Skeletal manifestations of rickets in infants and young children in a historic population from England

Gross and radiographic changes characteristic of inadequate bone mineralization due to rickets are described in 21 immature skeletons from a 19th century urban population from Birmingham, England. The aims of the study are as follows: to evaluate and if possible augment existing dry-bone criteria for the recognition of rickets in immature skeletal remains; to investigate the value of radiography for the paleopathological diagnosis of rickets; and to compare and contrast the expression of rickets in this group with that previously documented for a rural agrarian population from Wharram Percy, England. Some gross skeletal signs of rickets which were not previously well-documented in paleopathological studies are noted. The worth of radiography for evaluating structural changes to both cortical and trabecular bone in the disease is demonstrated, and features useful for the interpretation of vitamin D deficiency are discussed. The pattern of skeletal elements affected and the severity of changes differs in the Birmingham group from that seen in the comparative rural population. It is emphasized that a variety of factors may influence the expression of rickets in paleopathological material, including rate of skeletal growth, age cohort affected, and intensity of vitamin D deficiency. Nevertheless, careful analysis, not only of the frequency of rickets but also of the degree of severity of lesions and the patterning with respect to skeletal elements affected, may enable more nuanced understanding of the biocultural context of the disease in earlier populations.

Third molar treatment outcome: a comparison of patients' preferences in Sweden and Wales

AIM

To elucidate and compare patients' outcome preferences for removal and retention of mandibular third molars in Sweden and Wales.

SUBJECTS AND METHOD

The subjects comprised patients referred and scheduled for removal of one or both mandibular third molars in Sweden and Wales. The multi-attribute utility (MAU) methodology was applied to study patients' preferences for outcomes of removal and retention of the mandibular third molar.

RESULTS

Relative weighting of domains was similar in the two countries. "Home and social life" received the highest relative weighting in Sweden and "general health and wellbeing" in Wales. "Your appearance" received the lowest relative weighting in both countries. In both Sweden and Wales operative jaw fracture was considered to be the outcome with most impact, and dentigerous cyst and imbricated incisors the least impact. Outcome ranking was similar in both countries and operative outcomes were considered by patients to be more detrimental to health than retention outcomes.

CONCLUSIONS

This comparison showed that patients' preferences in Sweden and Wales were similar and that the outcomes of surgery were considered worse after third molar removal than retention. Patient-orientated treatment decisions were less subject to variation than clinician-orientated decisions.

Comparison of decisions regarding prophylactic removal of mandibular third molars in Sweden and Wales

OBJECTIVE

To test the hypothesis that Swedish dentists schedule more mandibular third molars for prophylactic removal compared with UK dentists and oral surgeons.

DESIGN

Clinical and radiographic information relating to a stratified sample of 36 disease-free mandibular third molars (equal distribution of males and females, patients' age, angular position and degree of impaction) was presented to 26 general dental practitioners (GDPs) and 10 oral surgeons in Sweden and 18 GDPs and 10 oral surgeons in Wales who were asked to decide whether or not the third molars should be removed.

RESULTS

There was no evidence of any difference in mean number of molars scheduled for removal by the GDPs, but the Swedish oral surgeons scheduled significantly more third molars for removal than oral surgeons in Wales.

CONCLUSION

The less interventionist approach among oral surgeons in the UK may reflect the development and application of authoritative guidelines in the UK and an extensive debate concerning appropriateness of prophylactic removal there.

