Preserving pulpal health of a geminated maxillary lateral incisor through multidisciplinary care.

AIM: To report the multidisciplinary care of an unaesthetic geminated maxillary lateral incisor tooth, which allowed its preservation in the mouth. SUMMARY: Preoperative examination of an unsightly geminated maxillary lateral incisor (tooth 22) demonstrated two pulp chambers and open apices, with normal pulp sensitivity responses. At surgery, a periodontal mucoperiosteal flap was reflected and the distal part of the geminated tooth was removed. The exposed root canal of the preserved tooth was sealed with mineral trioxide aggregate (MTA). The extraction socket and osseous defect was grafted with decalcified freeze-dried bone allograft (DFDBA) before flap closure. During follow-up, distal caries in tooth 22 and a diastema between tooth 22 and 23 were managed with composite resin restorations. Forty-two months postoperatively, normal thermal and electrical pulp sensitivity tests confirmed pulp health. Convincing apexogenesis and dentinogenesis of the developing root was confirmed by radiographic examination. Acceptable periodontal health including 3-4 mm clinical probing depths was achieved. Optimizing aesthetics and occlusion was accomplished without orthodontic treatment.

Seroprevalence of hepatitis C virus infection and its association with natural infection of hepatitis B virus among preschool children in Taiwan.

Taiwan is a hyperendemic area of hepatitis B virus (HBV) infection where chronic hepatitis B is the most important cause of liver cirrhosis and hepatoma. Since, diagnostic kit for detecting hepatitis C virus (HCV) infection has been developed, HCV was found to be another important etiology of chronic liver disease. In order to study the seroprevalence of HCV infection among preschool children after mass hepatitis B vaccination program in Taiwan, a community-based survey was carried out in 54 kindergartens in 10 urban areas, 10 rural areas, and two aboriginal areas randomly selected through stratified sampling. Serum specimens of 2538 preschool children were screened for the HCV antibodies (anti-HCV) by a commercially available third-generation microparticle enzyme immunoassay and for HBV markers by radioimmunoassay methods. The multivariate-adjusted odd ratios (ORm) with their 95% confidence intervals (CI) were estimated through the multiple logistic regression analysis. A total of 58 children were anti-HCV seropositive, giving a prevalence of 2.3%. The prevalence of anti-HCV was 1.0% (5 of 484) among aboriginal children, a significantly decreased seroprevalence compared with those among other ethnic groups after multivariate adjustment. Boys had a higher anti-HCV seroprevalence, but not statistically significantly different from girls (ORm: 1.6; 95% CI: 0.9-2.8; p = 0.08). The seroprevalence of the age group of 3-4 years was lower than that of the age group of 5-6 years (ORm: 2.2; 95% CI: 1.1-4.2; p = 0.02). After multivariate adjustment, preschool children with natural HBV infection had a higher anti-HCV seroprevalence, but not statistically significantly different from those without natural HBV-infection (ORm: 2.6; 95% CI: 0.9-7.4; p = 0.08 for HBV-infected vs. uninfected). HCV infection varies with gender, residential area, and natural HBV infection. HCV and HBV might share common transmission routes in Taiwan.

Extraction as a treatment alternative follows repeated trauma in a severely handicapped patient.

Handicapped patients with protruding maxillary incisors are prone to repeated dental trauma. A 13-year-old girl with cerebral palsy, severe mental retardation and seizure disorder was referred to our department for restoring the traumatized anterior teeth. Despite drug combination, the frequency of seizure attack was around 10 times a month. The oral examination showed multiple caries, gingival hyperplasia, class II malocclusion with 14 mm overjet and deep overbite. During the first 3 years of a 7-year follow-up period, six episodes of anterior tooth trauma due to seizure attack occurred. The trauma-related treatment performed included endodontic therapy, multiple composite restorations, apical repositional flap, and finally extraction of all four upper incisors with fabrication of a semi-fixed band-retained denture. The denture restored normal overbite and overjet with improved esthetics. For 4 years following the fabrication of denture, no trauma occurred to the anterior teeth in later seizure attacks. Considering inadequate control of seizure disorder, little ability of the patient to receive comprehensive orthodontic treatment, poor prognosis of restorations, and possible future injuries, the removal of non-functional, nonesthetic, trauma-susceptible incisor teeth can be justified as an alternative to tooth preservation.

