Fluoride release potential of arginine-incorporated fluoride varnishes

The study aimed to examine the fluoride (F) release potential of arginine (Arg)-incorporated F varnishes. Four commercially available F varnishes were included in the study: Duraphat® (5% NaF), Flúor Protector® (0.9% SiH2F2), Fluor Protector S® (NH4F), and Fluorimax™ (2.5% NaF). L-arginine (2% w/v.) was incorporated in these varnishes to estimate F release at 1 h, 4 h, 6 h, 24 h, 3 days, and 7 days using an F-ion selective electrode. The media pH of eluded varnishes was estimated and primary inorganic F extraction was performed. The main effects pH, F release, and computed integrated mean/cumulative F release for experimental groups were significantly higher than the controls (p<0.01). The primary extracted F concentrations for the Arg-containing groups were significantly lower than the control groups (p<0.001) demonstrating a chemical interplay with Arg incorporation. To conclude, irrespective of the inorganic F content, incorporating Arg in F-containing varnishes increases their F release potential.

Effect of arginine-fluoride varnish on preventing enamel erosion by paediatric liquid medicaments

BACKGROUND

The study objective was to examine the effect of arginine-sodium fluoride (Arg-NaF) varnish on preventing enamel erosion by acidic paediatric liquid medicaments (PLM).

METHODS

The treatment groups were: 1) 2% Arg-NaF; 2) 4% Arg-NaF; 3) 8% Arg-NaF; 4) NaF; 5) MI (CPP-ACFP) varnishes; and 6) no varnish. The pH of PLM (paracetamol and chlorpheniramine) was measured at baseline and after immersing the Perspex® blocks coated with varnishes at 0 min, 30 min, 1 h, and 4 h. Seventy-two enamel specimens (n = 72) were randomly divided into 2 groups by PLM and further by treatment groups. Then, the specimens were pre-treated with varnishes and subjected to erosive cycles (5 min, 2×/day for 4 days) by PLM. After each erosive challenge, the specimens were stored in artificial saliva. At baseline and after 4 days, the specimens were assessed for surface roughness (Ra) using 2D-surface profilometric analysis (SPA) and atomic force microscopy (AFM). Additionally, the Ca/P ratio was determined using scanning electron microscopy with energy-dispersive X-ray spectroscopy. Paired samples dependent t-test, 1-way ANOVA and 2-way ANOVA with Bonferroni post-hoc tests were used to analyse data with the level of significance set at p < 0.05.

RESULTS

The pH of PLM with 8% Arg-NaF was significantly higher than the other groups at 30 min and 4 h (p < 0.05). With paracetamol, no significant difference was observed between the baseline and post-erosive cycle measured enamel Ra (by SPA/AFM) and Ca/P ratio for all treatment groups (p > 0.05). The Ra determined by AFM, at the post-erosive cycle with chlorpheniramine, when treated with 4 and 8% Arg-NaF was significantly lower than the other groups (p < 0.05); except CPP-ACFP (p > 0.05). With the chlorpheniramine post-erosive cycle, the Ca/P ratio for 4, 8% Arg-NaF and CPP-ACFP treated specimens was significantly higher than the baseline Ca/P (p < 0.05).

CONCLUSION

The 4%/8% Arg-NaF and MI varnish® application exhibit an enhanced preventive effect against low pH (pH < 3.0) PLM-mediated enamel erosive challenges compared to 5% NaF varnish.

966 The Surgical Handbook: Enhancing Surgical Education for Medical Students and Foundation Doctors

Aim

In recent years, the GKT School of Medical Education has introduced a new curriculum resulting in a shift from a single surgical block to an integrated approach. After recognising the potential challenges that the lack of standardisation across various hospitals may cause, we created the Surgical Handbook to supplement learning, improve confidence in approaching surgical patients and prepare students for the United Kingdom Foundation Programme (UKFP).

Method

We sought authorisation for the Surgical Handbook from the GKT medical education faculty, assembled a team and conducted further background research. The National Undergraduate Curriculum by the Royal College of Surgeons of England was an excellent resource in the design of the Surgical Handbook. The handbook underwent multiple cycles of review by senior medical education faculty before its final digital and physical distribution for students.

Results

The Surgical Handbook has resulted in a sustained positive impact on surgical education for GKT students, with feedback highlighting it as an excellent additional resource for placements, exams, and the Foundation Programme.

Conclusions

Most doctors in the United Kingdom will undertake a surgical rotation as part of the Foundation Programme. Preparation for this role is essential and linked to the quality of undergraduate surgical education. Nevertheless, the importance of surgical teaching within the undergraduate curriculum remains a topic of debate. Our Surgical Handbook addresses this issue, and we are in the process of collaborating with other medical schools across the United Kingdom and beyond.

