Objective assessment of dermal fibrosis in cutaneous scarring, using optical coherence tomography, high-frequency ultrasound and immunohistomorphometry of human skin.

BACKGROUND: Noninvasive quantitative assessment of dermal fibrosis remains a challenge. Optical coherence tomography (OCT) and high-frequency ultrasound (HFUS) can accurately measure structural and physiological changes in skin. OBJECTIVES: To perform quantitative analysis of cutaneous fibrosis. METHODS: Sixty-two healthy volunteers underwent multiple sequential skin biopsies (day 0 and 1-8 weekly thereafter), with OCT and HFUS measurements at each time point supported with immunohistomorphometry analysis. RESULTS: HFUS and OCT provided quantitative measurements of skin thickness, which increased from uninjured skin (1·18 and 1·2 mm, respectively) to week 1 (1·28 mm, P = 0·01; 1·27 mm, P = 0·02), and compared favourably with haematoxylin and eosin. Spearman correlation showed good agreement between techniques (P < 0·001). HFUS intensity corresponded to dermal density, with reduction from uninjured skin (42%) to week 8 (29%) (P = 0·02). The OCT attenuation coefficient linked with collagen density and was reduced at week 8 (1·43 mm, P < 0·001). Herovici analysis showed that mature collagen levels were highest in uninjured skin (72%) compared with week 8 (42%, P = 0·04). Fibronectin was greatest at week 4 (0·72 AU) and reduced at week 8 (0·56 AU); and α-smooth muscle actin increased from uninjured skin (11·5%) to week 8 (67%, P = 0·003). CONCLUSIONS: Time-matched comparison images between haematoxylin and eosin, OCT and HFUS demonstrated that epidermal and dermal structures were better distinguished by OCT. HFUS enabled deeper visualization of the dermis including the subcutaneous tissue. Choice of device was dependent on the depth of scar type, parameters to be measured and morphological detail required in order to provide better objective quantitative indices of the quality and extent of dermal fibrosis.

Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae.

Striae distensae (SD) are common dermal lesions, with significant physical and psychological impact. Many therapeutic modalities are available but none can completely eradicate SD. The most common therapy is the application of topicals used both therapeutically and prophylactically. Even though there are many commercially available topical products, not all have sufficient level of evidence to support their continued use in SD. The aim here was to assess the evidence for the use of topicals in SD and to propose a structured approach in managing SD. A systematic search of published literature and manufacturer website information for topicals in SD was carried out. The results showed that there are few studies (n = 11) which investigate the efficacy of topicals in management of SD. Trofolastin and Alphastria creams demonstrated level-2 evidence of positive results for their prophylactic use in SD. Additionally, tretinoin used therapeutically showed varying results whilst cocoa butter and olive oil did not demonstrate any effect. Overall, there is a distinct lack of evidence for each topical formulation. The majority of topicals failed to mention their effect on early vs. later stages of SD (striae rubrae compared to striae albae) and their role in both prevention and treatment. In conclusion, there is no topical formulation, which is shown to be most effective in eradicating or improving SD. A structured approach in identification and targeted management of symptoms and signs with the appropriate topical is required. Randomized controlled trials are necessary to assess the efficacy of topical products for treatment and prevention of different stages of SD.

Introducing Scenario Based Learning interactive to postgraduates in UQ Orthodontic Program.

INTRODUCTION: E-learning has gained momentum in health sciences and seems to have great potential in specialist dental education. Higher acceptability by learners is particularly associated with the surge of smart devices. Currently, there are limited number of e-learning modules available for dental education, particularly in Orthodontics. MATERIAL AND METHODS: Scenario Based Learning interactive (SBLi(®)) software was used for the first time in Orthodontics Postgraduate training at the University of Queensland. Nine interactive modules were created embedded with clinical procedure videos, web-links, evidence-based literature, along with opportunity for self-assessment and evaluation. Qualitative data were collected before and after the administration of the SBLi(®) for Orthodontics. The purpose of this data was to investigate learning styles and the acceptance of e-modules as part of postgraduate training. RESULTS: Advantages of the package included high acceptance rate, greater confidence in the application of clinical skills covered in the modules and reduced contact time particularly with limited academic staff. E-modules demonstrated high compatibility with the learning styles of the participants and were considered engaging. CONCLUSIONS: It seems apparent that e-learning is most effective in a blended learning environment, supplemented with the traditional classroom approach, rather than as a sole mechanism for postgraduate training.

Evaluation of a novel approach in the prevention of white spot lesions around orthodontic brackets.

