Anti-resorptive therapy and MRONJ. A survey of the Italian Society of Periodontology and Implantology.

OBJECTIVES: Anti-resorptive agents have been linked to the development of MRONJ in patients undergoing dental surgical procedures. This survey aims to explore the level of knowledge and experience of Italian Society of Periodontology and Implantology members in the management of patients treated with anti-resorptive agents and with the risk of developing MRONJ. MATERIALS AND METHODS: An 18-item questionnaire was submitted by e-mail to the SIdP members. Statistical analyses were carried out. Continuous variables were described as mean ± standard deviation (SD) or median, and first and third quartile according to distribution's normality. Normality of data was checked with Shapiro-Wilk test. RESULTS: Four hundred and fifty-one questionnaires were returned by e-mail (32%). Most of the respondents were private practitioners (81.8%). Only 47.7% declared to be highly confident in managing patients on anti-resorptive therapy while 92.5% reported to have performed tooth extractions and 52.3% implant surgery in patients under anti-resorptive therapy for osteometabolic disorders. One or more MRONJ-affected patients were encountered by 63.2% of the respondents. CONCLUSIONS: This survey highlights the need to develop a "dedicated" program both for dentists and prescribers to improve the level of cooperation and to increase the level of awareness of patients treated with anti-resorptive agents.

Anti-resorptive therapy in the osteometabolic patient affected by periodontitis. A joint position paper of the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP).

This joint report from the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP) aims for a consensus around the scientific rationale and clinical strategy for the management of osteoporotic patients affected by periodontitis who are undergoing anti-resorptive (AR) therapy to manage the risk of the occurrence of a medication-related osteonecrosis of the jaws (MRONJ). Osteoporosis and periodontitis are chronic diseases with a high prevalence in aging patients, and they share some of the same pathogenetic mechanisms based upon inflammation. Available evidence shows the relationship among osteoporosis, AR agents, periodontitis and implant therapy in relation to the incidence of MRONJ. Uncontrolled periodontitis may lead to tooth loss and to the need to replace teeth with dental implants. Tooth extraction and surgical dental procedures are recognized as the main risk factors for developing MRONJ in individuals taking AR therapy for osteometabolic conditions. Although the incidence of MRONJ in osteometabolic patients taking AR therapy may be as low as 0.9%, the increasing prevalence of osteoporosis and the high prevalence of periodontitis suggest that this potential complication should not be overlooked. Good clinical practice (GCP) guidelines are proposed that aim at a more integrated approach (prescriber, dentist, periodontist and dental hygienist) in the management of periodontitis patients undergoing AR therapy for osteometabolic disorders to reduce the risk of MRONJ. Dental professional and prescribers should educate patients regarding the potential risk associated with the long-term use of AR therapy and oral health behavior.

Hyperinsulinemic hypoglycemia in adolescents: case report and systematic review.

BACKGROUND: Hyperinsulinemic hypoglycemia is the most common cause of severe and persistent hypoglycemia in neonates and children. It is a heterogeneous condition with dysregulated insulin secretion, which persists in the presence of low blood glucose levels. CASE PRESENTATION: We report a case of a 15 year-old male with hyperinsulinemic hypoglycemia, who underwent a subtotal pancreatectomy after inadequate response to medical therapy. Pathological examination was positive for nesidioblastosis (diffuse ß-cell hyperplasia by H-E and immunohistochemical techniques). The patient's blood glucose levels normalized after surgery and he remains asymptomatic after 1 year of follow-up. The systematic review allowed us to identify 41 adolescents from a total of 205 cases reported in 22 manuscripts, from a total of 454 found in the original search done in PubMed and Lilacs. CONCLUSIONS: Although very well reported in children, hyperinsulinemic hypoglycemia can occur in adolescents or young adults, as it happens in our reported case. These patients can be seen, treated and reported by pediatricians or adult teams either way due to the wide age range used to define adolescence. Most of them do not respond to medical treatment, and subtotal distal pancreatectomy has become the elected procedure with excellent long-term response in the vast majority.

