quality management into dental academics: a case report.

Financial challenges to dental education and accreditation requirements for outcomes assessment prompted the Florida College of Dentistry to consider CQI (Continuous Quality Improvement) processes. Key concepts in CQI are identified and a case study of its implementation is presented. The program was more successful in the process aspects of patient care (e.g., patient intake) and with staff than with faculty and educational or dental quality aspects.

An evaluation of bioactive ceramic in the treatment of periodontal osseous defects.

Bioglass particulates were surgically placed in the periodontal osseous defects of 12 patients. The clinical parameters studied were probing depth, attachment level as measured with the Florida Probe, and standardized bitewing radiograph comparisons. Data was collected initially, and at 3-, 6-, and 24-month posttreatment intervals. Statistically significant improvements were demonstrated in all clinical parameters studied. There was a mean probing depth reduction of 3.33 mm, a mean attachment gain of 1.92 mm, and a mean radiographic bone fill of 3.47 mm. Results were stable over the 24-month period. Ease of handling and excellent tissue response were characteristic of the material.

An accurate, time-efficient method to assess plaque accumulation.

The authors compared the accuracy and time efficiency of a simplified index called the Plaque Assessment Scoring System, or PASS, and the O'Leary Plaque Control Record. Using both indexes, they examined 35 participants. They found a strong correlation between the results achieved with each method. They also noted that the mean time required to complete the PASS examination was considerably less than that needed to record the O'Leary index, 1.47 vs. 7.07 minutes, respectively.

Treatment of subjects with refractory periodontal disease.

The aim of the present study was to evaluate the effect of non-surgical periodontal therapy with the adjunct of a selected antibiotic in subjects diagnosed with refractory periodontal disease. 21 subjects were selected for the study; all had a history of periodontal surgery, tetracycline therapy, and regular maintenance by a periodontist. When disease activity was detected, a bacterial sample was taken and a whole plaque susceptibility test was performed. Before the outcome of the susceptibility test the subjects were assigned to either antibiotic or placebo therapy. All subjects received scaling and rootplaning prior to antibiotic or placebo therapy. Based on the susceptibility test, subjects in the antibiotic group were treated either with Augmentin or clindamycin. The results demonstrated that in subjects with refractory periodontal disease there was no significant difference (N.S.) in the proportion of sites losing attachment before and after treatment (11.3% and 12.4%, respectively) over a 2-year post therapy observation period. However, the proportion of sites showing gain of attachment increased from 0.9% before therapy to 5.1% (p = 0.029) following selective antibiotic therapy when combined with scaling and rootplaning. The remainder of sites showed no change between pre- and post-therapy monitoring periods. The progression of attachment loss in the active sites could not be completely stopped over the entire 2-year period. After 12-15 months following therapy, there was a tendency towards new loss of attachment and an increase of pocket depth. However, all 4 subjects treated with placebo drug demonstrated continuous deterioration and had to be retreated. Although the proportion of sites losing attachment decreased from 5.1% to 2.3% (N.S.), the proportion of sites gaining attachment also decreased from 2.0% to 1.0% (N.S.). The results suggest that scaling and rootplaning together with selected antibiotic therapy repeated every 12-15 months may be beneficial for these subjects although it may not completely stop progressive attachment loss.

Periodontal repair using PerioGlas in nonhuman primates: clinical and histologic observations.

This article describes a new synthetic material for grafting periodontal osseous defects. Compared to grafts of similar-sized hydroxyapatite, tricalcium phosphate, and unimplanted controls, PerioGlas achieved histologically superior repair of surgically created defects in the monkey model. Superior repair was noted when evaluating for new bone and the degree of cementum regeneration. Epithelial downgrowth appeared to be retarded in the PerioGlas sites and not in the other materials. When comparing clinical handling characteristics, PerioGlas was found to have excellent packing and manipulative features that were preferred by the operators to the other materials. The property of epithelial downgrowth inhibition may be significant in the superior regenerative property of PerioGlas.

Survival characteristics of periodontally-involved teeth: a 40-year study.

Four hundred and fifty-five teeth that were judged clinically to have a questionable prognosis were observed over a 40-year span in 166 patients in a private practice. Therapy initially was debridement with oral hygiene instruction, followed by flap curettage procedures and preventive maintenance recall therapy. An assessment of compliance based on oral hygiene and recall attendance was also performed. A total of 55 (12%) teeth were lost with an average survival rate of 8.8 years prior to extraction. No teeth were lost during the first 2 years of observation. The majority of extracted teeth were maxillary second molars (38.2%), followed by maxillary first molars (25.5%), and mandibular second molars (16.4%). Tooth loss patterns appeared to be bilaterally symmetrical, with 51% of teeth lost in the right quadrants and 49% lost in the left quadrants. Indications for extraction were primarily periodontal abscesses. Teeth that were considered to have a very questionable prognosis have been retained for many years after therapy, supportive treatment, and patient compliance with recall attendance.