Acute and long-term effects of atrioventricular junction ablation and VVIR pacemaker in symptomatic patients with chronic lone atrial fibrillation and normal ventricular response.

INTRODUCTION: The precise role of irregular ventricular response in atrial fibrillation (AF) has not been fully elucidated. This study examined the independent effects of rhythm regularity in patients with chronic AF. METHODS AND RESULTS: This study included 50 patients who had chronic lone AF and a normal ventricular rate. Among these patients, 21 who underwent AV junction ablation and implantation of a VVIR pacemaker constituted the ablation group; the other 29 patients were the medical group. Acute hemodynamic findings were measured in 21 ablation patients before ablation (during AF, baseline) and 15 minutes after ablation (during right ventricular pacing). Compared with baseline data, ablation and pacing therapy increased cardiac output (4.7 +/- 0.8 vs 5.2 +/- 0.9 L/min; P = 0.05), decreased pulmonary capillary wedge pressure (16 +/- 5 vs 13 +/- 4 mmHg; P = 0.001), and decreased left ventricular end-diastolic pressure (14 +/- 4 vs 11 +/- 3 mmHg; P < 0.05). After 12 months, the ablation group patients showed lower scores in general quality of life (-20%; P < 0.001), overall symptoms (-24%; P < 0.001), overall activity scale (-23%; P = 0.004), and significant increase of left ventricular ejection fraction (44% +/- 6% vs 49% +/- 5%; P = 0.02) by echocardiographic examination. CONCLUSION: AV junction ablation and pacing in patients with chronic AF and normal ventricular response may confer acute and long-term benefits beyond rate control by eliminating rhythm irregularity.

Current seroprevalence of hepatitis A virus infection among kindergarten children and teachers in Taiwan.

Taiwan was a hyperendemic area for hepatitis A virus (HAV) infection before the late 1980s. The seroprevalence of HAV infection was higher than 90% with most HAV infection occurring during childhood. This study was to estimate the seroprevalence of HAV infection among preschool children in central Taiwan. A community-based survey was carried out in 54 kindergartens in 10 urban areas, 10 rural areas and 2 aboriginal areas randomly selected through stratified sampling. Serum samples of 2,549 healthy preschool children and 104 teachers in study kindergartens were screened for the HAV antibodies (anti-HAV) by means of a commercially available microparticle enzyme immunoassay (AxSYM HAVAB). Among aboriginal kindergarten children, more than 96% of them were anti-HAV seropositive due to a mass HAV vaccination program. In urban and rural areas, kindergarten children had a very low prevalence of anti-HAV (0.4%) in contrast to a high seroprevalence in their teachers (78%). There was no gender difference in seroprevalence of anti-HAV, while the anti-HAV seroprevalence was significantly higher in urban areas than in rural areas. Crowdedness of living in urban areas might facilitate the person-to-person transmission of infectious agents.

Effects of cancer therapy on dental and maxillofacial development in children: report of case.

Malignant lymphoma is one of the most common hematological diseases of children. The prognosis is fairly good with multimodal cancer therapy. We reported a boy with Burkitt's lymphoma in the nasal cavity who received chemotherapy and irradiation of the head and neck area at four years of age. During seven years of follow-up, we studied the developmental effects of cancer therapy, including general growth, maxillofacial bones, and dentition. Compared with boys of matching age, the development of his entire body and maxillofacial bones was delayed. In the irradiated areas, the roots of teeth were short or poorly developed and the root apices showed premature closure. After the patient was in remission from the tumor in his early childhood, the long-term effects of cancer therapy on dental and maxillofacial development are worth our further evaluation and follow-up.

Association between seropositivity of antibodies against hepatitis a virus and Helicobacter pylori.

Helicobacter pylori and hepatitis A virus (HAV) are documented to share common transmission routes including fecal-oral. This study examined the association between seropositivity of antibodies against H. pylori (anti-HP) and HAV (anti-HAV) via a community-based survey of 40 randomly selected kindergartens in 10 urban and 10 rural areas. Serum samples from 2,047 healthy preschool children and 104 teachers were screened for anti-HP by enzyme-linked immunosorbent assay, and for anti-HAV by microparticle enzyme immunoassay. In children, a low prevalence of anti-HAV (0.44%) was found, in contrast to a high prevalence in their teachers (78.8%); anti-HP seroprevalence was 6.4% for children and 30.8% for teachers. Anti-HAV and anti-HP seropositivities were significantly associated in teachers after adjustment for age, sex, and residential area through multiple logistic regression analysis (multivariate-adjusted odds ratio = 7.3; 95% confidence interval [CI] = 1.4-36.8, P < 0.001). Our findings suggest that HAV and H. pylori may have shared transmission routes in central Taiwan 15 years or more ago, but not any recently.