Relevance of TSH evaluation in elderly in-patients with non-thyroidal illness.

BACKGROUND: Non-thyroidal illness (NTI) is frequent in hospitalized patients. Its recovery is characterized by a raise in TSH levels. However, the clinical significance of high TSH levels at admission in hospitalized elderly patients with NTI remains uncertain. AIM: To explore the relevance of baseline TSH evaluation in hospitalized elderly patients with NTI. METHODS: We examined the participants with NTI (n = 123) from our previous study (Sforza, 2017). NTI was defined as: low T3 (< 80 ng/dL) and normal or low total T4 in the presence of TSH values between 0.1 and 6.0 mU/L. Thyroid function tests were performed on day 1 and day 8 of the hospital stay. Positive TSH changes (+ ΔTSH) were considered when the day-8 TSH value increased more than the reference change value for TSH (+ 78%). Multiple logistic regression was used to evaluate the independent association of baseline TSH, sex, clinical comorbidities (by ACE-27) and medications with + ΔTSH. RESULTS: Out of 123 patients (77 ± 8 years, 52% female), 34 showed a + ΔTSH. These patients had a lower TSH at admission (p < 0.001) and intra-hospital mortality (p = 0.003) than the others. In multiple logistic regression, TSH > 2.11 mU/L at baseline was associated with reduced odds to show + ΔTSH [odds ratio (95 CI) 0.29 (0.11-0.75); p = 0.011] in a model adjusted by age, sex and ACE-27. DISCUSSION: Inappropriately higher TSH levels at admission in hospitalized elderly patients were associated with a reduced ability to raise their TSH levels later on. The present results confront the idea that TSH levels at admission are irrelevant in this clinical context.

Hypothyroidism in hospitalized elderly patients: a sign of worse prognosis.

PURPOSE: Overt hypothyroidism has adverse clinical consequences and might worsen prognosis in critically ill elderly patients. However, the difficult interpretation of thyroid function tests (TFT) due to non-thyroidal illness (NTI) has led to discouragement of screening for thyroid dysfunction. Our aim was to determine the prevalence of TFT compatible with hypothyroidism and to study its influence on mortality among hospitalized elderly patients. METHODS: In this prospective study we consecutively included all patients ≥60 years admitted by the Internal Medicine Department to the hospital ward (n = 451) of the Cesar Milstein Hospital in Buenos Aires, Argentina. TFT were done on day 1 and 8. Thyroid function categories were defined as overt and subclinical hypothyroidism, overt and subclinical hyperthyroidism, euthyroidism and NTI. Stage of chronic kidney disease (CKD), Adult Comorbidity Evaluation (ACE)-27, and intra-hospital mortality were recorded. The association between mortality and TFT categories was studied by Cox regression. RESULTS: Out of 451 patients (77.0 ± 7.9 years, 54% females) 76% were categorized as NTI, 4% as overt hypothyroid, 10% as subclinical hypothyroid, 1% as subclinical hyperthyroid and 9% as euthyroid. Overt hypothyroid patients showed significantly higher mortality than the rest of the groups (25%, p < 0.05) while ACE-27 was similar among all of them (p = 0.658). In addition, patients within the overt hypothyroid category showed a higher mortality rate than NTI in a model adjusted by Stage 5-CKD, ACE-27, sex and age [HR 3.1 (1.14-8.41), p < 0.026]. CONCLUSION: Overt hypothyroidism during hospitalization was associated with elevated mortality. Further studies would reveal if TFT alterations compatible with hypothyroidism should be diagnosed/treated in hospitalized elderly patients.

Rotator cable at MR imaging: considerations on morphological aspects and biomechanical role.