Biochemical changes and macrophage polarization of a silane-based endodontic irrigant in an animal model

Silane-based/fully hydrolyzed, endodontic irrigant exhibiting antimicrobial properties, is prepared, and is hypothesized to control macrophage polarization for tissue repair. Albino wistar rats were injected with 0.1 ml root canal irrigant, and bone marrow cells procured. Cellular mitochondria were stained with MitoTracker green along with Transmission Electron Microscopy (TEM) performed for macrophage extracellular vesicle. Bone marrow stromal cells (BMSCs) were induced for M1 and M2 polarization and Raman spectroscopy with scratch assay performed. Cell counting was used to measure cytotoxicity, and fluorescence microscopy performed for CD163. Scanning Electron Microscopy (SEM) was used to investigate interaction of irrigants with Enterococcus faecalis. K21 specimens exhibited reduction in epithelium thickness and more mitochondrial mass. EVs showed differences between all groups with decrease and increase in IL-6 and IL-10 respectively. 0.5%k21 enhanced wound healing with more fibroblastic growth inside scratch analysis along with increased inflammation-related genes (ICAM-1, CXCL10, CXCL11, VCAM-1, CCL2, and CXCL8; tissue remodelling-related genes, collagen 1, EGFR and TIMP-2 in q-PCR analysis. Sharp bands at 1643 cm^-1 existed in all with variable intensities. 0.5%k21 had a survival rate of BMSCs comparable to control group. Bacteria treated with 0.5%k21/1%k21, displayed damage. Antimicrobial and reparative efficacy of k21 disinfectant is a proof of concept for enhanced killing of bacteria across root dentin acquiring functional type M2 polarization for ethnopharmacological effects.

Concentration-Dependent Multi-Potentiality of L-Arginine: Antimicrobial Effect, Hydroxyapatite Stability, and MMPs Inhibition

This study's objective was to examine L-arginine (L-arg) supplementation's effect on mono-species biofilm (Streptococcus mutans/Streptococcus sanguinis) growth and underlying enamel substrates. The experimental groups were 1%, 2%, and 4% arg, and 0.9% NaCl was used as the vehicle control. Sterilised enamel blocks were subjected to 7-day treatment with test solutions and S. mutans/S. sanguinis inoculum in BHI. Post-treatment, the treated biofilms stained for live/dead bacterial cells were analysed using confocal microscopy. The enamel specimens were analysed using X-ray diffraction crystallography (XRD), Raman spectroscopy (RS), and transmission electron microscopy (TEM). The molecular interactions between arg and MMP-2/MMP-9 were determined by computational molecular docking and MMP assays. With increasing arg concentrations, bacterial survival significantly decreased (p < 0.05). The XRD peak intensity with 1%/2% arg was significantly higher than with 4% arg and the control (p < 0.05). The bands associated with the mineral phase by RS were significantly accentuated in the 1%/2% arg specimens compared to in other groups (p < 0.05). The TEM analysis revealed that 4% arg exhibited an ill-defined shape of enamel crystals. Docking of arg molecules to MMPs appears feasible, with arg inhibiting MMP-2/MMP-9 (p < 0.05). L-arginine supplementation has an antimicrobial effect on mono-species biofilm. L-arginine treatment at lower (1%/2%) concentrations exhibits enamel hydroxyapatite stability, while the molecule has the potential to inhibit MMP-2/MMP-9.

Physicochemical Characteristics of Arginine Enriched NaF Varnish: An In Vitro Study

The in vitro study objectives were to investigate the effect of arginine (Arg) incorporation in a 5% sodium fluoride (NaF) varnish on its physical and chemical properties including F/Arg release. Six experimental formulations were prepared with L-arginine (L-Arg) and L-arginine monohydrochloride at 2%, 4%, and 8% w/v in a 5% NaF varnish, which served as a control. The varnishes were subjected to assessments for adhesion, viscosity, and NaF extraction. Molecular dynamics were simulated to identify post-dynamics total energy for NaF=Arg/Arg>NaF/Arg<NaF concentrations. The Arg/F varnish release profiles were determined in polyacrylic lactate buffer (pH-4.5; 7 days) and artificial saliva (pH-7; 1 h, 24 h, and 12 weeks). Incorporation of L-Arg in NaF varnish significantly influences physical properties ameliorating retention (p < 0.001). L-Arg in NaF varnish institutes the Arg-F complex. Molecular dynamics suggests that NaF>Arg concentration denotes the stabilized environment compared to NaF<Arg (p < 0.001). The 2% Arg-NaF exhibits periodic perennial Arg/F release and shows significantly higher integrated mean F release than NaF (p < 0.001). Incorporating 2% L-arginine in 5% NaF varnish improves its physical properties and renders a stable matrix with enduring higher F/Arg release than control.

Properties of a modified quaternary ammonium silane formulation as a potential root canal irrigant in endodontics

OBJECTIVES

Evaluate a new modified quaternary ammonium silane irrigant solution for its antimicrobial, cytotoxic and mechanical properties of dentine substrate.

METHODS

Root canal preparation was performed using stainless steel K-files™ and F4 size protaper with irrigation protocols of 6% NaOCl + 2% CHX; 3.5% QIS; 2% QIS and sterile saline. Biofilms were prepared using E. faecalis adjusted and allowed to grow for 3 days, treated with irrigants, and allowed to grow for 7 days. AFM was performed and surface free energy calculated. MC3T3 cells were infected with endo irrigant treated E. faecalis biofilms. Raman spectroscopy of biofilms were performed after bacterial re-growth on root dentine and exposed to different irrigation protocols and collagen fibers analysed collagen fibers using TEM. Antimicrobial potency against E. faecalis biofilms and cytoxicity against 3T3 NIH cells were also. Resin penetration and MitoTracker green were also evaluated for sealer penetration and mitochondrial viability. Data were analysed using One-way ANOVA, principal component analysis and post-hoc Fisher's least-significant difference.