Comparative analysis between a modified ultrasonic tip and hand instruments on clinical parameters of periodontal disease.

The goal of this study was to determine whether an ultrasonic scaler with a modified tip is as effective as a curet in providing supportive periodontal treatment for patients, based on clinical parameters of periodontal disease. Nine patients with 10 sites exhibiting probing pocket depth > or = 3 mm were treated at 0, 90, and 180 days in a single-blind, split-mouth design for supportive periodontal treatment with either Gracey curets (GC) or an ultrasonic scaler with a modified tip (MU). Clinical parameters included plaque index, gingival index, bleeding on probing, darkfield microscopy, and elastase presence. Probing pocket depths and attachment levels were measured using an electronic probe. Measurements of clinical parameters were taken at 0, 14, 45, 90, 135, and 180 days. The results showed that treatment with MU was as effective as treatment with GC in all clinical parameters measured. Both treatment modalities were effective in reducing the elastase levels. Instrumentation time was significantly reduced with the MU (3.9 minutes vs. 5.9 minutes, P < 0.05). The MU instrument effectively reduced the microbial environment in a significantly shorter time as compared to GC.

Bioactive ceramics for periodontal treatment: comparative studies in the Patus monkey.

Four bioactive ceramic materials currently recommended for regeneration of osseous tissues in treatment of periodontal disease have been compared with Bioglass particulates, of equivalent size in two compositions, in a monkey model. Both Bioglass materials were found to be easily manipulated, were haemostatic and osteoproductive allowing restoration of both alveolar bone and periodontal ligament. Epithelial downgrowth was inhibited and epithelial attachment was close to the preimplantation level. The other materials were slower to act and epithelial downgrowth was to the same level as in unfilled control defects.

Reproducibility of attachment level measurements with two models of the Florida Probe.

Clinical assessment of the progression of periodontitis is based on the measurement of periodontal probing attachment levels over time. In calculating these changes, duplicate measurements from fixed reference points, including cemento-enamel junctions and acrylic stents, have been used to assist in detecting progressive disease. The Florida Probe has been previously shown to improve the reproducibility of these measurements when used with an acrylic stent. The objective of the present study was to evaluate the reproducibility of 2 models of the Florida Probe, the original stent model and the modified disk model, in measuring attachment level. The disk probe differs from the stent probe in that it uses the occlusal surface of the tooth as a static reference point in calculating changes in attachment level measurements. In 10 subjects, sites were probed 2 x by 2 examiners using both types of probe. Standard deviations and intra- and inter-examiner correlations were calculated. These results demonstrate that the new disk probe yields reproducible measurements similar to the stent probe and is therefore suitable for use in longitudinal clinical studies.

Clinical, microbiological and immunological characteristics of subjects with "refractory" periodontal disease.

The aim of the present study was to analyze the relationship between attachment loss and clinical, microbiological, and immunological parameters in a group of 21 human subjects exhibiting poor response to previous periodontal therapy. All had been treated with periodontal surgery, tetracycline, and subsequent maintenance recalls to periodontists who, upon detection of disease progression, referred the subjects to our clinic. In our clinic, each subject received oral hygiene instruction and a thorough subgingival scaling and root planing utilizing as many appointments as necessary. Clinical indices, including gingival index, bleeding on probing, suppuration, plaque index, pocket depth, and duplicate measurements of attachment level from an acrylic stent, were collected at monthly intervals. Probing measurements were performed using the Florida Probe. When significant attachment loss (0.8-1.2 mm) was detected in at least 1 site, a bacterial sample was taken from that site and from a comparably deep, but non-progressing, control site. Microbial samples were enumerated by darkfield microscopy, on selective and non-selective media, and by predominant cultivable technique. Blood samples were also collected to determine antibody levels against potential pathogens. There was no difference in the amount of plaque present in sites gaining or losing attachment, but losing sites exhibited more bleeding and suppuration. 20 of the 21 subjects were tested; of these, 17 exhibited elevated serum antibody against one or more of the following microorganisms: Actinobacillus actinomycetemcomitans, Bacteroides, gingivalis, and Eikenella corrodens. However, few, if any, of the "classical" pathogens were detected in the plaque samples obtained at the time progressive disease was diagnosed. The only exception was Streptococcus intermedius, which occurred in slightly higher numbers in active sites.