Survey of incisor trauma in second grade students of central Taiwan.

BACKGROUND: The purpose of this study was to investigate the prevalence and related factors of incisor trauma among 1200 second grade students in Taichung City, Taiwan. METHODS: The study population consisted of 1200 second grade students, 645 boys (53.8%) and 555 girls (46.3%), at four elementary schools in Taichung City, Taiwan. This survey was composed of two parts: (1) a questionnaire of dental traumatic history, and (2) a clinical examination of each subject to record any clinical evidence of traumatic dental injury on permanent incisors. RESULTS: The questionnaires indicated that 16.5% of the children had a positive history of dental trauma. The male to female ratio of a prior dental trauma was 1.4:1. The maxilla (78.2%) was affected more frequently than the mandible. Most of the injuries had occurred at home (63.7%). Clinical examinations disclosed that 3% of the subjects, 43 teeth in 37 children, had clinical signs and symptoms of dental trauma. Maxillary central incisors (77%) were the teeth most often affected. The most common type of crown injury was enamel fracture (67%). CONCLUSION: The prevalence of a history of dental trauma and clinical findings of incisor injury in this study was lower than that in previous reports. Home and school were the settings where dental injury was most likely to occur. Clinical signs and symptoms of dental trauma were found in 3% of the subjects. Maxillary incisors were the most commonly affected teeth, and 67% of these cases involved enamel fracture.

Cardiac reoperations in octogenarians: analysis of outcomes.

BACKGROUND: With the rapid growth of the elderly segment of the population, more octogenarians are referred for complex cardiac interventions, including reoperations. Data regarding the outcomes, quality of life, and long-term results after reoperative open-heart surgical procedures in octogenarians are scarce. METHODS: We retrospectively studied 113 consecutive octogenarians (mean age, 83+/-2.6 years) who underwent reoperative cardiac procedures within a 13-year period. Coronary artery bypass grafting (CABG) was performed in 49 patients (CABG group), valvular procedures (aortic, mitral, or tricuspid valve, alone or in combination) in 35 (valve group), and combined CABG and valve intervention in 29 (combined CABG and valve group). RESULTS: The 30-day mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. One- and 5-year actuarial survival rates were, respectively, 85%+/-5% and 58%+/-10% for the CABG group, 78%+/-7% and 53%+/-12% for the valve group, and 69%+/-9% and 63%+/-10% for the combined CABG and valve group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in New York Heart Association class I or II postoperatively at a mean follow-up time of 2.1+/-2.4 years. Similarly, 91%, 85%, and 80%, respectively, thought that they had an improved quality of life and were satisfied with their functional status. CONCLUSIONS: Cardiac reoperations can be performed successfully in most octogenarians, although with an increased risk, particularly in the combined CABG and valve group. Long-term survival is acceptable with improved quality of life and functional status. However, it is possible that these results could be improved in this high-risk group of patients with earlier referral and surgical intervention, for the effective use of health care resources.

Distribution patterns of primary and permanent dentition in children with unilateral complete cleft lip and palate.

