Accuracy of different approaches for detecting proximal root caries lesions in vitro

OBJECTIVES

The objective was to evaluate the diagnostic accuracy of radiographic evaluation (XR), visual-tactile assessment (VT), laser-fluorescence (LF) (DIAGNOdent Pen/KaVo), and near-infrared-light transillumination (NILT) (DIAGNOcam/KaVo) on proximal root caries lesions in vitro.

METHODS

Two-hundred extracted permanent premolars and molars with and without proximal root caries lesions were allocated to 50 diagnostic models simulating the proximal contacts between teeth and mounted in a phantom dummy head. Two independent examiners used the diagnostic approaches to detect any or advanced root caries lesions, with histologic evaluation of the lesions serving as reference. Receiver operating characteristic (ROC) curves were employed, and sensitivity, specificity, and the area under the ROC curve (AUC) are calculated. Significant differences in mean AUCs between approaches were assumed if p < 0.05 (two-sample t-test).

RESULTS

NILT was not applicable for proximal root caries detection. The sensitivity/specificity to detect any lesions was 0.81/0.63 for XR, 0.76/0.88 for VT and 0.81/0.95 for LF, and the sensitivity/specificity to detect advanced lesions was 0.43/0.94 for XR, 0.66/0.99 for VT, and 0.83/0.78 for LF, respectively. For both, any and advanced root caries lesions, mean AUCs for LF and VT were significantly higher compared to XR (p < 0.05). For any root caries lesions, LF was significantly more accurate than VT (p = 0.01), but not for advanced root caries lesions (p = 0.59).

CONCLUSIONS

Under the in vitro conditions chosen, LF and VT were more accurate than XR to detect proximal root caries lesions, with LF being particularly useful for initial lesion stages.

CLINICAL RELEVANCE

LF might be a useful diagnostic aid for proximal root caries diagnosis. Clinical studies are necessary to corroborate the findings.

Outcome of revascularization therapy in traumatized immature incisors

Background

The aim of this retrospective analysis was to evaluate the clinical and radiological outcome of revascularization therapy in traumatized permanent incisors to determine whether this approach could be implemented into clinical routine.

Methods

A total of 16 traumatized incisors (either avulsion or severe luxation/intrusion) with open apices (> 1 mm) that underwent revascularization following a standardized protocol were analyzed with a mean follow-up of 22 months. Radiographs and clinical parameters (such as root length, pulp space, dentin wall width, apical foramen, alveolar bone loss, ankylosis/mobility, supra−/infraposition, discoloration, probing depth) were compared pre- and postoperatively and statistically analyzed.

Results

Over the follow-up period, 81.3% of the teeth survived revascularization and regained sensitivity, while 18.7% failed, as they had to be extracted due to serious root resorption. Regarding radiographic outcomes a significant difference could only be found in the decrease of apical foramina (p = 0.04). The other parameters showed no significant difference between pre- and postoperative measurements. More than half of the teeth (56.3%) developed root resorptions and 31.3% displayed signs of ankylosis and 92.9% developed discolorations during follow-up. However, 85.7% of the teeth maintained the bone level and outcomes of mobility showed a significant solidification.

Conclusions

Revascularization is a promising approach for the treatment of immature incisors to regain sensitivity and to enhance apical closure and at least to maintain alveolar bone in terms of a socket preservation. Further studies have to be performed to determine ideal conditions (type of trauma, age, width of apical foramen) for a revascularization.

Effect of iloprost on serum creatine kinase and lactate dehydrogenase isoenzymes after isoprenaline-induced cardiac damage in rats

