Dental student application of artificial intelligence technology in detecting proximal caries lesions

OBJECTIVES

This study aimed to investigate the caries diagnosis performances of dental students after training with an artificial intelligence (AI) application utilizing deep learning techniques, a type of artificial neural network.

METHODS

A total of 1200 bitewing radiographs were obtained from the institution's database and two specialist dentists labeled the caries lesions in the images. Randomly selected 1000 images were used for training purposes and the remaining 200 radiographs were used to evaluate the caries diagnostic performance of the AI. Then, a convolutional neural network, a deep learning algorithm commonly employed to analyze visual imagery problems, called "You Only Look Once," was modified and trained to detect enamel and dentin caries lesions in the radiographs. Forty dental students were selected voluntarily and randomly divided into two groups. The pre-test results of dental caries diagnosis performances of both groups were recorded. After 1 week, group 2 students were trained using an AI application. Then, the post-test results of both groups were recorded. The labeling duration of the students was also measured and analyzed.

RESULTS

When both groups' pre-test and post-test results were evaluated, a statistically significant improvement was found for all parameters examined except precision score (p < 0.05). However, the trained group's accuracy, sensitivity, specificity, and F1 scores were significantly higher than the non-trained group in terms of post-test scores (p < 0.05). In group 2 (trained group), the post-test labeling time was considerably increased (p < 0.05).

CONCLUSIONS

The students trained by AI showed promising results in detecting caries lesions. The use of AI can also contribute to the clinical education of dental students.

A novel deep learning-based perspective for tooth numbering and caries detection

OBJECTIVES

The aim of this study was automatically detecting and numbering teeth in digital bitewing radiographs obtained from patients, and evaluating the diagnostic efficiency of decayed teeth in real time, using deep learning algorithms.

METHODS

The dataset consisted of 1170 anonymized digital bitewing radiographs randomly obtained from faculty archives. After image evaluation and labeling process, the dataset was split into training and test datasets. This study proposed an end-to-end pipeline architecture consisting of three stages for matching tooth numbers and caries lesions to enhance treatment outcomes and prevent potential issues. Initially, a pre-trained convolutional neural network (CNN) utilized to determine the side of the bitewing images. Then, an improved CNN model YOLOv7 was proposed for tooth numbering and caries detection. In the final stage, our developed algorithm assessed which teeth have caries by comparing the numbered teeth with the detected caries, using the intersection over union value for the matching process.

RESULTS

According to test results, the recall, precision, and F1-score values were 0.994, 0.987 and 0.99 for teeth detection, 0.974, 0.985 and 0.979 for teeth numbering, and 0.833, 0.866 and 0.822 for caries detection, respectively. For teeth numbering and caries detection matching performance; the accuracy, recall, specificity, precision and F1-Score values were 0.934, 0.834, 0.961, 0.851 and 0.842, respectively.

CONCLUSIONS

The proposed model exhibited good achievement, highlighting the potential use of CNNs for tooth detection, numbering, and caries detection, concurrently.

CLINICAL SIGNIFICANCE

CNNs can provide valuable support to clinicians by automating the detection and numbering of teeth, as well as the detection of caries on bitewing radiographs. By enhancing overall performance, these algorithms have the capacity to efficiently save time and play a significant role in the assessment process.

Effect of perception of sustainability in local food experiences on healthy eating tendency: mediator and moderator effects

Tourists who favor local food typically care about healthy food choices. Their view of locally produced food as healthy is related to perceptions of sustainability. This relationship can be explained by tourists' personality traits and tendency to eat local food. This study aimed to establish the effect of tourists' perceptions of sustainability in the context of local food experiences on healthy eating tendencies. In addition, we aimed to determine the role of tourists' personality traits and local eating tendencies and elucidate the moderating role of searching online for information on food choices. An online questionnaire (via e-mail and WhatsApp) was used to obtain data from 379 research participants, recruited using a non-probabilistic sampling technique. A research model and hypotheses were formed based on Hayes PROCESS Macro models 90 and 6, and moderator and mediator effects were analyzed using these models. Healthy eating was well-explained by the model, and the perception of social and environmental sustainability in local food experiences (LFE-SES) positively affected food-related personality traits (FRPT), local food eating tendencies (LFET), and healthy eating (HE). While food-related personality traits did not mediate the relationship between the perception of sustainability and healthy eating, local food eating tended to mediate this relationship. In addition, when food-related personality traits and local food eating tendencies were evaluated together, they had a mediating role between the perception of sustainability and healthy eating. Searching online for information had an insignificant moderating effect. These findings help promote an understanding of healthy eating tendencies. Within the context of local food, they suggest critical theoretical and practical implications for the relationship between the perception of sustainability, food-related personality traits, local food eating tendencies, and healthy eating.

The effect of perceived stress on organizational silence in emergency service doctors in Turkey: The mediating role of emotional intelligence

Objectives

The purpose of this study is to determine the role of emotional intelligence in the relationship between the stress perceptions of emergency medicine doctors and their organizational silence behaviors.

Methods

Data were collected digitally from 434 doctors working in emergency departments in Turkey. On the assumption that perceived stress was effective on organizational silence behavior and that emotional intelligence mediates this relationship, hypotheses were developed and a mediating effect model was established. The research model and hypotheses were shaped through Structural Equation Modeling (SEM). Hayes 4th model was used to test the research hypotheses. The research model was tested via SPSS Process v4.1 by Andrew F. Hayes.

Results

According to the correlation analysis to determine the relationship between the variables, it was determined that perceived stress was positively correlated with organizational silence behavior, emotional intelligence was negatively correlated with perceived stress, and emotional intelligence was negatively correlated with organizational silence. As a result of the mediating effect model test, it was determined that emotional intelligence had a statistically significant mediating effect in the effect of perceived stress on organizational silence.

Conclusion

Within the framework of the findings, it is thought that emotional intelligence is a key variable in turning the negative energy between stress and silence into positive.

The effect of SARS-CoV-2 effective mouthwashes on the staining, translucency and surface roughness of a nanofill resin composite

PURPOSE

To evaluate the effect of SARS CoV-2 effective mouthwashes on the color change (ΔE), translucency parameter (TP) and average surface roughness (Ra) of a nanofill resin composite (Filtek Ultimate).