RESULTS

Elastic moduli were maintained amongst control (5.5 ± 0.9) and 3.5% QIS (4.4 ± 1.1) specimens with surface free energy higher in QIS specimens. MC3T3 cells showed reduced viability in 6%NaOCl+2%CHX specimens compared to QIS specimens. DNA/purine were expressed in increased intensities in control and 6% NaOCl + 2% CHX specimens with bands around 480-490 cm^-1 reduced in QIS specimens. 3.5% QIS specimens showed intact collagen fibrillar network and predominantly dead bacterial cells in confocal microscopy. 3.5% QIS irrigant formed a thin crust-type surface layer with cytoplasmic extensions of 3T3NIH spread over root dentine. Experiments confirmed MitoTracker accumulation in 3.5% treated cells.

SIGNIFICANCE

Novel QIS root canal irrigant achieved optimum antimicrobial protection inside the root canals facilitating a toxic effect against the Enterococcus faecalis biofilm. Root dentine substrates exhibited optimum mechanical properties and there was viability of fibroblastic mitochondria.

Contribution of Mitophagy to Cell-Mediated Mineralization: Revisiting a 50-Year-Old Conundrum

Biomineralization in vertebrates is initiated via amorphous calcium phosphate (ACP) precursors. These precursors infiltrate the extracellular collagen matrix where they undergo phase transformation into intrafibrillar carbonated apatite. Although it is well established that ACP precursors are released from intracellular vesicles through exocytosis, an unsolved enigma in this cell-mediated mineralization process is how ACP precursors, initially produced in the mitochondria, are translocated to the intracellular vesicles. The present study proposes that mitophagy provides the mechanism for transfer of ACP precursors from the dysfunctioned mitochondria to autophagosomes, which, upon fusion with lysosomes, become autolysosomes where the mitochondrial ACP precursors coalesce to form larger intravesicular granules, prior to their release into the extracellular matrix. Apart from endowing the mitochondria with the function of ACP delivery through mitophagy, the present results indicate that mitophagy, triggered upon intramitochondrial ACP accumulation in osteogenic lineage-committed mesenchymal stem cells, participates in the biomineralization process through the BMP/Smad signaling pathway.

Collagen Degradation by Host-derived Enzymes during Aging

Incompletely infiltrated collagen fibrils in acid-etched dentin are susceptible to degradation. We hypothesize that degradation can occur in the absence of bacteria. Partially demineralized collagen matrices (DCMs) prepared from human dentin were stored in artificial saliva. Control specimens were stored in artificial saliva containing proteolytic enzyme inhibitors, or pure mineral oil. We retrieved them at 24 hrs, 90 and 250 days to examine the extent of degradation of DCM. In the 24-hour experimental and 90- and 250-day control specimens, we observed 5- to 6-μm-thick layers of DCM containing banded collagen fibrils. DCMs were almost completely destroyed in the 250-day experimental specimens, but not when incubated with enzyme inhibitors or mineral oil. Functional enzyme analysis of dentin powder revealed low levels of collagenolytic activity that was inhibited by protease inhibitors or 0.2% chlorhexidine. We hypothesize that collagen degradation occurred over time, via host-derived matrix metalloproteinases that are released slowly over time.

In vivo and in vitro Permeability of One-step Self-etch Adhesives

Adhesive dentistry should effectively restore the peripheral seal of dentin after enamel removal. We hypothesize that non-rinsing, simplified, one-step self-etch adhesives are effective for minimizing dentin permeability after tooth preparation procedures. Crown preparations in vital human teeth were sealed with Adper Prompt, Xeno III, iBond, or One-Up Bond F. Epoxy resin replicas were produced from polyvinyl siloxane impressions for SEM examination. Dentin surfaces from extracted human teeth were bonded with these adhesives and connected to a fluid-transport model for permeability measurements and TEM examination. Dentinal fluid droplets were observed from adhesive surfaces in resin replicas of in vivo specimens. In vitro fluid conductance of dentin bonded with one-step self-etch adhesives was either similar to or greater than that of smear-layer-covered dentin. TEM revealed water trees within the adhesives that facilitate water movement across the polymerized, highly permeable adhesives. Both in vitro and in vivo results did not support the proposed hypothesis.

Current update of chemomechanical caries removal methods

Chemomechanical caries removal is an excellent method for minimally invasive caries excavation, and the removal agents are either sodium hypochlorite (NaOCl)- or enzyme-based. The NaOCl-based agents include GK-101, GK-101E (Caridex) and Carisolv, and the enzyme-based agents include Papacarie and the experimental material, Biosolv. This review outlines the changes in chemomechanical caries removal methods and focuses on recently published laboratory and clinical studies. The historical development, mechanism of action, excavation time and biological effects on pulp and dental hard tissues are described. Based on existing evidence, the currently available chemomechanical caries removal methods are viable alternatives to conventional rotary instrument methods. Chemomechanical methods could be extremely useful in very anxious, disabled and paediatric patients. It does seem some of these agents would still benefit from quicker excavation times in order to achieve more universal acceptance. However, as a means of conserving the caries-affected dentine, chemomechanical caries removal is possibly much more successful than conventional rotary instrumentation.