The effect of iloprost was investigated in an experimental model of cardiac damage in rats after isoprenaline (isoproterenol) treatment. Iloprost was administered by continuous subcutaneous infusion at a dose of 0.44 micrograms/kg body weight (b.w.)/min over a total period of 9 days. On day 8, 5 mg isoprenaline/kg b.w. was applied subcutaneously to induce the cardiac damage. The determinations of creatine kinase (CK, EC 2.7.3.2) and CK isoenzymes, lactate dehydrogenase (LDH, EC 1.1.1.27) and LDH isoenzymes as well as a-hydroxybutyrate dehydrogenase (a-HBDH, no EC) were performed 2, 6 and 24 h after isoprenaline application. Immediately after the last blood sampling, the animals were sacrificed and the hearts were examined histologically. Iloprost-pretreated animals showed a reduction in the rise in heart-specific isoenzymes CK-MB and LDH1-3 in the serum after isoprenaline application. A decrease in isoenzymes CK-BB and LDH4-5 in the serum was also observed in iloprost-pretreated rats. However, no difference could be detected histologically in the extent of myocardial necrosis between animals treated with isoprenaline alone or in combination with iloprost. These results suggest a biochemical cardioprotective effect of iloprost in this rat model after isoprenaline application and the lack of correlation with histological findings is discussed.

Serum isoenzyme pattern of creatine kinase and lactate dehydrogenase in various animal species

The creatine kinase and lactate dehydrogenase isoenzyme pattern were determined in the serum of normal and untreated rats, rabbits, dogs, monkeys and pigs. The relative distribution of all isoenzymes in the serum and an electrophoretic pattern for each animal species are presented. The isoenzyme serum pattern showed a great variation between the species. The diagnostic value of serum creatine kinase isoenzyme MB and lactate dehydrogenase isoenzymes 1 and 2 in predicting cardiac lesions in different animal species is briefly discussed.

Diagnostic value of serum creatine kinase and lactate dehydrogenase isoenzyme determinations for monitoring early cardiac damage in rats

Serum activities of creatine kinase (CK, EC 2.7.3.2) and CK isoenzymes, lactate dehydrogenase (LDH, EC 1.1.1.27) and LDH isoenzymes, alpha-hydroxybutyrate dehydrogenase (alpha-HBDH, no EC) and the LDH/alpha-HBDH ratio were studied following a single s.c. application of 5-250 mg isoproterenol/kg body weight (b.w.) in rats. Measurements of the serum enzymes and histological and enzyme-histochemical examinations of hearts were performed 2, 4, 6, 8 and 24 h after treatment. A drastic increase in serum levels of the isoenzymes CK-MB, LDH1, LDH2 and alpha-HBDH and decrease in the ratio LDH/alpha-HBDH were observed from 2 h onwards after isoproterenol application in all dose groups, the maximum effect being after 4-8 h. Focal cellular injury in the myocardium could also be observed from 2 h onwards after isoproterenol application by an enzyme-histochemical method using nitro blue tetrazolium (NBT) whereas the earliest histological alterations using haematoxylin and eosin (HE) stain could be detected 6 h after treatment. A dose-dependent effect as to enzyme values as well as to myocardial necrosis was observed 24 h after isoproterenol application. No kidney damage could be detected on the basis of serum urea nitrogen and histological examinations. Thus, measurement of serum activities of CK-MB isoenzyme alone or LDH1-2 isoenzymes in combination with other tests to exclude kidney damage are valuable indicators of cardiac lesions in rats.

An aminopterin-like syndrome without aminopterin (ASSAS)

In two patients that closely resembled the phenotype of the syndrome produced by aminopterin in early pregnancy, no evidence of maternal exposure could be elicited. These, plus two similar cases from the literature, suggest the existence of an "aminopterin-like syndrome sine aminopterin" (ASSA) syndrome. Characteristic traits are: ossification defects of the cranium, temporal recession of hairline with upswept frontal hair pattern, ocular hypertelorism, prominent nose root, low set posteriorly rotated ears, limited elbow movement, variable digital defects, simian creases, short stature, and mild to moderate psychomotor retardation. Autosomal recessive inheritance is a possibility.