METHODS

91 composite specimens (10 mm in diameter, 1 mm thickness) were prepared using a stainless-steel mold and randomly divided to seven groups as follows: Group 1 (CHX) : 0.12% CHX digluconate + 0.15% benzydamine hydrochloride (96% alcohol), Group 2 (HAc): hypochlorous acid (500 ppm), Group 3 (PVP-I) : 1% povidone iodine, Group 4 (H2O2) : 1.5% hydrogen peroxide, Group 5 (CHX + C) : 0.09% chlorhexidine digluconate + cyclodextrin + citrox, Group 6 (CPC) : 0.075% cetylpyridinium hydrochloride, Group 7 (Control) : artificial saliva. The initial color values were determined by a spectrophotometer on both white and black backgrounds. The specimens were immersed in 20 mL mouthwash for 1 minute with a 12-hour interval. The Ra, ΔE and TP were determined after 1, 2 and 3 weeks. Data were analyzed using repeated measures ANOVA, one-way ANOVA, post-hoc Bonferroni and Tukey tests (P< 0.05).

RESULTS

The highest and the lowest ΔE3 (after 3 weeks) value were observed in H2O2 (1.57± 0.29) and CHX (0.92± 0.17) groups, respectively. The CHX and CPC groups demonstrated significantly lower ΔE3 values than the control group (P< 0.05). CHX, HAc and PVP-I significantly affected the TP (P< 0.05). None of the groups demonstrated any significant changes of Ra scores (P> 0.05).

CLINICAL SIGNIFICANCE

Within the limitations of this study some of the mouthwashes affected the ΔE and TP of the Filtek Ultimate nanofill resin composite. The Ra was not affected by any of the mouthwashes.

Repair bond strength and surface topography of resin-ceramic and ceramic restorative blocks treated by laser and conventional surface treatments

This study intended to compare the repair bond strength of computer-aided design/computer-aided manufacturing (CAD/CAM) blocks consisting of resin and feldspathic ceramics following different surface treatments using the microtensile bond strength (μTBS) test. Ten specimens were prepared with 4 mm height for Vita Enamic (VE), Lava Ultimate (LU), Vita Mark II (VM), and thermocycled (10,000 cycle, 5-55°C). Each material was categorized into one of five subgroups according to following surface treatments: (a) bur grinding (BG), (b) hydrofluoric acid etching (HF), (c) neodymium-doped yttrium aluminum garnet (Nd:YAG or NY), (d) erbium-doped yttrium aluminum garnet (Er:YAG or EY), and (e) erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG or ECY) laser conditioning. After surface treatment procedures, specimens were properly restored to 4 mm high with a micro-hybrid composite resin. Bar specimens (1 × 1 × 8 mm) were obtained using a low-speed cutting machine and then thermocycled (10,000 cycle, 5-55°C). The μTBS was tested at 1 mm/min crosshead speed, and failure modes were evaluated. Data were analyzed with two-way ANOVA and post hoc Tukey tests. LU-BG showed significantly higher μTBS (32.94 ± 5.80 MPa) compared to LU-laser groups (p < .05). VE-BG showed significantly higher μTBS (22.06 ± 4.26 MPa) compared to other VE groups (p < .05). Among the laser groups, the NY laser produced the lowest (p < .05) μTBS for LU (13.42 ± 3.44 MPa) and VE (2.27 ± 0.85 MPa), while EY showed the highest (p < .05). Laser-treated VM groups were all prefailured. VM-HF produced a higher μTBS (18.73 ± 3.75 MPa) than VM-BG (5.05 ± 1.76 MPa) (p < .05).

Effect of Saliva Contamination on Microleakage of Open Sandwich Restorations

Objectives

The purpose of the present study was to evaluate the microleakage of conventional glass-ionomer, resin modified glass-ionomer and glass hybrid ionomer Class II open sandwich restorations with or without saliva contamination.

Materials and methods

Sixty extracted sound human molar teeth were used and 120 class II slot cavities were prepared in mesial and distal surfaces. The gingival margins were located 1 mm below the cementoenamel junction. All specimens were randomly divided in 4 groups (n=15): Group I: High-Viscous Glass Ionomer (Fuji IX GP) Group II: Resin Modified Glass Ionomer (Fuji II LC) Group III: Glass Hybrid Ionomer (Equia-fil Forte), Group IV: Composite Resin (G'aenial Posterior). In open sandwich restoration groups, glass ionomer materials were placed to gingival floor in 1 mm thickness and rest of the cavity was filled with resin composite. After the restorations in mesial surfaces had been performed, distal cavities were restored with the same protocol after saliva contamination. The specimens were thermo-cycled for 10000 cycles at 5⁰C to 55⁰C and immersed in methylene blue dye solution (% 0,5) for 24 hours. Then, they were sectioned vertically through the center of the restorations from mesial to distal surface with a water-cooled diamond saw with 1mm thickness. Subsequently, the dye penetration was evaluated with image analysis software. Data were statistically analyzed (p<0.05).

Results

There was a statistically significant difference between gingival microleakage scores in no contamination groups, between high-viscous glass ionomer, Fuji IX GP and other materials tested (p<0.05). In saliva contaminated groups, there was no statistically significant difference between gingival microleakage scores (p>0.05). Additionally, there was not a statistically significant difference between the no contamination and saliva contaminated groups regardless of dental materials tested (p>0.05).

Conclusion

Within the limitations of this study, in open sandwich restorations, saliva contamination did not show an adverse effect on microleakage irrespective of dental materials tested. Glass hybrid ionomers and resin modified glass ionomers showed lower microleakage scores in gingival margins compared to high-viscous glass ionomer material in no contamination groups.

Evaluation of the repair capacities and color stabilities of a resin nanoceramic and hybrid CAD/CAM blocks

PURPOSE

This study evaluated the color stabilities of two computer-aided design and computer-aided manufacturing (CAD/CAM) blocks and a nanofill composite resin and the microtensile bond strength (µTBS) between the materials.