OBJECTIVE: To investigate the distribution patterns of primary and permanent teeth in the cleft area and the numerical variation in teeth in unilateral complete cleft lip and palate (UCLP) patients. DESIGN: A survey of the dentition in UCLP patients. SETTING: Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan. PATIENTS: 137 UCLP patients who met the following criteria: (1) have had at least one panoramic film taken, (2) the first panoramic film illustrates either primary or early mixed dentition. Evaluation of both permanent and primary dentition was available in 91 cases. MAIN OUTCOME MEASURES: Two evaluators performed independent evaluations of number and distribution of teeth in UCLP patients. The hypothesis that there are two odontogenic origins for maxillary lateral incisors was proposed to explain the occurrence of distribution patterns of dentition in the cleft area and to explain differences between primary and permanent dentition in UCLP patients. RESULTS: Four distribution patterns in the cleft area were identified in both the primary and the permanent dentition. In the primary dentition, placement of the lateral incisor distal to the alveolar cleft was the predominant pattern (pattern y, 82.4%), followed by absence of the cleft side maxillary lateral incisor (pattern ab, 9.9%), presence of one tooth on each side of the alveolar cleft (pattern xy, 5.5%), and placement of the lateral incisor mesial to the alveolar cleft (pattern x, 2.2%). In the permanent dentition, the most common pattern was the absence of the maxillary lateral incisor on the cleft side (pattern AB, 51.8%), followed by lateral incisor placement distal to the alveolar cleft (pattern Y, 46%), lateral incisor placement mesial to the alveolar cleft (pattern X, 1.5%) and the presence of one tooth on each side of the alveolar cleft (pattern XY, 0.7%). The discrepancy between the distribution patterns of primary dentition and permanent dentition successors is 57.1%. Variations in tooth number in both primary and permanent dentition of UCLP patients occurred most often in the cleft area. Abnormalities in the number of teeth (hypodontia or hyperdontia) outside the cleft area were more common in the permanent dentition than in the primary dentition (24.1% versus 4.4%). CONCLUSIONS: Four distribution patterns in the cleft area were identified in both sets of dentition. Our findings of distribution patterns in UCLP patients support the hypothesis that there may be two odontogenic origins for maxillary lateral incisors. Clinicians involved in managing the dentition of UCLP patients should consider the high frequency of numerical variation both in and outside the cleft area before starting dental treatment.

Vertical root fracture in nonendodontically treated teeth--a clinical report of 64 cases in Chinese patients.

Vertical root fractures (VRFs) in teeth without endodontic treatment are uncommon. A clinical study was done on 64 cases of VRFs in 61 Chinese patients to define better the clinical characteristics, diagnostic signs, and possible causes. Results showed that fractures occurred most often in first molars of patients between 40 and 69 yr of age, and the incidence was two times higher in males than in females. Flat roots with smaller mesiodistal diameters were more prone to fracture. The majority (79%) of patients had intact dentition with less than four teeth missing. Fractured teeth were frequently attrited with no restorations. VRFs may result from excessive or repetitive masticatory force due to damaging chewing habits exerted on flat roots of smaller mesiodistal diameter. Nonendodontic VRFs seem to occur more frequently than earlier believed and may represent an underdiagnosed clinical entity deserving of our attention.

The effect of coagulation protection with combination of epsilon aminocaproic acid and plasma saver in open-heart surgery.

BACKGROUND: Bleeding remains a major complication and a major determinant in the prognosis of open-heart surgery. Coagulopathy related to cardiopulmonary bypass (CPB) seems to be the culprit. Since homologous blood transfusion in many occasions is not only responsible for mobidity and mortality but also increases medical costs. Therefore, the application of autologous blood transfusion including components such as PRBC, FFP and platelets concentrate is inevitable and comes in its stead. To reduce the use of homologous plasma and platelets transfusion in open-heart surgery, we designed a study to utilize the combination of autologous platelet rich plasma (PRP) and epsilon aminocaproic acid (EACA) to evaluate its effects on blood loss and blood component transfusion in open-heart patients. METHODS: Sixty patients who received elective cardiac surgery were randomly divided into 3 groups: 1. Control group; 2. EACA group (150 mg/kg, i.v. before CPB); 3. PRP-EACA group (PRP 10 ml/kg harvested with a plasma saver followed by i.v. EACA 150 mg/kg). Anesthesia was uniform in all patients. Coagulation profile was evaluated by thromboelastography (TEG) during the operation. Blood loss during operation and the amount of drainage from the chest tubes in the postoperative period were recorded and compared between groups. RESULTS: Patients who were given EACA injection before CPB saw less blood loss perioperatively and received less transfusion of blood components. TEG analysis showed that patients who received EACA injection had a better coagulation profile and the platelet function was also better after CPB. However, no additive effect can be attained from combination of autologous PRP transfusion and EACA injection. CONCLUSIONS: With Pre-CPB EACA as protection, reduction of both blood loss and blood transfusion could be realized in open-heart surgery.

Superior vena cava stenosis after orthotopic heart transplantation: complication of an alternative surgical technique.