BACKGROUND: The purpose of this study was to evaluate and compare the relative efficacy of a resin fissure sealant, nano-filled self-adhesive protective coating, resin infiltrant, glass ionomer cement (GIC), and GIC containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in preventing the formation of subsurface lesions of enamel (SLE) adjacent to orthodontic brackets by acting as an enamel surface sealant (ESS). METHODS: Eighty-five enamel specimens with molar tubes bonded at their centre were randomly divided into five groups, each treated with a different material at the bracket's periphery. Specimens were stored in an acetate demineralization solution at pH 4.5 for 7 days at 37 °C then imaged using quantitative light-induced fluorescence (QLF) to determine the difference in fluorescence (∆F) between sound- and acid-exposed enamel. Lesion cross-sections were then examined using backscattered scanning electron microscopy (SEM) to measure lesion depth. RESULTS: The use of GIC alone or incorporating CPP-ACP significantly reduced ∆F compared with other materials. Backscattered SEM images showed no measurable demineralization for enamel treated with either GIC material in contrast with other groups, which showed statistically significant demineralization levels. CONCLUSIONS: The fluoride-releasing effects and CPP-ACP benefits of the GIC materials show promise as an effective ESS in inhibiting enamel demineralization adjacent to orthodontic brackets.

Striae distensae: a comprehensive review and evidence-based evaluation of prophylaxis and treatment.

Striae distensae are an extremely common, therapeutically challenging form of dermal scarring. Risk factors have been reported but much remains to be understood about their epidemiology, diagnosis and treatment. Up-to-date knowledge of the scientific research and the evidence behind both preventative and therapeutic agents are vital in order to understand striae and to offer patients the best therapeutic alternatives. We present a clinical review of the current literature concerning striae distensae and their prevention and treatment. A systematic review of the literature was undertaken using Medline, Embase and Google Scholar. Articles in English, Spanish, Portuguese, Turkish and French were included. Striae distensae occur in pregnancy, puberty and obesity as well as in numerous medical conditions and following therapeutic interventions. Proposed aetiological mechanisms relate to hormones, physical stretch and structural alterations to the integument. Assessment methods include subjective visual scoring and various imaging modalities. Treatments that we have evaluated include topical agents, used prophylactically or therapeutically, as well as light and laser therapies, which have shown improvements in the appearance of striae. Few high level evidence based medicine randomized controlled trials evaluating treatments for striae distensae exist. Topical therapeutic agents appear to lack efficacy in the prevention of striae distensae.

Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature.

Keloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.

Age-related changes in maxillary and mandibular cortical bone thickness in relation to temporary anchorage device placement.

BACKGROUND: The aim of this study was to investigate the correlation between alveolar bone cortical thickness (ABCT) and age in the maxillae and mandible in humans. This information could then be translated into clinical application with temporary anchorage devices (TADs) in orthdontics. METHODS: Samples comprised 82 post-mortem CT datasets (41 males and 41 females) aged between 11 to 50 years, and were divided into five different age groups and gender. Alveolar ABCT was measured in the labial/buccal and palatal/lingual sides of the incisor, canine, premolar, molar and tuberosity/retromolar regions of the maxillae and mandible. Correlations between ABCT and age and gender were analysed with linear regression analysis. RESULTS: Strong correlation between ABCT and age was found for the maxilla on the labial side of the maxillary incisor region (p < 0.001). On the palatal aspect, significant correlations between ABCT and age were found in the maxillary incisor and maxillary premolar regions (p = 0.01 and p = 0.047 respectively). Significant correlation between ABCT and gender was found only at the buccal aspect of the maxillary molar region (p = 0.022). In the mandible, a statistically significant correlation between ABCT and age was found in the cortical bone of the labial side of the mandibular incisor region (p = 0.017). However, statistically significant negative correlation between ABCT and age was found in the mandibular canine region (p = 0.033). The only site to demonstrate a significant difference in change in ABCT with age between males and females was the lingual side of the retromolar region, in which female ABCT increased more than in males (slope = 0.015). CONCLUSIONS: There is minimal clinically significant correlation between ABCT and age at the alveolar bone level. Although investigations show statistically significant correlations, these may not be clinically significant as those regions are not ideal for anchorage reinforcement with TADs in orthodontic practice.

Ultrasonography, lateral cephalometry and 3D imaging of the human masseter muscle.