The outcomes of mandibular third molar removal and non-removal: a study of patients' preferences using a multi-attribute method

The aim was to study patients' preferences about outcomes of mandibular third molar removal and non-removal using multi-attribute utility (MAU) methodology. The study comprised three stages. Stage 1: Elicitation of domains, i.e. main areas of patients' lives which could be affected by third molar removal and non-removal. Stage 2a: Interdomain weighting was obtained by relative weighting of the domains elicited in Stage 1. Stage 2b: Intradomain weighting obtained by patients' designation of values for different health states of each domain. Stage 3: Rating of outcomes. The patients were asked to imagine experiencing a variety of outcomes of mandibular third molar removal and non-removal, described in 19 short vignettes. The numbers of patients interviewed for the three stages were 30, 78, and 55, respectively. Five domains were identified. The mean relative weightings were approximately equal for the domains "Home and social life" and "General health and well-being", followed in order of importance by 'Job and studies" and "Health and comfort of mouth, teeth and gums". "Your appearance" received the lowest mean relative weighting. The vignette, which described the presence of a fluid-filled sac and suggested that this tooth must be removed, received the highest mean preference (least effect on patients' lives). The lowest mean preference (most effect on patients' lives) was generated by the vignette, which stated that the jaw was broken and that the teeth must be wired together for 6 weeks. We conclude that, from the patient's perspective, outcomes of non-removal were preferable to outcomes of mandibular third molar removal.

Relationship between bone density and osteoarthritis in a skeletal population from London

To determine whether bone density was related to the presence of osteoarthritis in past populations, bone density was determined directly on bone slices taken from the fourth lumbar vertebra of a series of skeletons from a cemetery in London used from the middle 18th to the early 19th centuries. Eighty male and 57 female skeletons were studied and standard anthropological methods were used to determine age and gender. Osteoarthritis was diagnosed by the presence of eburnation on joint surfaces. The mean bone density in the males was 0.351 (+/-0.071) g/cm2, and in the females 0.332 (+/-0.091); this difference was statistically significant (p = 0.045). There was a significant, negative relationship with bone density and age in females (p = 0.0023), but not males (p = 0.073). Forty-seven of the males and 30 of the females had osteoarthritis, the most commonly affected joints being the facet joints of the spine and the hands. For the males there was no significant difference in bone density in those with or without osteoarthritis, but in females the bone density was significantly lower (p = 0.021) in those with osteoarthritis than in those without. The reasons why this result differs from modern populations in which patients with osteoarthritis tend to have higher bone density are discussed, and it is suggested that the most plausible explanation may relate to differences in nutritional status between past and modern populations.

Public health aspects of third molar surgery. The effect of surgeons' treatment thresholds on efficiency and effectiveness

Disease associated with third molars is being recognised increasingly as a public health problem in terms both of rising incidence and of appropriate use of resources. Since minor alterations in treatment philosophy can have a substantial impact on the efficiency and effectiveness of oral surgery services, this study examines the sensitivity and specificity of oral surgeons' decisions and uses Receiver Operator Characteristics (ROC) analysis to investigate their ability to detect and make appropriate judgements about teeth which need extraction according to established criteria. The study shows that the seniority of the surgeon making the treatment decisions had no significant effect on the decisions made and also demonstrated wide variations between the treatment plans made by individual clinicians. It is clear from this study that if an efficient and effective service for the treatment of third molar disease is to be commissioned, policy decisions about criteria for intervention must be made by health service purchasing authorities, adhered to by secondary care providers, and shared with the primary care practitioners who refer patients for treatment.

The relevance of health state utilities to lower third molar surgery

A study of the attitudes of 102 arts and science undergraduate students was carried out to establish relative utility values, that is the participants own assessments, for possible outcomes of surgical intervention and non-intervention in lower third molar management. Using a standardised visual analogue scale, respondents were asked to rate 17 outcomes of treatment presented to them by means of short descriptions (vignettes). Ranking of mean utility values showed that post operative complications were considered to be a greater handicap than the sequelae of leaving third molars in situ. The respondents considered that the effects of irreversible lingual and inferior dental nerve damage reduced health to a major degree, and that normally encountered post operative complications such as moderate pain, swelling and trismus were a greater handicap than recurrent mild/moderate pericoronitis.