Effect of dentine conditioning on adhesion of resin-modified glass ionomer adhesives

BACKGROUND

The aim of this study was to investigate the use of phosphoric acid as a surface treatment compared to traditional conditioning agents to dentine bonded with resin-modified glass ionomer (RMGIC) adhesives.

METHODS

Forty human molars were utilized in microtensile bond strength testing, while another 16 were used for evaluation of the bonded interface with scanning electron microscopy. Three RMGIC adhesives were evaluated: Fuji Bond LC (GC Corp); Riva Bond LC (SDI Ltd); and Ketac N100 (3M-ESPE). Surface treatments were 37% phosphoric acid (5 s) or 25-30% polyacrylic acid (PAA) (10 s), or the manufacturer's method - Fuji Bond LC: Cavity Conditioner (20% PAA + 3% AlCl3 10 s) or Ketac N100 primer: Ketac Nano priming agent (15 s). Teeth were finished with 600-grit SiC paper, surfaces treated and bonded with RMGIC adhesive and stored in distilled water for 24 h then subjected to microtensile bond strength testing.

RESULTS

Two-way analysis of variance (ANOVA) revealed adhesion was affected by the 'type of RMGIC adhesive' and 'method of dentine surface treatment' (p < 0.05). The microtensile bond strength of Ketac N100 primer groups was lower than Fuji Bond LC and Riva Bond LC (p < 0.05).

CONCLUSIONS

For RMGIC adhesives a brief etch with phosphoric acid does not adversely effect short-term bond strengths, but is no better than traditional conditioning with PAA.

In vitro effect of hesperidin on root dentin collagen and de/re-mineralization

The aims of this study were to investigate the effects of hesperidin, a citrus flavonoid, on human root dentin demineralization and collagen preservation, and compare it with chlorhexidine and grape seed extract. Specimens were assigned to different treatment groups: hesperidin, chlorhexidine and grape seed extract. Specimens were subjected to pH cycling by demineralization for 14 h, incubation in testing solutions for 2 h and remineralization in presence of bacterial-derived collagenase for 8 h, for 8 days. Calcium release was measured by means of an atomic absorption spectrophotometer, and degraded collagen matrix was investigated by hydroxyproline assay. Specimens were assessed longitudinally with transverse micro-radiography to investigate lesion depth and mineral loss. In hesperidin and grape seed extract groups, demineralization was reduced when the collagen matrix was preserved. The hesperidin group showed the lowest value in lesion depth and mineral loss, indicating that hesperidin inhibited demineralization and probably enhanced remineralization even under fluoride-free conditions.

Durability of resin-dentin bonds related to water and oil storage

PURPOSE

To evaluate the long-term effects of etching time, adhesive system and storage condition on resin bond strength to dentin.

METHODS

Twenty-five extracted human third molars had a flat dentin surface exposed. Two total-etch adhesives, Single Bond (SB) and One-Step (OS), and one self-etching adhesive system, Clearfil Liner Bond 2V (CL), were used. The adhesives were bonded to dentin according to their respective manufacturer's instructions. Additional groups of SB and OS systems were created, in which the phosphoric acid etching time was doubled (30 seconds). After bonding, build-up crowns were constructed incrementally with Z250 resin composite and the teeth were stored for 24 hours in distilled water at 37 degrees C. The teeth were serially and vertically sectioned to obtain several bonded beams with approximately 0.8 mm2 of cross-sectional area. Beams were tested in microtensile (0.6 mm/minute) either immediately (control) or after storage for 6 months or 1 year in either distilled water or mineral oil. Data were analyzed by ANOVA and Tukey's multiple comparison tests.

RESULTS

Significant reductions (P< 0.05) in bond strength were observed after both long-term storage periods in water for all the materials, regardless of the etching time for SB and OS. Bond strengths were either preserved or increased in specimens stored in oil.

Effects of resin hydrophilicity on water sorption and changes in modulus of elasticity

As acidic monomers of self-etching adhesives are incorporated into dental adhesives at high concentrations, the adhesive becomes more hydrophilic. Water sorption by polymers causes plasticization and lowers mechanical properties. The purpose of this study was to compare the water sorption and modulus of elasticity (E) of five experimental neat resins (EX) of increasing hydrophilicity, as ranked by their Hoy's solubility parameters and five commercial resins.

METHODS

After measuring the initial modulus of all resin disks by biaxial flexure, half the specimens were stored in hexadecane and the rest were stored in water. Repeated measurements of stiffness were made for 3 days. Water sorption and solubility measurements were made in a parallel experiment.