MATERIALS AND METHODS

Twelve specimens of 4 mm height were prepared for both Lava Ultimate (L) and Vita Enamic (E) CAD/CAM blocks. Half of the specimens were thermocycled (10,000 cycle, 5° to 55℃) for each material. Both thermocycled and non-thermocycled specimens were surface treated with one of the three different methods (Er,Cr:YSGG laser, bur, or control). For each surface treatment group, one of the thermocycled and one of non-thermocycled specimens were restored using silane (Ceramic Primer II), universal adhesive (Single Bond Universal), and nanofill composite resin of 4-mm height (Filtek Ultimate). The other specimens were restored with the same procedure without using silane. For each group, 1 × 1 × 8 mm bar specimens were prepared using a microcutting device. Bar specimens were thermocycled (10,000 cycle, 5° to 55℃) and microtensile tests were performed. Staining of the materials in coffee solution was also compared using a spectrophotometer. Data were analyzed using one-way ANOVA, t-test and post-hoc Scheffe tests.

RESULTS

µTBS were found similar between the thermocycled and non-thermocycled groups (P>.05). The highest µTBS (20.818 MPa) was found in the non-thermocycled, bur-ground, silane-applied E group. Silane increased µTBS at some E groups (P<.05). Composite resin specimens showed more staining than CAD/CAM blocks (P<.05).

CONCLUSION

CAD/CAM blocks can be repaired with composite resins after proper surface treatments. Using silane is recommended in repair process. Color differences may be shown between CAD/CAM blocks and the nanofill composite after a certain time period.

Evaluation of Microleakage and Degree of Conversion of Three Composite Res-ins Polymerized at Different Power Densities

Objectives: This study aims to evaluate the degree of conversion (DC) and microlekage scores of three different composite resins polymerized with a LED curing device in standard and extra-power mode. Material and Methods: One bulk-fill (Tetric EvoCeram Bulk-Fill – TECBF) and two conventional composite materials (Clearfil Majesty Posterior – CMP and Tetric EvoCeram – TEC) were evaluated. A total of 30 specimens were prepared for six groups (N = 5). These groups were polymerized with a LED curing device as follows: TECBF-6: 3200mW/cm2 for six seconds, TECBF-20: 1000mW/cm2 for 20 seconds, CMP-6: 3200mW/cm2 for six seconds, CMP-20: 1000mW/cm2 for 20 seconds, TEC-6: 3200mW/cm2 for six seconds, TEC - 20: 1000 mW/cm2 for 20 seconds. After 24 hours of water storage, DC was measured by Raman spectroscopy. Microleakage scores of the six groups were bonded to various adhesive systems (Clearfil SE Bond or Adhese Bond Universal) were also evaluated at Class II box cavities (N = 10). Results: While the highest DC was found at the top (TECBF-20= 79.92% and TECBF-6= 79.02%) and bottom surfaces (TECBF-20 = 68.94% and TECBF-6= 71.04%) for TECBF groups, TEC groups (TEC-20top = 59.06%, TEC-6top=49.66%, TEC-20bottom = 43.72% and TEC-6bottom= 40.68%) showed the lowest DC for the both surfaces (p < 0.05). Polymerization of materials in standard or extra-power mode was similar to DC (p > 0.05). Microleakage scores were found to be similar (p > 0.05). Conclusion: According to the results of the study, different power densities of LED curing light did not affect the DC of composite resins and microleakage values of restorations at small Class II cavities.KEYWORDSBulk-fill composite; degree of conversion; LED curing device; microleakage; Raman spectroscopy.

Outcomes of partial splenic embolization in patients with massive splenomegaly due to idiopathic portal hypertension

AIM

To determine the outcomes of partial splenic embolization (PSE) for massive splenomegaly due to idiopathic portal hypertension (IPH).

METHODS

In this prospective study, we evaluated the characteristics and prognosis of consecutive patients with IPH who underwent PSE for all indications at a single medical center between June 2009 and January 2015. The inclusion criteria were: presence of hypersplenism, massive splenomegaly, and resultant pancytopenia. The exclusion criteria were: presence of other diseases causing portal hypertension. During the post-PSE period, the patients were hospitalized. All patients underwent abdominal computed tomography imaging 4 wk post-PSE to determine total splenic and non-infarcted splenic volumes.

RESULTS

A total of 11 patients, with median age of 33.27 ± 4.8 years, were included in the study. Mean spleen size was 22.9 cm (21-28 cm), and severe hypersplenism was diagnosed in all patients before PSE. Post-PSE, leukocyte and platelet counts increased significantly, reaching peak levels in the second week with gradual decreases thereafter. Liver function tests did not exhibit significant changes during post-intervention follow-up. All patients developed post-embolization syndrome, and one patient experienced serious complications; all complications were successfully treated with conservative therapy and no death occurred.

CONCLUSION

Our findings showed that PSE has a lower complication rate than previously-reported surgical complication rates, which supports this intervention as a viable alternative for high-risk operable patients with severe hypersplenism.

Angiographic Findings of Great Vessel Involvement in Behçet's Disease

Behçet's disease (BD) is a systemic disorder and vasculitis is a common pathologic finding that may give clues in the understanding of the vascular involvement. During the period between 1968 and 1988, 30 patients with BD had vascular complications that were diagnosed by conventional venography (indud ing cavography) (in 15 patients prior to 1985) and then by computed tomography, digital subtraction angiography (DSA), and sonography in the remaining 15 patients for the last four years . The group included 13 patients with superior vena caval obstruction (SVCO), 3 with inferior vena caval obstruction (IVCO), 4 with both SVCO and IVCO, 2 with IVCO and hepatic veins obstruction (Budd-Chiari syndrome, BCS), 1 patient with SVCO, IVCO, and BCS, 1 with BCS, 1 with portal vein and IVCO, 4 patients pulmonary artery occlusion (1 of them also had pulmonary artery aneurysm), and finally, 1 patient with right illiac artery aneurysm. In many cases, classical clinical features of BD were not evident when great vessels were involved.

The authors concluded that DSA and sonography are the preferred method in demonstrating vascular complications of BD and that BD should be taken into consideration when a patient presents with a great vessel involvement due to unknown cause.