Decision analysis for lower-third-molar surgery

The objective of the study was to identify those factors that should affect treatment planning for patients who have lower third molars, using decision-analytic techniques. Utility values based on data from 104 patients indicated that the respondents considered that postoperative complications (except mild pain and temporary paresthesia) reduced health to a greater degree than did complications following non-intervention. A decision analysis indicated that the maximum expected utility of prophylactic third-molar surgery (60.25) was lower than that for non-intervention (76.96). The decision was sensitive to changes in the probabilities of occurrence of recurrent pericoronitis (threshold = 0.52), resorption of an adjacent tooth (threshold = 0.29), loss of an adjacent tooth (threshold = 0.32), and cystic change (threshold = 0.34). These thresholds are much higher than the incidence of problems affecting the lower third molar shown by a concurrent clinical audit and literature review. This study therefore suggests that lower third molars should not be removed prophylactically.

Comparison of clinical treatment decisions with US National Institutes of Health consensus indications for lower third molar removal

Treatment decisions about lower third molar surgery have important clinical and cost implications. Although indications for surgery have been the subject of a National Institutes of Health (NIH) consensus conference at which several unambiguous criteria were agreed, no prospective investigations have been carried out to compare clinic treatment decisions with these consensus criteria. Treatment decisions made by six Hospital Service oral surgeons were therefore evaluated for 72 consecutive patients (28 men, 44 women) aged 15-44 years (mean age 25 years), referred for lower third molar assessment. The presence of local disease; recurrent pericoronitis; caries not amenable to restorative measures; follicular cyst formation; internal/external resorption and periodontal disease was recorded by an independent observer immediately after treatment planning had been completed. Of the 139 third molars present, 55 were unerupted, 79 partially erupted and 5 fully erupted. Thirty patients had been scheduled for surgery under general anaesthesia (GA), 36 under local anaesthesia and six patients had not been scheduled for surgery. A total of 42 teeth, according to NIH consensus criteria, had no indications for removal, of which 27 had been scheduled for surgery. These excluded disease-free contralateral teeth that had been scheduled for removal under GA. When a single episode of pericoronitis was excluded as a valid indication, 39 teeth did not meet criteria for removal but had been scheduled for surgery. It was concluded that two-thirds of lower third molars not meeting NIH consensus criteria for surgery had been scheduled for removal. The reasons for this, which may include inappropriate criteria, require further research.

Activity analysis: measurement of the effectiveness of surgical training and operative technique

All surgical procedures are characterised by a sequence of steps and instrument changes. Although surgical efficiency and training in operative technique closely relate to this process, few studies have attempted to analyse it quantitatively. Because efficiency is particularly important in day surgery and lower third molar removal is a high-volume procedure, the need for which is responsible for particularly long waiting-lists in almost all UK health regions, this operation was selected for evaluation. A series of 80 consecutive procedures, carried out for 43 day-stay patients under general anaesthesia by seven junior staff (senior house officers and registrars: 39 procedures) and four senior staff (senior registrars and consultants: 41 procedures) were analysed. Median operating time for procedures which required retraction of periosteum was 9.5 min (range 2.7-23.3 min). Where these steps were necessary, median time for incision was 25 s (range 10-90 s); for retraction of periosteum, 79 s (range 5-340 s); for bone removal, 118 s (range 10-380 s); for tooth excision, 131 s (range 10-900 s); for debridement, 74 s (range 5-270 s); and for suture, 144 s (range 25-320 s). Junior surgeons could be differentiated from senior surgeons on the basis of omission, repetition and duration of these steps. Juniors omitted retraction of periosteum in 10% of procedures (seniors 23%) and suture in 13% (seniors 32%). Juniors repeated steps in 47% of operations; seniors, 14%. Junior surgeons took significantly more time than senior surgeons for incision, bone removal and tooth excision. No significant differences between junior and senior surgeons were found in relation to the incidence of altered lingual and labial sensation at 7 days. It was concluded that activity analysis may be a useful measure of the effectiveness of surgical training and the efficiency of operative technique.