Spondylocostal/spondylothoracic dysostosis: the clinical basis for prognosticating and genetic counseling

Short trunk dwarfism involving skeletal anomalies of vertebrae and ribs have been reported under various names. Both dominant and recessive and severe and mild conditions are found. We report on a patient without a severe handicap by age 3 years despite severe involvement of the thorax at birth, suggesting that a more complete classification of such anomalies is needed for counseling. We have used an objective method to classify 39 informative patients from the literature, 35 said to have a recessive disease and four a dominant one. Two patients with the costovertebral segmentation defect with mesomelia (COVESDEM) syndrome were added for comparison with our patient. The results of cluster analysis show that there are three phenotypic groups of patients. Cluster 1 contains 19 patients with a severe form of spondylothoracic dysplasia; cluster 2 includes patients with a mild autosomal recessive and a dominant type; cluster 3 groups the two sibs with the COVESDEM syndrome and our patient. One must be cautious in advising families of the prognosis for a child with severe structural chest deformity since it may not be severe from a functional point of view. More data are needed for complete discrimination between the mild autosomal recessive and dominant forms.

Diagnosis of chromosome 3 duplication q23----qter, deletion p25----pter in a patient with the C (trigonocephaly) syndrome

The cells of a deceased patient previously reported to have the C (trigonocephaly) syndrome were reinvestigated because his phenotype resembled that of a patient with a duplication-deficiency of chromosome 3. This diagnosis was confirmed using fibroblasts grown from frozen cells, and his mother was shown to carry an inversion of chromosome 3 in her peripheral blood leukocytes. His findings are compared to those of another patient with the C trigonocephaly syndrome with normal chromosomes and to others from the literature. At least one other patient from the literature has a phenotype compatible with "3q duplication syndrome."

Heterogeneity by cluster analysis techniques of Graves' patients typed for HLA DR and IgG heavy chain markers

In a previous study we were able to separate, using cluster analysis, 196 patients with Graves' disease evaluated for a large number of clinical and laboratory characteristics, including HLA-A and HLA-B typing into one subset with recurring disease and a high prevalence of ophthalmopathy and another subset with mild disease and little ophthalmopathy. Prevalence of HLA-B8 was much higher in the first as compared to the second group. The present study was undertaken in 117 new patients with Graves' disease, typed for HLA-A, HLA-B, HLA-C and DR antigens and IgG heavy chain markers, to determine whether these characteristics could be used to segregate patients into clinically relevant subsets. There was a greater proportion of Gm fb homozygotes among patients than among controls (chi2 = 4.71, p less than 0.05) as well as individuals with HLA-B8 and DR3, previously documented for this disease. Two patient clusters were identified. In one (C1), there is a high incidence of exophthalmos, recurrence of hyperthyroidism after drug treatment, high titres of anti-thyroglobulin antibody, and an association with other autoimmune (including thyroid) diseases, a tendency for the disease to be familial and the presence of larger goitres. The incidence of HLA-B8 was greater in C1, while HLA-B12 was more frequent in the mild cluster, C2. HLA-DR3 was found to be associated with patients in the severe cluster and HLA-DR2 with patients in the mild cluster.(ABSTRACT TRUNCATED AT 250 WORDS)

A prognostic score for Graves' disease

We have reanalysed the clinical and laboratory data on 196 individuals with Graves' disease. The consensus of two clustering techniques and a new method of allocating patients to a cluster resulted in two groups of patients, those with a severe and others with a mild disease. The severe disorder is characterized by a high frequency of HLA-B8 and -Al, a low complement level, high titres of circulating immune complex and anti-thyroglobulin antibody, a high lymphocyte transformation index and serum T3 level, a low level of active E-rosettes, large goitres and a high value for the Crooks test. The mild disorder shows a higher frequency of HLA-B12 and an abnormally low absolute lymphocyte number. A weight was calculated for each character according to the relative frequency in the two clusters. A total score could then be calculated for each patient based on their clinical and laboratory findings. There were two distinct distributions of scores corresponding to the two subgroups. This suggests different aetiological factors which may be more easily studied in these more homogeneous groups. Prognostic predictions can be made using the score. The risk of recurrence and the frequency and severity of ophthalmopathy increases dramatically as the score increases. The use of the score in making therapeutic decisions needs to be tested.