One-year clinical evaluation of different types of bulk-fill composites

AIM

In the present study, we evaluated the 1-year clinical performance of a conventional posterior composite resin and three bulk-fill composite resins.

METHODS

Fifty patients with four class II restorations under occlusion were enrolled in the present study. A total of 200 restorations were placed in the cavity, 50 for each material (Clearfil Photo Posterior, Filtek Bulk-Fill Flowable and Filtek P60, Tetric EvoCeram Bulk-Fill, and SonicFill). One operator placed the restorations in the cavity, and 1 week later the patients were called for baseline examination. Two calibrated examiners evaluated the restorations once every 3 months for 1 year, according to United States Public Health Service criteria. The data were analyzed using SPSS. Non-parametric tests (Kruskal-Wallis, Mann-Whitney U-test, and Friedman) were used for the analysis at a confidence level of 95%.

RESULTS

The 1-year recall rate was 86%. All restorations showed minor modifications after 1 year. However, no statistically-significant differences were detected between the materials' performance at baseline and after 1 year for all criteria (P > 0.05).

CONCLUSIONS

The bulk-fill composite resin materials showed similar clinical performance when compared with a conventional posterior composite resin. Further evaluations are necessary for the long-term clinical performance of these materials.

Novel variant syndrome associated with congenital hepatic fibrosis

Congenital hepatic fibrosis is part of many different malformation syndromes, of which oculo-encephalo-hepato-renal syndrome is the most common. These syndromes largely overlap, and so accurate classification of individual patients may be difficult. We present herein three syndromic siblings who were products of a consanguineous marriage. We investigated in detail at least six organ systems in these patients, namely the liver, brain, eye, kidneys, skeleton, and gonads. The common features observed in these three cases were congenital hepatic fibrosis, retinitis pigmentosa, truncal obesity, rotatory nystagmus, mental retardation, advanced myopia, and high-arched palate. The clinical dysmorphology in these patients was distinct and lacked the major features of the known syndromes associated with congenital hepatic fibrosis. Although some features of these presented cases are similar to those found in Bardet-Biedl syndrome (BBS), the absence of some major criteria of BBS (polydactyly, renal abnormality, and hypogonadism) suggests that this may be a new syndrome. All three patients remain under follow-up in the departments of Gastroenterology, Ophthalmology, and Neurology at Hacettepe University.

Primary amyloidosis presenting intrahepatic cholestasis and fulminant hepatic failure

A 69-year-old man noticed abdominal pain located on right upper quadrant. Physical examination showed hepatosplenomegaly and icteric discoloration of sclera. On evaluation, patient was diagnosed to have hepatic amyloidosis related monoclonal gammopathy of undetermined significance (MGUS) and sinusoidal obstruction syndrome with intrahepatic cholestasis. In this case report we emphasize fulminant hepatic failure due to primer amyloidosis in diagnosed with MGUS patient.

Transarterial chemoembolization for treatment of hepatocellular carcinoma: A single center experience

BACKGROUND/AIMS

We aimed to determine the effect of transarterial chemoembolization treatment on survival in patients with hepatocellular carcinoma and to investigate the efficacy and tolerability of two different transarterial chemoembolization procedures, conventional transarterial chemoembolization and drug-eluting beads, in these patients.

MATERIALS AND METHODS

A total of 40 patients with hepatocellular carcinoma treated with transarterial chemoembolization between January 2007 and March 2011 were included. Thirty-seven patients had Child-Pugh class A and the remaining 3 had class B. Intra-arterial administration of doxorubicin with lipiodol-based conventional transarterial chemoembolization or drug-eluting beads-transarterial chemoembolization was performed. Eighty sessions were performed with a median of 2 sessions. Sixteen patients were treated with conventional transarterial chemoembolization and 11 with drug-eluting beads-based transarterial chemoembolization, and 13 were treated with both treatment procedures in separate sessions. Primary outcome was defined as patient survival after treatment.

RESULTS

The median follow-up was 19 months. The median overall survival of patients was 23.2 months. The survival of patients with Child-Pugh class A was significantly better than that of patients with class B (24 vs 6 months, p=0.004). No statistically significant difference in survival was observed between conventional transarterial chemoembolization and drug-eluting beads-based transarterial chemoembolization treatments (p>0.05). Baseline low serum albumin level (p=0.003) and the presence of portal vein thrombosis (p=0.011) negatively affected patient survival. Side effects of conventional transarterial chemoembolization and drug-eluting beads-based transarterial chemoembolization were similar.

CONCLUSIONS

Based on the results of this study and in comparison with the findings in the literature, transarterial chemoembolization treatment was seen to improve overall survival and provide better outcome in selected patients with hepatocellular carcinoma. No differences in survival or side effects were observed between the two transarterial chemoembolization treatment modalities.

Taurodontism in a central anatolian population

The aim of this retrospective study was to evaluate the frequency of the occurrence of taurodontism in a Turkish population with using panoromic radiographs. A retrospective study was performed using full-mouth periapical and panoramic radiographs of 6912 patients (3860 females and 3052 males) ranging in age from 15 to 50. A total of 97362 posterior (including third molars) were evaluated. A chi-square test was used to determine the difference in the prevalence of tauorodntism between genders. Eighteen patients were found to have a taurodont molar (10 women and 8 men [P = 0.98]). The overall incidence of patients with taurodont molars was 0.26 % and the prevalence of taurodont molars from all teeth examined was 0.024%, and the prevalence taurodonts were significantly more common in the mandibula compared with the maxilla (71.0% cf 29.0% respectively, P < 0.05). It was almost equally distributed between males and females. Taurodontism is not uncommon in Turkish population but further larger scale studies are required to assess its prevalence in the general population to compare it with other ethnic groups.

How confocal laser endomicroscopy can help us in diagnosing gastric lymphomas?