RESULTS

None of the specimens stored in oil showed any significant decrease in modulus. All resins stored in water exhibited a time-dependent decrease in modulus that was proportional to their degree of water sorption. Water sorption of EX was proportional to Hoy's solubility parameter for polar forces (delta(p)) with increasing polarity resulting in higher sorption. The least hydrophilic resin absorbed 0.55 wt% water and showed a 15% decrease in modulus after 3 days. The most hydrophilic experimental resin absorbed 12.8 wt% water and showed a 73% modulus decrease during the same period. The commercial resins absorbed between 5% and 12% water that was associated with a 19-42% reduction in modulus over 3 days.

Nanoleakage types and potential implications: evidence from unfilled and filled adhesives with the same resin composition

PURPOSE

To compare nanoleakage patterns of an unfilled (OS; One-Step), a 6 wt% spherical silica-filled (OSs; One-Step Plus) and a 15 wt% glass-filled (OSg) version of a two-step, acetone-based self-priming adhesive. Permeability of bonded dentin treated with OS and OSs was also examined.

METHODS

Deep, coronal dentin from extracted third molars were etched and bonded using these adhesives. One-mm thick sections were immersed in 50 wt% ammoniacal silver nitrate (pH 9.5) for 24 hours. Unstained, undemineralized sections were examined by TEM. The permeability of dentin bonded with OS and OSs were investigated at 20 cm of H2O hydrostatic pressure and compared with the osmotic conductance determined with 4.8 M CaCl2 at zero hydrostatic pressure. Composite-dentin beams bonded with OS, OSs and OSg that were fractured after microtensile bond testing were examined by SEM.

RESULTS

Two types of nanoleakage patterns were recognized along the resin-dentin interfaces. The reticular type consisted of discontinuous islands of silver deposits and was exclusively seen in hybrid layers. The spotted type consisted of isolated silver grains and was evident throughout the hybrid and adhesive layers in OS. These two patterns were seen to variable extents in the two filled adhesive versions OSs and OSg and their distribution was independent of one another. OS and OSs bonded dentin were permeable to fluid filtration. However, part of this fluid movement was due to the permeability of the adhesive layer, as demonstrated by osmotic fluid conductance in the absence of hydrostatic pressure. Fractographic analysis revealed denuded collagen fibrils within fractured hybrid layers that were indicative of incomplete resin infiltration.

Ultrastructural study of a glass ionomer-based, all-in-one adhesive

OBJECTIVE

Reactmer Bond (Shofu Inc., Kyoto, Japan) is a glass ionomer (GI) based, tri-curable, all-in-one, filled adhesive. Both fluoroaluminosilicate glass (FASG) and fully pre-reacted glass (F-PRG) are used as fillers. This study examined the ultrastructure and elemental composition of resin-dentine interfaces that were treated with this adhesive.

METHODS

Dentine disks prepared from human third molars were abraded with either 600- or 60-grit SiC paper to create smear layers of different thickness. They were bonded using Reactmer Bond. Cryo-fractured dentine surfaces devoid of smear layers were also bonded by chemical-activation and GI reaction without additional light-activation, or allowing the GI reaction to proceed for 1min before the adhesive was applied and light-activated. Undemineralised and demineralised sections were processed for TEM examination and STEM/EDX analysis.

RESULTS

Resin-dentine interface from specimens with smear layers consisted of a mineral-dense surface layer that resided on top of a partially demineralised dentine. The partially demineralised zone was considerably thicker in the 600-grit than the 60-grit specimens. In smear layer-free specimens that were cured by chemical-activation/GI modes only, the surface layer concurred with the partially demineralised zone, and appeared as an electron-dense layer over the undemineralised intact dentine. Smear layer-free specimens that were cured by the light-activation of the partially neutralised adhesive contained incomplete amorphous surface layers only. Apart from colloidal silica, FASG fillers were the predominant filler type within the resin matrices. Peripheral hydrogel layers that contained electron-dense "seeds" were found around the FASG fillers. F-PRG fillers were only sparsely observed. In specimens that were laboratory demineralised with formic acid, phase separation of the unstained resin matrices into electron-dense and electron-lucent domains occurred. Artefactual dendritic deposits were found within the electron-dense domains.

CONCLUSIONS

The presence of a surface interaction layer on top of a partially demineralised zone along the resin-dentine interface suggests that either a GI-type reaction or precipitation of insoluble carboxylate salts around remnant apatite crystallites may occur when this single-step adhesive interacts with dentine. Appearance of artefactual dendritic deposits suggests that continuous ion movement is possible within the hydrophilic portion of the resin matrix in this fluoride-releasing adhesive.

Evaluation of treatment and posttreatment changes of protraction facemask treatment using the PAR index