Noonan syndrome: the changing phenotype

Among the multiple congenital anomalies (MCA) syndromes, the Noonan syndrome (NS) is a cardiofacial syndrome in which affected individuals may be short and mildly mentally retarded. Autosomal dominant inheritance of Noonan syndrome with variable expressivity has been documented in many families. Genetic heterogeneity has been postulated in Noonan syndrome because of the wide phenotypic variability, the relatively high incidence, and the occasional recurrence in sibs with apparently normal parents. Clinical variability is usual in autosomal dominant disorders, and mildly affected individuals may be difficult to recognize as gene carriers. Thus, a family with two or more affected children may simulate autosomal recessive inheritance. We have studied serial and family photographs of NS individuals in order to assess the likelihood of gene carriers' being missed in genetic studies. We have confirmed wide clinical variability within families, and more importantly, we have documented marked change of phenotype with age from the newborn period, infancy, childhood, and adolescence to adulthood. Manifestations in adults may be subtle and some without a known heart defect or other medically significant problems may have been considered normal in the past. Our study, while not ruling out causal heterogeneity, suggests that the change of phenotype with age may have been falsely perceived as clinical heterogeneity. A particular and subtle phenotype must be searched for in parents of affected children.

A taxonomic approach to the del(4p) phenotype

The findings of 23 patients with the del(4p) phenotype are compared systematically. Three patients with a small deletion evident only on analysis of extended chromosomes have a phenotype comparable to 13 patients with a more extensive chromosomal deletion. Two patients with no detectable deletion also fit into the phenotypic spectrum of patients with del(4p), suggesting the same etiology. Five patients with fewer typical and more atypical findings probably represent a heterogeneous group of other syndromes. Numerical analysis of the phenotype allows one to identify patients who most likely have a deletion requiring a more intensive cytogenetics analysis.

Clinical confusion of the Noonan syndrome with the Börjeson-Forssman-Lehmann syndrome

The diagnosis of Börjeson-Forssman-Lehmann syndrome in a patient reported by Veall et al. (1979) is challenged. The clinical findings were compared with those in 32 patients with the Noonan syndrome using the extensive description, dermatoglyphics, photographs and anthropometric measurements provided in the paper. The patient's findings are compatible with the Noonan syndrome based on his overall phenotypic similarity to the 32 patients, even though the severity of his mental retardation is atypical.

Trisomy 9 (pter----q1 to q3): the phenotype as an objective aid to karyotypic interpretation

The phenotypic findings of three patients whose karyotypic interpretations were uncertain were compared to patients with trisomy 9 (pter---q1 to q3). One with an extra, small acrocentric chromosome and another with a trisomy due to an inherited C/G translocation have a phenotype compatible with the trisomy 9 (pter----q1) syndrome. In a third patient reported with 47,XY,?16+, the trisomy 9p probably extends past the q1 region.

Differential diagnosis of the Williams and the Noonan syndromes

A diagnostic index has been devised to distinguish between the Noonan and the Williams syndromes. Twins from the literature reported as having the Williams syndrome more likely represent the Noonan syndrome.

The Williams syndrome: objective definition and diagnosis

Fifty-two patients referred for suspicion of the Williams syndrome have been evaluated and divided into those with and without the syndrome by numerical analysis. A diagnostic index using 50 characters separates patients into two groups with an expected accuracy of 99%. An index using 40 of the characteristics is expected to be applicable to young infants without a substantial decrease in accuracy.

The Marshall and Stickler syndromes: objective rejection of lumping

To answer the question of whether nosological splitting of the Marshall and Stickler syndromes is justified at the phenotypic level, we surveyed published reports on the two syndromes and applied an objective method to determine this. A set of 18 patients with clinical description, photographs, and radiographs was used to tabulate a list of 53 signs. Cluster analysis using these signs showed that there are two groups of patients with different phenotypes. An index score based on the 20 most discriminating signs was applied to other reported patients and the authors' diagnosis confirmed. There is therefore no objective reason to consider that these two syndromes are not separate dominant disorders with variable expressivity.