Primary gastric diffuse large cell lymphoma is one of the most common extranodal lymphomas of the gastrointestinal system. Diagnosing gastrointestinal lymphomas can be difficult, since there is no pathognomonic sign in endoscopy to distinguish it from other malignancies. In some cases biopsy can be non-diagnostic. Therefore, multiple endoscopic examinations and biopsies can be necessary. With using confocal endomicroscopy, histology of the tissue can be seen in vivo and a range of diseases can be identified by using this technique. We are presenting a case, which is diagnosed as primary gastric diffuse large cell lymphoma during the evaluation of erythema nodosum etiology. We want to emphasize the role of confocal laser endomicroscopy for in vivo diagnosis of gastric lymphoma and directing the endoscopist for sampling the diseased mucosa. Confocal endomicroscopy decreases non-diagnostic rates in endoscopic biopsy and can be performed successfully in cases of gastric lymphoma. Pit patterns of gastric lymphoma, ring cell gastric carcinoma and gastric adenocarcinoma are similar. To best of our knowledge, this case is the fifth case of confocal laser endomicroscopy aided in diagnosing gastric lymphomas (Tab. 1, Fig. 2, Ref. 13).

Successful management of severe acute liver disease related with adult-onset Still's disease in a pregnant patient

Adult-onset Still's disease is a rare systemic inflammatory disease, which is characterized by varying degrees of liver involvement. Herein we present a rare case of pregnancy onset adult onset Still's disease with severe acute liver disease which worsened after labor. The patient was successfully managed with medical treatment preventing acute liver failure, and is currently in remission from adult onset Still's disease with liver tests that have returned to normal.

Prevalence of root dilacerations in Central Anatolian Turkish dental patients

OBJECTIVE

The aim of this study was to determine, retrospectively, the prevalence and distribution of the dilaceration of the root for each tooth-type in a sample of Central Anatolian Turkish population by using panoramic radiographs.

METHOD

Panoramic radiograhs of 6912 patients (3860 women and 3052 men, mean age 29.04 years, range, 15 to 50 years) were examined for the presence of root dilacerations. Chi-square test was also used to compare the prevalence of dilacerations between male and female subjects and upper and lower jaws.

RESULTS

Data showed that 1108 (16.0%) of these subjects had one or more teeth that were dilacerated and these were detected in 466 (15.2%) males and 642 (16.6%) females. Statistical analysis (chi2 test) showed a significant difference in the prevalence of dilaceration among male and female patients. Mandibular third molars were dilacerated most often (3.76%), followed by mandibular second molars (1.81%). Dilaceration was found in 1.23% of maxillary second premolars and 1.23% of mandibular second molars.

CONCLUSION

Root dilacerations are not uncommon among Turkish dental patients, and their early detection could be important in treatment problems associated with it. However further larger scale studies are required to assess its prevalence in the general population in order to compare it with other ethnic groups.

Abdominal tuberculosis leading to portal vein thrombosis, mimicking peritoneal carcinomatosis and liver cirrhosis

Abdominal tuberculosis is a rare infectious disease that can involve the peritoneum and lead to portal vein thrombosis and mimic peritoneal carcinomatosis. We report on a 43-year-old male patient with fatigue and progressive weight loss for two years. Ascites was the only pathologic finding in his physical examination and laboratory findings revealed only a mild anaemia with Ca-125 elevation. The ascitic fluid Adenosine deaminase (ADA) level was also elevated. Computed tomography revealed splenomegaly, a mesenteric mass measuring 3.5 cm and intra-abdominal lymphadenopathies at the hepatic hilum. Oesophagogastroduodenoscopy (EGD) revealed oesophageal varices which was also consistent with portal hypertension. Diagnostic laparotomy and biopsies obtained from the omentum and the lymph nodes revealed acid-fast staining tuberculosis bacilli.

How can portal vein cavernous transformation cause chronic incomplete biliary obstruction?

Biliary disease in the setting of non-cirrhotic portal vein thrombosis (and similarly in portal vein cavernous transformation) can become a serious problem during the evolution of disease. This is mostly due to portal biliary ductopathy. There are several mechanisms that play a role in the development of portal biliary ductopathy, such as induction of fibrosis in the biliary tract (due to direct action of dilated peribiliary collaterals and/or recurrent cholangitis), loss of biliary motility, chronic cholestasis (due to fibrosis or choledocholithiasis) and increased formation of cholelithiasis (due to various factors). The management of cholelithiasis in cases with portal vein cavernous transformation merits special attention. Because of a heterogeneous clinical presentation and concomitant pathophysiological changes that take place in biliary anatomy, diagnosis and therapy can become very complicated. Due to increased incidence and complications of cholelithiasis, standard treatment modalities like sphincterotomy or balloon sweeping of bile ducts can cause serious problems. Cholangitis, biliary strictures and hemobilia are the most common complications that occur during management of these patients. In this review, we specifically discuss important issues about bile stones related to bile duct obstruction in non-cirrhotic portal vein thrombosis and present evidence in the current literature.

Assessment of the prevalence of pulp stones in a sample of Turkish Central Anatolian population

Objective. The aim of this study was to determine the prevalence of pulp stones (PS) in a Turkish dental patient population with respect to sexes and dental localization in relation between sex and this anomaly. Materials Methods. A retrospective study was performed using bitewing radiographs of 814 patients ranging in age from 15 to 65. All data (age, sex, and location) was obtained from the files. These patients were analyzed for pulp stones. Descriptive characteristics of sexes, jaws, and dental localization were recorded. The Pearson chi-squared test was used. Results. Of the patients, 462 (56.8%) were female and 352 (43.2%) were male. Sixty (12%) had one or more teeth that contained pulp stones. Pulp stones were identified in 518 (63.6%) of the subjects and in 2391 (27.8%) of the teeth examined. Pulp stone occurrence was significantly more common in the females than in males. With the increasing of age, the prevalence of pulp stones increased. Molars had statistically more pulp stones than premolars. Pulp stones were significantly more common in the maxilla compared with mandible. Conclusion. Prevalence of pulp stones in Turkish population was 27.8% but further larger-scale studies are required to assess its prevalence in the general population to compare it with other ethnic groups.

Liver biopsy is a superior diagnostic method in some patients showing the typical laboratory features of autoimmune hepatitis

AIMS

To investigate whether liver diseases other than autoimmune hepatitis (AIH) can present with the typical features of AIH, and to determine the impact of liver biopsy for differentiating AIH from these conditions.