PURPOSE: To develop prediction equations to assist the clinician to derive cephalometric norms from the non-invasive investigations of ultrasonography (US) and 3D imaging. SETTING AND SAMPLE POPULATION: Adult volunteers from University of Adelaide participated in the study. METHODS: Eleven volunteers (eight women, three men; age range 22-30 years) were recruited for US and standard lateral radiographs measurements along with 3D facial imaging using a structured light technique. The three examinations were performed to assess the vertical and transverse dimensions of the face along with superficial masseter muscle dimensions. In total, 31 variables were statistically analysed for relationship among the three imaging modalities. RESULTS: Pearson's correlation coefficients showed highly significant correlations between lateral cephalometric (Co-Go to R3-R4) and US (volume--thickness) variables (r = 0.92, p < 0.0001; r = 0.95, p < 0.0001, respectively). Strong correlations were also observed with Co-Go and masseter muscle area derived from US r = 0.81 (p = 0.01). Similarly, strong correlations were seen between gonion-menton (Go-me) and facial width from 3D imaging (r = 0.83, p = 0.003). A high statistical significance (p > 0.0001) for curvilinear measurements compared with linear counterparts was revealed with the paired t-test. Factor analyses provided meaningful interrelationships for predictive equations generated for lateral cephalometric variables from 3D image coordinates. CONCLUSIONS: This preliminary investigation suggests that useful clinical information for treatment planning and follow-up can be gathered without repeated exposure to ionizing radiation. For more robust predictive equations, a larger sample would be required to validate such a model.

Ultrasound measurements of the masseter muscle as predictors of cephalometric indices in orthodontics: a pilot study.

This study investigated the potential of ultrasound measurements of the masseter muscle to accurately predict indices normally derived from cephalograms. Masseter muscle measurements on 11 adults (22 to 30 y) were made using lateral cephalometrics and extended field-of-view ultrasound. The ultrasound technique was validated in a simulation pilot study using 12 dry skulls and raw chicken breasts. Twenty cephalometric variables were analyzed against four ultrasound measurements of the masseter muscle. Highly significant correlations (r = 0.81-0.85, p = 0.001-0.002) between ultrasound measurements of the masseter muscle and cephalometric measurements representing the length of the superficial masseter muscle, the length and shape of the mandible and vertical facial proportions were demonstrated. Predictive equations from regression analyses were constructed to deduce ramus length and shape from the ultrasound measurements. The results provide pilot data suggesting that ultrasound is a potential clinical tool for sequential evaluation of masseter muscle length in orthodontics and facial muscle growth studies.

Modulation of masseteric reflexes by simulated mastication.

It is well-known that limb muscle reflexes are modulated during human movements. However, little is known about the existence of equivalent masticatory muscle reflex modulation. We hypothesized that masticatory reflexes would be modulated during chewing so that smooth masticatory movements occur. To examine this hypothesis, we studied the modulation of inhibitory reflexes evoked by periodontal mechanoreceptor activation and of excitatory reflexes evoked by muscle spindle activation during simulated mastication. In 28 participants, 1- and 2-N mechanical taps were delivered to the incisor. Reflex responses to these taps were examined in the average masseteric electromyogram. To differentiate between periodontal mechanoreceptor- and muscle-spindle-mediated reflex components, we performed experiments prior to, and in the presence of, periodontal anesthesia. Both periodontal mechanoreceptor and muscle spindle reflexes were reduced during simulated masticatory movements.

An environmentally viable waste disposal method for oil-producing countries.

The increasing amount of oil field waste is a matter of concern. This study proposes the Slurry Fracture Injection (SFI) technique as an alternative waste disposal method. The proposed waste disposal method is complete and leaves few future liabilities. The entire waste can be injected into an isolated deep geologic zone with no contamination of water-bearing formations or formations outside the targeted zone. The method can lead to the reclamation of oil industry landfills and the oil pits and dumps. We propose a two-tiered screening method for evaluating the feasibility of this technology and identification of a suitable target zone. A stringent environmental monitoring program should complement the SFI process to ensure environmental compatibility.

Prescription and dispensing practices in public sector health facilities in Pakistan: survey report.

OBJECTIVES: To gather information on existing prescription practices, dispensing practices and patient satisfaction in government health services of the NWFP, Baluchistan and Punjab province. METHODS: A cross sectional study design was used for this purpose. Ten health care facilities were selected from each province keeping appropriate representation from first level health facilities, district health facilities and tertiary care hospital. Analysis of selected indicators was carried out on the basis of provinces, health facilities, gender and different age groups. RESULTS: Documentation of 914 responses was completed from three provinces. Almost equal distribution of encounters was maintained representing different health facilities. Forty seven percent of encounters involved children under 15 years of age. Female patients comprised of 56% and the mean age of the entire sample was 26 years. The mean dispensing time was only 38 seconds, the mean consultation time was 1.79 minutes and the average number of drugs per prescription turned out to be 2.7 out of which only 1.6 drugs were being dispensed from the facility. More than half of the prescriptions contained antibiotics and 15% of patients were prescribed with injectables. Only half of the patients expressed satisfaction with their visit to health facility. CONCLUSIONS: Like many other developing countries, prescription and dispensing practices are not satisfactory in public sector health facilities of Pakistan. Appropriate and workable solutions need to be developed and implemented in the country to improve systems. Regular audits and qualitative studies should become part of the effort.