An oculocerebral hypopigmentation syndrome

An oculocerebral hypopigmentation syndrome consisting of growth retardation, dolichocephaly, cataracts, high arched palate, small, widely spaced teeth, generalized hypopigmentation, psychomotor retardation, progressive neurological manifestations and hypochromic anemia is described in sibs. The finding of parental consanguinity supports autosomal recessive inheritance. The syndrome resembles the Cross syndrome (1,2).

Definition and diagnosis of the Brachmann-De Lange syndrome

We have classified patients referred for suspicion of the Brachmann-De Lange syndrome (BDLS) into two groups using techniques of numerical taxonomy. Patients with the syndrome share an array of abnormal characteristics, and those without it have different abnormal characteristics. A group of 30 characters that best distinguish the two groups of patients was used to construct a diagnostic index. The index score is expected to divide 99% of patients into those with and without the syndrome, leaving 1% in a "zone of doubt." All 46 patients used to construct the index and 16 new patients had scores in either the BDLS or non-BDLS range and none were in the zone of doubt. A previously published index using metacarpal-phalangeal measurements, although less discriminatory, confirmed our findings in 84% of 25 patients tested, the remainder having scores in the zone of doubt for that index.

Waardenburg syndrome--penetrance of major signs

We have estimated that 83% of individuals carrying the gene for Waardenburg syndrome type I show penetrance of the gene as measured by dystopia canthorum. This is lower than previous estimates, which failed to consider the frequency of equivocal dystopia in the general population. The addition of three other major signs (hearing loss, white forelock, and premature graying of the hair or vitiligo) does not substantially increase the discrimination of gene carriers (85% versus 83%). We estimate that about 75% of the first-degree relatives of probands can be assigned as normal or a gene carrier on the basis of the four major signs.

Formal analysis of dysmorphism: objective methods of syndrome definition

A set of descriptors was developed and used to code patients with 4p or 9p monosomy or trisomy, "blind" as to their karyotype. Techniques of numerical taxonomy were used to classify the patients on the basis of their phenotypic resemblance. As expected, the results confirm strong phenotype-karyotype correlations. When cytogenetic interpretations are uncertain, the phenotypic findings may confirm or refute the interpretations. The approach has practical implications, providing further knowledge of phenotypic effects of specific chromosomal segments, which will aid cytogeneticists in their search for karyotypic defects. More important, the results also serve as an excellent model for developing strategies for the classification of syndromes of unknown etiology.

Increased morphological variants in children with learning disabilities

Previous studies have shown that children with learning disabilities have more morphological variants or anomalies than normal children, suggesting that the morphological and central nervous system effects may be the result of the same prenatal factors. The morphological variants were assumed to have arisen in the first 3 months of prenatal development, which may not be so. We have partitioned variants into those that probably arise early in fetal development ("early" variants) and those that could arise later and could be due to altered growth ("late" variants). There was an increase in both "early" and "late" variants but only that the "late" variants was statistically significant. Although the method of measuring one "early" variant (dermal patterns) was sensitive enough to detect mild disturbances in children with isolated congenital heart disease, such a disturbance was not found in our group of learning-disabled patients. Our findings suggest that the developmental disturbances resulting in morphological variants may act later in prenatal development than was previously believed. This information may be helpful in searching for clues to the etiology of this heterogeneous group of disabilities.

A diagnostic index for Down syndrome

We have made use of eight phenotypic findings of Down syndrome to develop an effective diagnostic index. We estimate that about 95% of patients who are suspected of having the syndrome can be categorized as having or not having it with 99.9% confidence. One can thereby make a fast clinical diagnosis on the majority of suspects before karyotyping is complete, allowing one to inform parents soon after birth and, in some instances, to make medical decisions about life-threatening defects. Furthermore, one can avoid the expense of chromosome studies on most patients who do not have the syndrome, unless there are other indications for chromosome studies. The eight features used in the index include three dermatoglyphic traits (hallucal and forefinger pattern, and palmar triradius), two measurements of physical traits (ear length and internipple distance), and three other clinical findings (Brushfield spots, wide-spaced first toe, and excess back neck skin).