The purpose of this study was to use the Peer Assesment Rating (PAR) index score to evaluate the treatment and posttreatment changes of Class III patients treated by protraction facemask. The sample consisted of 20 Chinese children, 6 to 11 years old, with Class III skeletal malocclusion who had been treated with maxillary expansion and a protraction facemask. The average treatment time was 8.2 months, followed by 1 year of retention with a Class III functional appliance. Study casts were taken pretreatment (T1), posttreatment (T2), 1 year follow-up (T3), and 2 years follow-up (T4). After treatment, PAR scores were calculated for each time period. Differences among the 4 time periods were analyzed with the Wilcoxin matched-pairs test. Significant reductions in PAR scores were found at T2 (56%), T3 (70%), and T4 (63%) compared with T1. Immediately posttreatment (T2), 17 (85%) of 20 patients had improved PAR scores by a reduction of at least 30%. Reductions were caused primarily by correction of the anterior crossbite. One year after treatment (T3), further reductions in PAR score were noted (P <.01) as a result of better alignment of the anterior segment, improvement of the buccal occlusion, and overbite and midline corrections. Two years after treatment (T4), PAR scores were higher than at the previous time period. The increases were due to relapses in overjet (4 of 20 patients), overbite, and centerline corrections. These results indicate that significant reductions in the severity of Class III malocclusion can be achieved with early orthopedic facemask treatment. In most cases, further improvement in the PAR score can be expected 1 and 2 years after treatment. In a few patients, the benefits of early treatment are negated by relapses in overjet, overbite, and centerline corrections during the follow-up period.

Pilomotor seizures

We report pilomotor seizures in two patients who had piloerection or gooseflesh spreading in a pattern like the 'Jacksonian march', confined ipsilaterally to the lesion side. The first patient presented this in conjunction with complex partial seizures. Left anterior temporal lobectomy abolished pilomotor and other seizures. Pathological study demonstrated hippocampal sclerosis. A meningioma near the left sphenoid region, incompletely removed, is the likely cause of pilomotor seizures in the second patient. Carbamazepine reduced these attacks. To our knowledge, hippocampal sclerosis and meningioma have never been linked to pilomotor seizures.

Cephalometric and occlusal changes following maxillary expansion and protraction

A prospective clinical trial was conducted to determine the cephalometric and occlusal changes following maxillary expansion and protraction. Twenty Southern Chinese patients (eight males and 12 females with a mean age of 8.4 +/- 1.8 years) with skeletal Class III malocclusions were treated consecutively with maxillary expansion and a protraction facemask. Growth adaptation of these patients was followed for 2 years after removal of the appliances and compared with a control group of subjects with no treatment. Lateral cephalometric radiographs were used to quantify the skeletal and dental changes before treatment (T1), immediately after treatment (T2) and 2 years after removal of appliances (T3). With 8 months of treatment (T2-T1), overjet was overcorrected from a -2.0 to 3.5 mm. The maxilla moved forwards by an average of 2.1 mm and the molar relationship was improved to a Class I dental arch relationship. The palatal and occlusal planes were tilted upward 1.0 and 2.0 degrees, respectively. Two years following removal of the appliances (T3-T2), a positive overjet was maintained in 18 out of 20 patients. The maxilla continued to move forwards in the treated subjects similar to the controls. The mandible outgrew the maxilia. In most instances, dental compensation with proclination of the maxillary incisors was observed. The palatal plane returned to pre-treatment value. The occlusal plane continued to tilt upward due to eruption of the molars and proclination of the incisors. Analysis of dental casts showed a significant increase in maxillary intercanine (2.2 mm) and intermolar widths (2.3 mm) with 7 days of rapid palatal expansion followed by maxillary protraction. The percentage relapse in maxillary intermolar widths was 30-45 per cent after 1 year, in most cases with minimal retention. In the mandibular arch, the concurrent increase in intermolar width (2.3 mm) was primarily due to buccal uprighting of the posterior molars when the maxilla was protracted into a Class I skeletal relationship and was stable after 1 year. The results of this study indicate stability of orthopaedic treatment of Class III malocclusions directed at the maxilla. Despite some relapse, a net improvement in maxillomandibular relationship and a positive overjet was maintained in 18 out of 20 patients at the end of the follow-up period.

Cephalometric comparisons of Chinese and Caucasian surgical Class III patients

Pretreatment cephalometric radiographs of 30 Chinese and 30 Caucasian surgical Class III patients were studied to determine if there were skeletal and soft tissue morphology differences between the groups. Nineteen hard tissue and 13 soft tissue measurements were traced and digitized. A two-sample t test was used to analyze sex and ethnic differences between groups. A significant difference between sexes was found in the linear skeletal measurements but not in the angular measurements for both ethnic groups. Ethnic differences were found in the anterior cranial base measurement, which was significantly shorter in the Chinese sample. In addition, a larger posterior cranial base, a smaller gonial angle, and an increase in mandibular length contributed to the increase in mandibular prognathism found in the Chinese sample. Few differences between sexes were found in the soft tissue measurements. However, ethnic differences were found in maxillary and mandibular soft tissue prognathism, upper and lower lip protrusion, and nasolabial angle, which reflected the more severe underlying skeletal disharmony in the Chinese sample. When the surgical samples were compared to a reference population, an increase in skeletal measurements was found with the Chinese sample in maxillary and mandibular prognathism and dentoalveolar protrusion. Soft tissue maxillary prognathism and upper lip protrusion were found to be smaller than the reference population in the Caucasian sample but greater in the Chinese sample.