PURPOSE: The rotator cable (RC) is a thickening of the coracohumeral ligament. It extends from the coracohumeral ligament to the inferior border of the infraspinatus tendon, with fibres running perpendicularly to the rotator cuff fibres. According to some authors, the RC tends to thicken with age, thus allowing some individuals with a cuff lesion to preserve normal shoulder function. We evaluated the RC with magnetic resonance (MR) imaging and investigated its possible role in the biomechanics of the shoulder affected by cuff lesions. MATERIALS AND METHODS: Between November 2007 and May 2008, we performed shoulder MR examinations for shoulder pain or disability on 94 patients (46 males, 48 females; age range 16-79 years; mean age 54.09 ± 15.09 years) for a total of 104 shoulders (62 right, 42 left). RESULTS: RC was more easily detectable in oblique coronal scans where it appeared as a crescent-shaped, regularly marginated structure adjacent to the articular surface of the supraspinatus tendon and medial to the insertion point of this tendon on the greater tuberosity. Its thickness was 2.8 ± 0.3 mm. The structure was identified in 62% of cases (mean patient age 55.3 ± 14.9 years). No statistically significant difference in age was found between patients with and without evidence of RC (Student's t test=0.05; p=0.82). Among patients with partial- or full-thickness supraspinatus tendon lesions at MR imaging, no statistically significant difference was found between the presence or absence of RC and disability on Jobe's test (χ(2)=1.17; p>0.05). CONCLUSIONS: RC can be observed at MR imaging in >60% cases. In our sample it did not seem to influence shoulder function in patients with cuff lesions.

Peritoneal wash cytology in gastric carcinoma. Prognostic significance and therapeutic consequences.

BACKGROUND AND AIMS: The prognosis of patients with gastric cancer is poor, even following curative resection, and is related primarily to the extent of disease at presentation. In locally advanced gastric tumors, peritoneal lavage cytology (PLC) is a relevant prognostic factor. The Authors present their results of peritoneal washing cytology, evaluating the prognostic value of this technique, and discussing the clinical impact. PATIENTS AND METHODS: From July 2003 to May 2008, results of PLC in 64 patients with histologically proven primary gastric adenocarcinomas were analyzed. At laparotomy the abdomen was irrigated with 200 ml of normal saline, and ≥50 ml were aspirated and examined by means of cytology and immunocytopathology. RESULTS: PLC was positive in 7 cases (11%). Overall, 86% of patients with a positive PLC had a pT3/pT4 tumor and 100% with a positive PLC had an N-positive tumor (p < 0.001); 71% of patients with a positive PLC had a grade G3/G4 tumor (p = 0.001). At a median follow-up of 32 months, the cumulative 5-year survival was 28%. The median survival of patients presenting positive PLC (19 months) was significantly lower than that of patients with negative peritoneal cytology (38 months) (p = 0.0001). Multivariate analysis identified cytology as a significant predictor of outcome (p = 0.018). CONCLUSIONS: Results in the present series demonstrated that patients with a positive peritoneal cytology had advanced disease and poor prognosis, thus indicating that patients with locally advanced gastric cancer should undergo staging laparoscopy and PLC examination in order to select those requiring more aggressive treatment. Future therapeutic strategies should include PLC examination in preoperative staging, in order to select patients for more aggressive treatment.

Hand and ultrasonic instrumentation in combination with root-coverage surgery: a comparative controlled randomized clinical trial.

BACKGROUND: The role of vigorous root planing in the surgical treatment of gingival recession was recently questioned. The aim of the present randomized controlled split-mouth clinical study was to compare the effectiveness, in terms of root coverage, of hand and ultrasonic root instrumentation in combination with a coronally advanced flap for the treatment of isolated-type recession defects. METHODS: Eleven systemically and periodontally healthy subjects with bilateral recession defects (> or = 3 mm) of similar (< or = 1 mm) depth affecting contralateral teeth were enrolled in the study. Only Miller Class I gingival recession with no deep cervical abrasion or root caries/demineralization were included in the study. Control root exposures were treated with curets, whereas test roots were instrumented with ultrasonic piezoelectric devices. Randomization for test and control treatment was performed by a coin toss immediately prior to surgery. All recessions were treated with a coronally advanced flap surgical technique. The clinical reevaluation was made 6 months after surgery. RESULTS: The two approaches resulted in a high percentage of root coverage (95.4% in the control group and 84.2% in the test group) and complete root coverage (82% in the control group and 55% in the test teeth), with no statistically significant difference between them. Clinical attachment level gains were clinically significant in both groups (3.36 +/- 0.92 mm in the control group and 2.90 +/- 0.70 mm in the test group), with no statistically significant difference between them. The increase in keratinized tissue height was statistically significant in both groups (0.55 +/- 0.52 mm in the control group and 0.36 +/- 0.67 mm in the test group), with no difference between them. CONCLUSIONS: The present study failed to demonstrate any superiority, in terms of root-coverage results, for hand instruments over ultrasonic treatment of the root surface in combination with coronally advanced flap mucogingival surgery. Further studies of longer-term duration and larger sample size could help to establish the superiority of one form of root instrumentation in conjunction with root-coverage surgery.