PATIENTS AND METHODS

The study used data collected at Hacettepe university hospital and numune education and research hospital from 2007 to 2011. The clinical, laboratory and histological findings of patients diagnosed with non-alcoholic steatohepatitis, drug-induced liver injury, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis and Wilson's disease were evaluated to identify those who presented with the typical features of AIH, but had no liver histology compatible with or suggestive of AIH.

RESULTS

A total of 386 patients were evaluated, and four patients with typical features of AIH were identified. Three patients were positive for antinuclear antibodies, and one was positive for smooth muscle antibodies. Also, all four had increased levels of immunoglobulin G, and aminotransferase levels that were five times above the upper limit. According to simplified AIH criteria, all patients had a score of 6, indicating probable AIH. On liver biopsy, two patients were diagnosed with non-alcoholic steatohepatitis, another with drug-induced liver injury and a further one with primary biliary cirrhosis.

CONCLUSION

Liver diseases other than AIH can present with the typical laboratory features of AIH and, without liver biopsy, it is difficult to distinguish AIH than these conditions. Although histological findings have little impact on patients' management and outcomes, for a definitive diagnosis of AIH, liver biopsy is essential and should be performed in all patients in whom it is suitable and not contraindicated.

Portal ductopathy: Clinical importance and nomenclature

Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term “portal ductopathy” has been put forth to replace “portal biliopathy”.

Is there an alternative to TIPS? Ultrasound-guided direct intrahepatic portosystemic shunt placement in Budd-Chiari syndrome

Budd-Chiari syndrome is a spectrum of manifestations which develops as a result of hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive vascular and interventional radiological procedure indicated in the management of refractory ascites in such patients. Conventional TIPS requires the presence of a patent hepatic vein and reasonable accessibility to the portal vein, and in patients with totally occluded hepatic veins, this procedure is technically challenging. Direct intrahepatic portosystemic shunt (DIPS) or so called "percutaneous TIPS" involves ultrasound-guided percutaneous simultaneous puncture of the portal vein and inferior vena cava followed by introduction of a guidewire through the portal vein into the inferior vena cava, as a deviation from conventional TIPS. Described here is our experience with DIPS. Three patients with BCS who had refractory ascites but were unsuitable for conventional TIPS due to occlusion of the hepatic veins were chosen to undergo the DIPS procedure. Our technical success was 100%. The shunts placed in two patients remain patent to date, while the shunt in a third patient with underlying antiphospholipid syndrome was occluded a month after the procedure. The percutaneous TIPS procedure seems to be technically feasible and effective in the management of refractory ascites as a result of BCS, particularly in the setting of occluded hepatic veins.

Unilobar tapering cirrhosis in a patient with Caroli syndrome associated with an abnormal common bile duct

Caroli syndrome is a rare condition and is composed of congenital cystic dilatation of the biliary system and congenital hepatic fibrosis. Although many associated conditions are defined and hypothesized to occur concomitantly, due to the rarity of this syndrome, none has proven to be an essential component of this syndrome. In order to investigate a patient presenting with a cholestatic clinical picture, ultrasound, endoscopic retrograde cholangiopancreatography, abdominal computed tomography, liver biopsy, splenoportal venous angiography, and all available liver tests were performed. Upon typical findings, a diagnosis of Caroli syndrome was made and an orthotopic liver transplantation was performed. Investigation of the patient demonstrated multiple intracystic stones mimicking hemangiomatosis in the ultrasound; severe irregularity and narrowing in the main bile duct mimicking sclerosing cholangitis in the endoscopic retrograde cholangiopancreatography; partial portal vein thrombosis with irregularity in the portography; and a unilobar cirrhosis of the left liver lobe while the right lobe demonstrated only congenital hepatic fibrosis in the explanted liver. Caroli syndrome may be associated with main bile duct and portal vein abnormalities. Although the syndrome can be monolobar in nature, a cirrhotic left lobe sparing the right lobe, partially affected by the cirrhotic process, has never been defined. Here, we report a case of Caroli syndrome who had liver transplantation, with very rare and interesting findings of the explanted liver, such as tapering cirrhosis from the left lobe to the right lobe and countless stones in biliary cysts mimicking hemangiomas.

Experience of a single center with congenital hepatic fibrosis: A review of the literature

Congenital hepatic fibrosis (CHF) is an autosomal recessive inherited malformation defined pathologically by a variable degree of periportal fibrosis and irregularly shaped proliferating bile ducts. It is one of the fibropolycystic diseases, which also include Caroli disease, autosomal dominant polycystic kidney disease, and autosomal recessive polycystic kidney disease. Clinically it is characterized by hepatic fibrosis, portal hypertension, and renal cystic disease. CHF is known to occur in association with a range of both inherited and non-inherited disorders, with multiorgan involvement, as a result of ductal plate malformation. Because of the similarities in the clinical picture, it is necessary to differentiate CHF from idiopathic portal hypertension and early liver cirrhosis, for which a liver biopsy is essential. Radiological tests are important for recognizing involvement of other organ systems. With regards to our experience at Hacettepe University, a total of 26 patients have been diagnosed and followed-up between 1974 and 2009 with a diagnosis of CHF. Presentation with Caroli syndrome was the most common diagnosis, with all such patients presenting with symptoms of recurrent cholangitis and symptoms related to portal hypertension. Although portal fibrosis is known to contribute to the ensuing portal hypertension, it is our belief that portal vein cavernous transformation also plays an important role in its pathogenesis. In all patients with CHF portal vein morphology should be evaluated by all means since portal vein involvement results in more severe and complicated portal hypertension. Other associations include the Joubert and Bardet-Biedl syndromes.

How useful is rectal endosonography in the staging of rectal cancer?