Masticatory muscle pain before, during, and after treatment with orthopedic protraction headgear: a pilot study

Protraction headgear has been used in conjunction with a palatal expansion appliance to correct Class III malocclusion with maxillary deficiency and/or mandibular prognathism. In general, 800 gm of orthopedic force is used to protract the maxilla, and 75% of this force is transmitted to the temporomandibular joint (TMJ) area via the mandible. The effect of this heavy intermittent force on the TMJ has not been reported in the literature. The objectives of this study were to determine the level of masticatory muscle pain and EMG activity in patients treated with maxillary protraction headgear. Ten patients with skeletal Class III malocclusion whose treatment plan called for maxillary protraction headgear treatment participated in this study. Nocturnal masticatory muscle activity was determined using a portable electromyographic (EMG) recording device. Subjects wore the EMG device 14 nights before treatment, 14 nights during treatment, and 14 nights 1 month after active treatment. Masticatory muscle pain level was determined by muscle palpation, scored on a scale of 0 to 3 each period, according to the method of Gross and Gale. The examiner followed a sequence outlined by Burch to examine the masticatory muscles. Results showed no significant differences for masticatory muscle activities before, during, and after treatment. Only a few patients experienced level 1 masticatory pain during treatment. None of the patients experienced masticatory muscle pain 1 month after treatment. These results demonstrate no significant increase in masticatory muscle activity or muscle pain associated with orthopedic treatment using maxillary protraction headgear.

Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction

The purpose of this article is to summarize the short-term and long-term results of the authors' clinical prospective study on the treatment of Class III malocclusion using the protraction facemask. An attempt is made to answer questions pertaining to this treatment modality. Twenty patients with skeletal Class III malocclusion were treated consecutively with maxillary expansion and a protraction facemask. A positive overjet was obtained in all cases after 6 to 9 months of treatment. These changes were contributed to by a forward movement of the maxilla, backward and downward rotation of the mandible, proclination of the maxillary incisors, and retroclination of the mandibular incisors. The molar relationship was overcorrected to Class I or Class II dental arch relationship. The overbite was reduced with a significant increase in lower facial height. The treatment was found to be stable 2 years after removal of the appliances. At the end of the 4-year observation period, 15 of the 20 patients maintained a positive overjet or an end-to-end incisal relationship. Patients who reverted back to a negative overjet were found to have excess horizontal mandibular growth that was not compensated by proclination of the maxillary incisors. A review of the literature showed that maxillary expansion in conjunction with protraction produced greater forward movement of the maxilla. Maxillary protraction with a 30 degrees forward and downward force applied at the canine region produced an acceptable clinical response. The reciprocal force from maxillary protraction transmitted to the temporomandibular joint did not increase masticatory muscle pain or activity. Significant soft tissue profile change can be expected with maxillary protraction including straightening of the facial profile and better lip competence and posture. However, one should anticipate individual variations in treatment response and subsequent growth changes. Treatment with the protraction facemask is most effective in Class III patients with a retrusive maxilla and a hypodivergent growth pattern. Treatment initiated at the time of initial eruption of the upper central incisors helps to maintain the anterior occlusion after treatment.

Timing for effective application of anteriorly directed orthopedic force to the maxilla

Class III malocclusion with retrusive maxilla can be orthopedically corrected in the deciduous and mixed dentition, with reverse-pull headgear in combination with rapid palatal expansion. The literature recommends this procedure be carried out before the patient is 8 years old to obtain the optimal orthopedic result. This statement, however, has not been supported by scientific data. The current study examined the treatment effects of patients younger than 8 years old (5 to 8 years) and patients older than 8 years old (9 to 12 years). Thirty patients treated with maxillary protraction and expansion in the Department of Children's Dentistry and Orthodontics, University of Hong Kong were included in this study. Cephalometric radiographs were taken 6 months before the initiation of treatment (T(0)), at the initiation of treatment (T1), and after 6 months of treatment (T2). In this way, (T(2)-T1) represented cephalometric changes during the treatment period and (T1-T0) represented 6 months of growth changes without treatment. Experimental subjects served as their own control in this study. A grid system consisting of maxillary occlusal plane (OL) and a line perpendicular to OL through sella (OLp) was used for linear measurements. A total of 15 linear and 3 angular cephalometric measurements were made. A multivariate analysis of variance (MANOVA), which used age and treatment time as its factors, was used to determine effect of age and/or treatment on each cephalometric parameter. Results indicated strikingly similar therapeutic response between the younger and older age groups. These data suggest that similar skeletal response can be obtained when maxillary protraction was started either before age 8 (5 to 8 years) or after age 8 years (8 to 12 years).

Cephalometric A point changes during and after maxillary protraction and expansion

The purpose of this study was to analyze the treatment and posttreatment maxillary changes achieved with maxillary protraction therapy. The cephalometric records of 25 consecutively treated Chinese children with Class III malocclusions (mean age 8.4 years) were analyzed for cephalometric A point changes, which were then compared with an untreated, age and sex matched Class III control sample. A cephalometric maxillary superimposition technique was used to differentiate between the skeletal and the local contributions to the total A point change. Results showed that 6 months of maxillary protraction therapy produced a mean A point advancement of 2.4 mm compared with 0.2 mm in the control group. Of this advancement, 75% was found to be due to skeletal maxillary advancement and 25% was attributed to local remodeling. Significantly less downward movement of A point was found with treatment compared with the controls, which could be related to the direction of force application. No significant differences were found in the horizontal and the vertical movements of A point between the treatment and the control groups during the 12-month posttreatment period, indicating stability of early maxillary protraction in patients with Class III malocclusions.