Superior vena cava stenosis presented as a postoperative complication of orthotopic heart transplantation in a patient in whom a new surgical technique was used. This alternative technique consists of total excision of the recipient's atria, with donor heart implantation performed using bicaval and pulmonary venous anastomoses. This rare complication required surgical repair 1 month after transplantation. The patient remains well on long-term follow-up. The pathogenesis, surgical management and modifications of the alternative technique to prevent this potentially serious complication are discussed.

The St. Jude Medical valve. Experience with 1,000 cases.

We analyzed the long-term results of valve replacement with the St. Jude Medical bileaflet valve (St. Jude Medical, Inc., St. Paul, Minn.) in our first 1000 implantations between 1978 and 1992. A total of 399 patients had mitral valve replacement, 471 aortic valve, and 130 double (mitral and aortic) valve replacement. The average patient age was 64 +/- 15 years and the majority of patients (52%) had concomitant coronary disease. With 4328 patient-years of follow-up, 83% of the mitral group, 76% of the aortic group, and 77% of the double valve group were free of thromboembolism at 10 years after operation, and 87% of the mitral group, 82% of the aortic group, and 85% of the double valve group were free of valve-related hemorrhage. At 10 years, 91% of the mitral group, 84% of the aortic group, and 84% of the double valve group were free of valve-related death. However, overall survival at 10 years was only 42% +/- 4% for the mitral group, 43% +/- 4% for the aortic group, and 43% +/- 6% for the double valve group. For all three groups, age was a highly significant factor stratifying survival (p < 0.001), as was the presence of coronary disease (all p < 0.001). The excellent freedom from valve-related death at 10 years of 84% to 91% is in striking contrast to the overall survivals of 42% to 43% at 10 years. This difference suggests that the primary factors limiting long-term survival after valve replacement with the St. Jude Medical valve are not valve-related factors, but other patient factors such as age and concomitant coronary disease.

Ten-year experience of cardiac surgery in patients aged 80 years and over.

Five hundred twenty-eight consecutive patients aged 80 years and over (mean age, 83.1 +/- 2.7 years) underwent cardiac operations with hypothermia (mean, 21.9 degrees +/- 2.2 degrees C), hyperkalemic cardioplegia, and cardiopulmonary bypass in a 10-year period. Fifty-six percent of the patients were male. Preoperatively, 68% of the patients were in New York Heart Association functional class IV, and 31% were in class III. Among them, 303 patients had isolated coronary artery bypass grafting (CABG) (group I), 132 had aortic valve replacement only or combined with CABG (group II), 42 had mitral valve replacement only or combined with CABG (group III), 31 had mitral valve repair and CABG (group IV), and 20 had double-valve procedure only or combined with CABG (group V). The 30-day or in-hospital mortality was 8.3% in group I, 4.5% in group II, 29% in group III, 23% in group IV, and 30% in group V. Total 30-day or in-hospital mortality was 10.6%. One-year and 5-year actuarial survival rates were as follows: group I, 82% and 62%; group II, 85% and 58%; group III, 61% and 37%; group IV, 56% and 19%; and group V, 63% and 15%. Total 1-year and 5-year actuarial survival were 79% and 54%. At follow-up (mean, 2 years), 70% of overall survivors reported that their general health had improved. Our experience demonstrates that for select patients aged 80 years and over with unmanageable cardiac symptoms, CABG and aortic valve replacement groups had better results in improving quality of life as compared with patients having mitral or combined procedures.

Glutaraldehyde preparations and pulpotomy in primary molars.

The study clinically and radiographically evaluated the long-term success rate of pulpotomy treatment in pulp-exposed primary molars. Five clinicians participated in this study and four glutaraldehyde preparations included 2% buffered, 2% unbuffered, 5% buffered, and 5% unbuffered glutaraldehyde solutions were used. There were 201 children, 108 boys and 93 girls, ranging in age from 4 to 7 years with 258 primary molars treated. After 36 months, 150 teeth with complete clinical records and radiographs were available for evaluation. The treatment of 98% of the patients was clinically successful, but when evaluated radiographically the overall success rate was 78.7%. The group treated with 5% buffered glutaraldehyde showed the highest success rate (87.5%) and group treated with the 5% unbuffered solution the lowest (74.1%), but no significant difference was found among the four groups. Canal obliteration was noted in 22 teeth successfully treated. Four of the teeth that were not successfully treated had canal obliteration before other pathoses became evident. The relative high failure rate in this long-term follow-up indicated that clinicians should be cautious before extensively using glutaraldehyde as a pulpotomy agent.