It is essential in treating rectal cancer to have adequate preoperative imaging, as accurate staging can influence the management strategy, type of resection, and candidacy for neoadjuvant therapy. In the last twenty years, endorectal ultrasound (ERUS) has become the primary method for locoregional staging of rectal cancer. ERUS is the most accurate modality for assessing local depth of invasion of rectal carcinoma into the rectal wall layers (T stage). Lower accuracy for T2 tumors is commonly reported, which could lead to sonographic overstaging of T3 tumors following preoperative therapy. Unfortunately, ERUS is not as good for predicting nodal metastases as it is for tumor depth, which could be related to the unclear definition of nodal metastases. The use of multiple criteria might improve accuracy. Failure to evaluate nodal status could lead to inadequate surgical resection. ERUS can accurately distinguish early cancers from advanced ones, with a high detection rate of residual carcinoma in the rectal wall. ERUS is also useful for detection of local recurrence at the anastomosis site, which might require fine-needle aspiration of the tissue. Overstaging is more frequent than understaging, mostly due to inflammatory changes. Limitations of ERUS are operator and experience dependency, limited tolerance of patients, and limited range of depth of the transducer. The ERUS technique requires a learning curve for orientation and identification of images and planes. With sufficient time and effort, quality and accuracy of the ERUS procedure could be improved.

What are the clinical implications of nodular gastritis? Clues from histopathology

There is no widely accepted histopathological definition for nodular gastritis. In this study we aim to uncover the pathologic entity responsible for the nodular appearance and to find clues about the clinical implications of nodular gastritis. Antral biopsy specimens of 160 patients with nodular gastritis and 133 patients without nodular gastritis were examined by an experienced pathologist for dysplasia, foveolar hyperplasia, inflammatory activity, intraepithelial lymphocytosis, intestinal metaplasia, and lymphoid follicle/aggregate formation, and comparative analysis was performed between the two groups of patients. The presence of intraepithelial lymphocytosis was more frequent in patients with nodular gastritis (P < 0.05). There was no difference between the two groups regarding the other pathological features such as presence of dysplasia, inflammatory activity, intestinal metaplasia, lymphoid hyperplasia, and Helicobacter pylori (H. pylori) infection. Increase of intraepithelial lymphocytes may contribute to formation of macroscopical nodules in this peculiar type of gastritis. Nodular gastritis would not indicate a new therapeutic approach in addition to the current measures for Helicobacter pylori infection.

Non-classical phenotypes of autoimmune hepatitis and advances in diagnosis and treatment

Non-classical manifestations of autoimmune hepatitis can delay diagnosis and treatment. Our aims were to describe the clinical phenotypes that can confound the diagnosis, detail scoring systems that can ensure their recognition, and outline advances in treatment that can improve their outcome. Prime source and review articles in English were selected through Medline from 1970-2008 and assimilated into personal libraries spanning 32 years. Acute severe or asymptomatic presentations and atypical histological findings, including centrilobular zone 3 necrosis and concurrent bile duct changes, are compatible with the diagnosis. Cholangiographic abnormalities may be present in children and adults with the disease, and autoimmune hepatitis must be considered in patients without autoantibodies or with antimitochondrial antibodies and no other cholestatic features. Asymptomatic patients frequently become symptomatic; mild disease can progress; and there are no confident indices that justify withholding treatment. Two diagnostic scoring systems with complementary virtues have been developed to evaluate patients with confusing features. Normal liver tests and tissue constitute the optimal end point of treatment, and the first relapse is an indication for long-term azathioprine therapy. Cyclosporine, tacrolimus and mycophenolate mofetil are promising salvage therapies, and budesonide with azathioprine may be a superior frontline treatment. We conclude that the non-classical phenotypes of autoimmune hepatitis can be recognized promptly, diagnosed accurately, and treated effectively.

Five years' experience with capsule endoscopy in a single center

Capsule endoscopy (CE) is a novel technology that facilitates highly effective and noninvasive imaging of the small bowel. Although its efficacy in the evaluation of obscure gastrointestinal bleeding (OGIB) has been proven in several trials, data on uses of CE in different small bowel diseases are rapidly accumulating in the literature, and it has been found to be superior to alternative diagnostic tools in a range of such diseases. Based on literature evidence, CE is recommended as a first-line investigation for OGIB after negative bidirectional endoscopy. CE has gained an important role in the diagnosis and follow-up of Crohn's disease and celiac disease and in the surveillance of small bowel tumors and polyps in selected patients. Capsule retention is the major complication, with a frequency of 1%-2%. The purpose of this review was to discuss the procedure, indications, contraindications and adverse effects associated with CE. We also review and share our five-year experience with CE in various small bowel diseases. The recently developed balloon-assisted enteroscopies have both diagnostic and therapeutic capability. At the present time, CE and balloon-assisted enteroscopies are complementary techniques in the diagnosis and management of small bowel diseases.

Potential role of lycopene in the treatment of hepatitis C and prevention of hepatocellular carcinoma

Hepatitis C virus (HCV) infection and hepatocellular carcinoma (HCC) are growing health problems around the world. Oxidative stress plays a significant role in the initiation and progression of hepatocellular damage and possibly in the development of HCC in HCV infected patients. In vitro, animal and clinical studies suggest that lycopene, a nonprovitamin A carotenoid and a potent antioxidant, may attenuate the liver injury and possibly prevent the development of HCC. In this article, we discuss the relationship between HCV infection and oxidative stress and review the potential role of lycopene in the treatment of HCV and prevention of HCC.

Prophylactic use of lamivudine with chronic immunosuppressive therapy for rheumatologic disorders

The objective of this study was to report our experience concerning the effectiveness of the prophylactic administration of lamivudine in hepatitis B virus surface antigen (HBs Ag) positive patients with rheumatologic disease. From June 2004 to October 2006, 11 HBs Ag positive patients with rheumatologic diseases, who were on both immunosuppressive and prophylactic lamivudine therapies, were retrospectively assessed. Liver function tests, hepatitis B virus (HBV) serologic markers, and HBV DNA levels of the patients during follow-up were obtained from hospital file records. Eleven patients (six male) with median age 47 years (range 27-73), median disease duration 50 months (range 9-178) and median follow-up period of patients 13.8 months (range 5-27) were enrolled in this study. Lamivudine therapy was started 3-7 days prior to immunosuppressive therapy in all patients. Baseline, liver function tests were elevated in two patients (fourth patient: ALT:122 IU/l, AST:111 IU/l, tenth patient:ALT:294 IU/l, AST:274 IU/l, with minimal changes in the liver biopsy in both). Shortly after treatment their tests normalized and during follow-up period none of the patients had abnormal liver function tests. In four patients HBV DNA levels were higher than normal at baseline. Two of these normalized and the others increased later. In three additional patients, HBV DNA levels were increased during follow-up. None of the patients had significant clinical sings of HBV activation. Lamivudine was well tolerated and was continued in all patients. Prophylactic administration of lamivudine in patients who required immunosuppressive therapy seems to be safe, well tolerated and effective in preventing HBV reactivation.