Treatment response to maxillary expansion and protraction

A prospective clinical trial was conducted to determine the skeletal and dental contributions to the correction of overjet and overbite in Class III patients. Thirty patients (12 males and 18 females with a mean age of 8.4 +/- 1.7 years) were treated consecutively with protraction headgear and fixed maxillary expansion appliances. For each patient, a lateral cephalogram was taken 6 months before treatment (T0); immediately before treatment (T1); and 6 months after treatment (T2). The time period (T1-T0) represented changes due to 6 months of growth without treatment; (T2-T1) represented 6 months of growth and treatment. Each patient served as his/her own control. Cephalometric analysis described by Björk (1947) and Pancherz (1982a,b) was used. Sagittal and vertical measurements were made along the occlusal plane (OLs) and the occlusal plane perpendicular (OLp), and superimposed on the mid-sagittal cranial structure. The results revealed the following: with 6 months of treatment, all subjects were treated to Class I or overcorrected to Class I or Class II dental arch relationships. Overjet and sagittal molar relationships improved by an average of 6.2 and 4.5 mm, respectively. This was a result of 1.8 mm of forward maxillary growth, a 2.5-mm of backward movement of the mandible, a 1.7-mm of labial movement of maxillary incisors, a 0.2-mm of lingual movement of mandibular incisors, and a 0.2-mm of greater mesial movement of maxillary than mandibular molars. The mean overbite reduction was 2.6 mm. Maxillary and mandibular molars were erupted occlusally by 0.9 and 1.4 mm, respectively. The mandibular plane angle was increased by 1.5 degrees and the lower facial height by 2.9 mm. Individual variations in response to maxillary protraction was large for most of the parameters tested. Significant differences in treatment changes between male and female subjects were found only in the vertical eruption of mandibular incisors and maxillary and mandibular molars. These results demonstrate that significant overjet and overbite corrections can be obtained with 6 months of maxillary protraction in combination with a fixed expansion appliance.

Soft tissue and dentoskeletal profile changes associated with maxillary expansion and protraction headgear treatment

One of the goals of early treatment of Class III malocclusion with maxillary expansion and protraction headgear is to significantly improve the dentofacial profile. The objectives of the present study were to determine (1) the interrelationships of the soft tissue and dentoskeletal profiles after maxillary expansion and protraction headgear treatment and (2) which cephalometric variables could contribute to an accurate prediction of the protraction effect on the soft tissue profile. Lateral cephalometric radiographs of 20 consecutively treated Class III patients (10 males, 10 females) by protraction headgear were included in this study. Their ages at the start of protraction headgear treatment ranged from 6 to 11 years, with an average of 8.1 +/- 2.1 years. None of the patients had previous orthodontic treatment. For each patient, the first lateral cephalogram was taken 6 months before the initiation of headgear treatment (T0), and the second radiograph at the start of treatment (T1). Therefore (T1-T0) represented 6 months of growth with no treatment. A third radiograph was taken 6 months after start of treatment (T2). In this way, (T2-T1)-(T1-T0) represented the effect the result of appliance therapy alone and each subject served as his/her own control. A computerized cephalometric analysis was used including variables assessing sagittal and vertical relationships of skeletal and soft tissue profiles, incisal relationships, soft tissue thickness, and lip structure. Data were analyzed by means of paired t tests, Pearson's product-moment coefficient correlation, and multiple regression analyses. The results showed significant improvements in dentofacial profile after 6 months of maxillary protraction. The skeletal and soft tissue facial profiles were straightened and the posture of the lips was improved. The normal incisal relationship (overjet) that was achieved had a significant impact on the soft tissues overlying both upper and lower incisors resulting in better lip competence and posture. Significant correlations were found between changes in the sagittal relationships of skeletal and soft tissue profiles in both the maxilla and the mandible (p < 0.05). The forward movement of the maxilla was accompanied by a corresponding forward movement of the soft tissue profile at 50% to 79% of the hard tissue. In the mandible, the downward and backward movements of the soft tissues were equivalent to 71% to 81% of the corresponding hard tissues. The lack of high r square values in the multiple regression analyses reflected a low prediction value for the maxillary variables, but moderately high prediction value for the mandibular variables that could be used in preorthopedic treatment planning. This study showed that significant dentoskeletal changes and improvements in dentofacial profile resulted from 6 months of treatment with maxillary expansion and protraction.

The significance of 5'-nucleotide phosphodiesterase isozymes in the diagnosis of liver carcinoma

The results of determination of the serum 5'-NPDase isozymes in 95 cases of primary liver carcinoma and other kinds of disease are presented. The 5'-NPDase-V was positive in 83.2% of primary liver cancer cases. This test might be a useful supplement to AFP determination, especially in AFP-negative liver cancer patients. In most patients who had undergone successful liver resection for primary carcinoma, the test became negative. A positive 5'NPDase-V test in patients with cancer elsewhere in the body may suggest liver metastasis. In addition, this test may be of some help in the differentiation of primary liver cancer from other kinds of liver disease. The problem of "false-positive" results of this test is discussed.