[Surgical therapy of Crohn's disease: observations on 63 patients]. / La terapia chirurgica della malattia di Crohn. Considerazioni su una casistica di 63 osservazioni.

AIM: The purpose of our retrospective study is to evaluate the correct indications for the surgical therapy of Crohn's disease. METHODS: Our case series consists of 63 patients admitted to our Surgery Department from January 1, 1973 to December 2002 with a diagnosis of Crohn's disease. Of the 56 operated patients, 43 patients were followed-up. For an objective evaluation of the Crohn's disease activity, the Crohn's Disease Activity Index (CDAI) was used. Surgical treatment has been carried out in 56 cases: in 29 cases of intestinal occlusion a minimal gut resection was performed; in the 26 cases of perforation a suture of the perforation was preferred, with a drainage of the peritoneal cavity and a toilette of abscess when it was present, and in 1 case an ileocolic resection was performed. RESULTS: Only 1 case showed a CDAI score >150 (153.63). This shows that in all the other cases the surgical and medical treatment has led to a satisfactory control of the disease. A relapse has been observed in 17 patients after an average period of 5 years without showing signs of disease. CONCLUSION: It is suggested that Crohn's disease therapy should be mainly of a medical nature and surgical treatment should be reserved for complicated cases.

Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study.

OBJECTIVES: Complete root coverage is the primary objective to be accomplished when treating gingival recessions in patients with aesthetic demands. Furthermore, in order to satisfy patient demands fully, root coverage should be accomplished by soft tissue, the thickness and colour of which should not be distinguishable from those of adjacent soft tissue. The aim of the present split-mouth study was to compare the treatment outcome of two surgical approaches of the bilaminar procedure in terms of (i) root coverage and (ii) aesthetic appearance of the surgically treated sites. MATERIAL AND METHODS: Fifteen young systemically and periodontally healthy subjects with two recession-type defects of similar depth affecting contralateral teeth in the aesthetic zone of the maxilla were enrolled in the study. All recessions fall into Miller class I or II. Randomization for test and control treatment was performed by coin toss immediately prior to surgery. All defects were treated with a bilaminar surgical technique: differences between test and control sites resided in the size, thickness and positioning of the connective tissue graft. The clinical re-evaluation was made 1 year after surgery. RESULTS: The two bilaminar techniques resulted in a high percentage of root coverage (97.3% in the test and 94.7% in the control group) and complete root coverage (gingival margin at the cemento-enamel junction (CEJ)) (86.7% in the test and 80% in the control teeth), with no statistically significant difference between them. Conversely, better aesthetic outcome and post-operative course were indicated by the patients for test compared to control sites. CONCLUSIONS: The proposed modification of the bilaminar technique improved the aesthetic outcome. The reduced size and minimal thickness of connective tissue graft, together with its positioning apical to the CEJ, facilitated graft coverage by means of the coronally advanced flap.

Plaque removal by worn toothbrush.