The distorted shell method for clustering for syndrome classification

Syndrome classification may be described as the arrangement of individuals into groups on the basis of their phenotypic resemblance. This paper describes how phenotypic resemblance may be quantified and demonstrates a numerical method called distorted shell clustering, which isolates groups of phenotypically similar individuals representing syndromes. This new method takes into consideration apparent biological properties of syndromes. It allows for overlapping phenotypes between syndromes, and differing character association and variability within syndromes. This method is compared to four other clustering methods by using suspects for a syndrome of known etiology (Down syndrome). The numerical results based on the phenotype then can be compared with the actual diagnosis. Only the distorted shell method classifies patients, without error, into two major clusters: the Down and the non-Down, while maintaining a high level of efficiency.

The hand profile on de Lange syndrome: diagnostic criteria

The hand pattern profiles of 18 previously published and 10 new cases of de Lange syndrome were compared to those of cases referred as suspects, but judged clinically and by numerical taxonomic methods not to have de Lange syndrome (non-de Lange). Based on a Poznanski metacarpophalangeal profile of the 2 groups of patients, a simple scoring system using 11 measurements was devised using the 16 most marked differences within and between metacarpals and phalanges. Of the metacarpals, the first is shorter than the second, third, fourth, or fifth; and the second and fifth are shorter than the third or fourth. Of the middle phalanges, the third and fourth are shorter than the respective metacarpal and than the second and fifth middle phalanx. Of the distal phalanges, the fifth is shorter than the second. The mean Z score for these 11 measurements is further below normal in the de Lange group than in the non-de Lange group. All 11 non-de Lange patients had a score less than 17, and all 28 de Lange patients had a score of 18 or more.

A diagnostic index for Down syndrome

A simple and effective index for the diagnosis of Down syndrome is presented. It makes use of 12 characters with from two to nine states. The simple format allows persons with limited knowledge of the characters to use it. Simplicity was attained by combining character states when this did not result in a loss of discrimination and by avoiding characters that were redundant, subject or difficult to evaluate. A combination of characters that occur frequently in Down syndrome (wide applicability and characters that have a high relative frequency (high probability) was used. Additional data from comparable samples were used to calculate more representative scores for some characters. Over 82% of suspected cases may be diagnosed as having or not having Down syndrome with 99.9% confidence. Conditional probabilities for the various scores are provided. Individuals whose scores are in the Down or non-Down zones have a 98.7% probability or greater of having or not having the syndrome, respectively. The index is more effective than others as measured both by the percentage of individuals with and without Down syndrome whose scores fall into distinct zones (overlap method) and by the percentage with Down syndrome who have positive scores and controls who have negative scores (single point classification).

Renal anomalies and oligohydramnios in the cerebro-oculofacio-skeletal syndrome

We describe two infants with the cerebro-oculofacio-skeletal syndrome in whom oligohydramnios is an additional finding. The oligohydramnios could be accounted for in one by renal agenesis but cannot in the other, who had a functioning and histologically normal kidney. The diagnosis of Potter syndrome was suspected in both patients. It is important in counseling to recognize the distinctive phenotype of this autosomal-recessive syndrome.

A methodology for establishing a diagnostic index for syndromes of unknown etiology

A method has been developed to test for heterogeneity in syndromes of unknown etiology and to distinguish between patients with and without the syndrome. The validity of the method was tested on a group of patients suspected of having a syndrome that can be diagnosed by other means (Down syndrome), and was found to be effective. The method was then applied to a group of patients suspected of having a syndrome of unknown etiology (de Lange). It was shown that the group appears to be heterogeneous. A preliminary diagnosis of having or not having the syndrome was made in about 80% of the patients.

A screening test for patients suspected of having Turner syndrome

An index has been devised using dermatoglyphics and selected physical traits to screen for patients suspected of having Turner syndrome. About 60% of females with and without Turner syndrome can be diagnosed as having or not having the syndrome with a 98% or greater probability. The patient's score on the index, expressed in probability, can be used to decide whether chromosome studies should be done. Using the approach demonstrated in this pilot study, the discriminative power can be increased by adding more features and by enlarging the sample to permit division of features into more discriminating classes.