Cholangiocarcinoma: A compact review of the literature

Cholangiocarcinoma (CC) is a devastating cancer arising from biliary epithelia. Unfortunately, the incidence of this disease is increasing in Western countries. These tumors progress insidiously, and liver failure, biliary sepsis, malnutrition and cancer cachexia are general modes of death associated with this disease. To date, no established therapy for advanced disease has been established or validated. However, our knowledge in tumor biology is increasing dramatically and new drugs are under investigation for treatment of this notorious tumor. In clinical practice, there are better diagnostic tools in use to facilitate an earlier diagnosis of CC, at least in those patients with known risk factors. CC is resectable for cure in only a small percentage of patients. Preoperative staging for vascular and biliary extension of CC is very important in this tumor. Laparoscopy and recently endosonography seem to protect against unnecessary laparotomies in these patients. During the last 15 years, aggressive surgical approaches, including combined liver resections and vascular reconstructive surgical expertise, have improved survival in patients with CC. Surgery is contraindicated in CC cases having primary sclerosing cholangitis (PSC). Although CC was previously considered a contraindication to liver transplantation, new cautious protocols, including neo-adjuvant chemoradiation therapies and staging procedures before the transplantation, have made it possible to achieve long-term survival after liver transplantation in this disease. New ablative therapies with photodynamic therapy, intraductal high-intensity ultrasonography and chemotherapy-impregnated plastic biliary endoprosthesis are important steps in the palliative management of extra-hepatic CCs. Radiofrequency and chemo-embolization methods are also applicable for intra-hepatic CCs as palliative modes of treatment. We need more prospective randomized controlled trials to evaluate the role of the new emerging therapies for CC patients.

Hepatic granuloma in Turkish adults: a report of 13 cases

BACKGROUND

Hepatic granuloma (HG) is a well defined histopathological finding with an heterogenous clinical presentation. Diagnosis of a specific clinical entity is not possible every time. Descriptive studies may shed light on the various etiologies also common and distinctive findings among these patients.

METHODS

We reviewed the results of the liver biopsies of 592 patients. Characteristics of the patients with HG were extracted from the hospital charts. Laboratory studies included biochemical tests, hepatitis C virus (HCV) antibody, Brucella agglutination tests, tuberculin skin test. According to the diagnostic clues further tests (thoracic computed tomography (CT), ultrasonography, organ biopsy in addition to liver, antimitochondrial antibody, hepatitis B surface (HBs) antigen, venereal disease research laboratory (VDRL)) were performed.

RESULTS

HG was found in 13 of the 592 patients (2.2%). Primary biliary cirrhosis (three cases) was the most frequent cause followed by sarcoidosis, miliary tuberculosis and BCGitis (Bacillus Calmette Guerin) (two cases each). Two patients with HG could not be diagnosed. Only three patients had remarkable physical examination findings. Alkaline phosphatase and gamma-glutamyl transpeptidase were the most frequently elevated enzymes. Abdominal ultrasonography provided no specific diagnostic clue in any patient. Localization of the HGs was portal in 6 patients, parenchymal in 5 patients and both portal and parenchymal in 2 patients. Three exitus were due to BCGitis, miliary tuberculosis and fungal infection.

CONCLUSIONS

Tuberculosis is still among the most common etiologic factors. BCGitis has a fulminant rather than an indolent course. Abdominal ultrasonography could be used to rule out obstructive jaundice rather than to reach a specific diagnosis. Involvement of portal area by HG in most of the cases might cause obstruction of the biliary canaliculi and elevation of the cholestatic enzymes. Follow up of the difficult cases may be the best approach since the presence of HG was not proved as a bad prognostic factor for any disease.

Primary sclerosing cholangitis--what is the difference between east and west?

Primary sclerosing cholangitis (PSC) is a chronic, progressive, cholestatic liver disease characterized by inflammation and fibrotic obliteration of the hepatic biliary tree. It is commonly associated with inflammatory bowel disease (IBD). A number of complications can occur which require special consideration, the most important of which is the development of cholangiocellular carcinoma (CCC). Unfortunately, no medical therapy is currently available for the underlying liver disease. Liver transplantation is an effective, life-extending option for patients with advanced PSC. Geographical variations between East and West include a second peak for age with a lower association with IBD in a Japanese population and female predominance in a lone study from Turkey. The clinical and biochemical Mayo criteria may not be universally applicable, as different patients show variations regarding the initial presentation and natural course of the disease. Directing research towards explaining these geographical differences and understanding the pathogenesis of PSC is required in order to develop better therapies for this devastating disease.

JAK2V617F mutation in patients with portal vein thrombosis

In a retrospective cohort, we investigated the presence of the JAK2V617F mutation in chronic non-cirrhotic portal vein thrombosis (PVT) patients, irrespective of the presence or absence of myeloproliferative diseases (MPDs). We identified 25 patients in whom thrombophilia workup was completed. The diagnoses of MPDs were made according to the World Health Organization (WHO) criteria. JAK2V617F mutation analysis was performed by allele-specific polymerase chain reaction (PCR). There were 9 male and 16 female patients. Prior to JAK2V617F analysis, there were one or more thrombophilic risk factors in 19 patients (76%). The JAK2V617F mutation analysis revealed the presence of this mutation (all in the heterozygote state) in six patients (24%; two male, four female). Five of the six cases with prior clinical diagnosis of MPDs were found to have wild-type JAK2. We found that the addition of JAK2V617F analysis into the thrombophilia workup in patients with chronic PVT contributes to a 4% increase in the diagnosis of thrombophilic conditions.