BACKGROUND/AIMS: Assessment of the influence of toothbrush wear on plaque (PI) and gingival (GI) indexes. METHOD: 20 university students were recruited. PI and GI were recorded at the starting point (T0). Each subject received a toothbrush and toothpaste. 5 measurements of toothbrush were recorded to establish the initial size. The subjects were instructed to brush 3 x a day and to refrain from using other plaque removal aids. After 1 month (T1), the subjects were randomly divided into 2 groups: group no. 1 substituted the toothbrush at each monthly visit; group no. 2 brushed only with the toothbrush provided at T0. Recalls were scheduled after 1 (T1), 2 (T2) and 3 months (T3). PI, GI and an index of wear (WI) were calculated using 5 measurements of the toothbrush head and were recorded at recalls. RESULTS: From T0 to T3, a significant increase of PI was found within both groups. Non-significant differences, but very close to the significant level (p= 0.063), in group no. 1 and significant differences in group no. 2 of GI were found. No significant differences of PI and GI were found between groups. Increase of the WI was registered from T0 to T3 (p<0.001). CONCLUSION: Each individual is capable of maintaining low PI, even if using a toothbrush that shows evidence of wear.

Topical and systemic antimicrobial therapy in guided tissue regeneration.

BACKGROUND: Bacterial contamination of membrane material negatively affects healing after guided tissue regeneration (GTR) procedures; conversely, flap connective tissue integration on barrier material improves the clinical outcomes. The objective of this study was to evaluate the effect of topical application of antibiotics on: 1) clinical outcomes of GTR surgical procedures using titanium reinforced expanded polytetrafluoroethylene (ePTFE) periodontal membrane; 2) bacterial colonization of membrane material; and 3) flap connective tissue-membrane integration. METHODS: Fifty-six deep interproximal bony defects were treated with GTR surgical procedures using titanium reinforced ePTFE periodontal membranes. Patients were randomly assigned to 1 of the 2 antimicrobial treatment groups: the test group received weekly topical application of 25% metronidazole gel and the control group received systemic antibiotics (amoxicillin plus clavulanic acid 1 g/day for 14 days). Clinical outcomes were assessed at 1 year; the amount of bacterial contamination and connective tissue integration on membrane material was evaluated at time of membrane removal by means of a morphological (SEM) method. RESULTS: No statistically significant difference was found between test and control groups in terms of clinical attachment (CAL) gain (baseline CAL - 12 months CAL; P = 0.2) and probing depth (PD) reduction (baseline PD - 12 months PD; P = 0.6). A greater increase in gingival recession (REC) (12 months REC - baseline REC) was found in the test group compared to the control group (P = 0.003). The SEM analysis revealed no statistically significant (t test) difference between test and control groups in the number of fields positive to integrated connective tissue (P = 0.82), while the number of fields positive to bacteria was statistically higher (P < 0.001) in the control group. CONCLUSIONS: Local antibiotic administration is more effective than systemic use in preventing membrane contamination, but it does not improve clinical outcomes due to an interference of the vehicle (gel) with gingival tissues which may reduce the potential benefits derived from better control of the bacterial load.

Preseasonal intranasal immunotherapy in birch-alder allergic rhinitis. A double-blind study.

A double-blind, placebo-controlled study was carried out to test the clinical efficacy and safety of local nasal immunotherapy (LNIT) in powder form. Twenty-two patients suffering from allergic rhinitis strictly associated with early spring symptoms, with positive skin prick tests and RAST for birch-alder, all responders to a specific nasal provocation test (NPT), received randomly active or placebo treatment for 4 months. Immunotherapy consisted of administration of a set of capsules containing progressively increasing amounts of birch (Betula pendula) and speckled alder (Alnus incana) allergens in powder form with controlled granulometry. The active (birch-alder) and placebo (lactose) group completed the treatment according to a similar schedule. During the pollen season (March-April), the patients who took the active treatment reported less sneezing and rhinorrhea than the placebo group, on the basis of a symptoms score, and the differences were statistically significant; the need for drugs (terfenadine) was also significantly reduced. These findings agreed well with the results of specific NPT after the treatment; only patients in the active group had a higher threshold dose of nasal specific reactivity to birch-alder allergens than in tests before the LNIT.