Reviewing nonsurgical periodontal therapy.

Selection of the appropriate case and clinical competency in treatment modalities results in success in nonsurgical periodontal therapy. The patient with early periodontitis with significant local factors in the form of professionally accessible plaque and calculus is the most receptive to nonsurgical periodontal treatment. The clinician must make decisions centering around the important question, "Can the patient, or moreover, can the therapist delivering the debridement, gain access to the microbial subgingival plaque on a frequent basis below the host defense threshold of the respective patient?" If the answer is "yes," nonsurgical periodontal therapy will be rewarding. If the answer is "no," other modalities such as periodontal surgery must be instituted.

Effect of non-surgical periodontal therapy combined with adjunctive antibiotics in subjects with "refractory" periodontal disease. (I). Clinical results.

The aim of the present study was to evaluate the clinical effect of non-surgical periodontal therapy with the adjunct of a selected antibiotic in subjects with refractory periodontitis. 10 subjects were selected for the study; all had a history of periodontal surgery, tetracycline therapy, and regular maintenance by a periodontist. Clinical registrations including gingival index, plaque index, presence of bleeding and suppuration, pocket depth, and duplicate measurements of attachment level were performed at baseline and at monthly intervals. When disease activity was detected based on the tolerance method, a bacterial sample was taken from the active site and its susceptibilities to a number of antibiotics were determined. For the selected 10 subjects, Augmentin was the antibiotic of choice. Each subject received 750 mg/day for 2 weeks, during which time a full-month scaling and root planing was performed under local anesthesia. Clinical re-evaluation was performed after 3, 6, 9 and 12 months. At the time disease activity was detected, the average loss of attachment at all active sites was 2.2 mm, and the increase in pocket depth 1.5 mm. At 3 months post-therapy, these sites had regained 2 mm of attachment which remained stable through the 12-month examination. Pocket depths decreased 2.5 mm over the first 6 months and then stabilized. The frequency of all sites that gained 1 mm or more of attachment increased by approximately 10% over the first 9 months following therapy. The frequency of all sites that decreased 1 mm or more in pocket depth increased approximately 15% over the same period.(ABSTRACT TRUNCATED AT 250 WORDS)

Attachment level measurements with a constant force electronic probe.

The purpose of the present investigation was to evaluate the reproducibility of probing attachment level measurements using a newly developed constant force electronic probe. The probing force was preset at 25 g (probe diameter 0.4 mm) and was connected to a computer through a variable differential transformer. The measurements were performed on 10 patients with minimal signs of periodontal disease, using individually made acrylic stents. When the probe was in place and a foot switch depressed, the measurement was stored on the computer to the nearest 0.1 mm. The measurements were performed by one periodontist and one hygienist during one visit, and were then repeated by the same periodontist and another hygienist during a second visit. The results showed high correlations between the periodontist and the hygienist during one visit, between the two visits for the periodontist, and between the two hygienists at two different visits. The subject threshold for attachment loss was calculated according to Haffajee and co-workers, and was found to average 0.84 mm for the measurements performed by the periodontist and the hygienist during the same visit. For the periodontist during two separate visits and for the two different hygienists, the average threshold was 0.99 and 1.02 mm, respectively. Duplicate measurements were also performed by one periodontist at one visit on 10 patients with advanced periodontal disease. The average subject threshold for these patients was 0.60 mm. It may be concluded that with the constant force electronic probe, loss of attachment can be detected earlier than when conventional instruments are used.

Description and clinical evaluation of a new computerized periodontal probe--the Florida probe.

A new periodontal probing system has been developed which incorporates the advantages of constant probing force, precise electronic measurement to 0.1 mm and computer storage of the data. The system includes a probe handpiece, displacement transducer with digital readout, foot switch, computer interface and personal computer. A unique movable arm design enables the probe handpiece to maintain smooth operation and makes it easy to clean and sterilize. Electronic recording of the data (actuated by pressing a foot switch) eliminates errors which occur when probe tip markings are read visually and the data are called to an assistant. Computer storage and analysis of the data facilitates detecting changes in pocket depth and attachment level by rapidly comparing data recorded at different visits. The system was evaluated in 3 experiments using a 0.4 mm diameter tip and a 25 g probing force. The standard deviation of repeated pocket depth measurement was less (0.58 mm versus 0.82 mm) than that of a common probe. With paired readings referenced to an occlusal stent, the standard deviation of repeated attachment level measurements was 0.28 mm. A loss of attachment level was detected to a certainty of 99% with less than a 1 mm change. This is a significant improvement over common probes, which require a 2-3 mm change for equivalent positive identification of change in attachment level.