Ixazomib, Lenalidomide, and Dexamethasone (IRD) Treatment with Cytogenetic Risk-Based Maintenance in Transplant-Eligible Myeloma: A Phase 2 Multicenter Study by the Nordic Myeloma Study Group

Scarce data exist on double maintenance in transplant-eligible high-risk (HR) newly diagnosed multiple myeloma (NDMM) patients. This prospective phase 2 study enrolled 120 transplant-eligible NDMM patients. The treatment consisted of four cycles of ixazomib-lenalidomide-dexamethasone (IRD) induction plus autologous stem cell transplantation followed by IRD consolidation and cytogenetic risk-based maintenance therapy with lenalidomide + ixazomib (IR) for HR patients and lenalidomide (R) alone for NHR patients. The main endpoint of the study was undetectable minimal residual disease (MRD) with sensitivity of <10-5 by flow cytometry at any time, and other endpoints were progression-free survival (PFS) and overall survival (OS). We present the preplanned analysis after the last patient has been two years on maintenance. At any time during protocol treatment, 28% (34/120) had MRD < 10-5 at least once. At two years on maintenance, 66% of the patients in the HR group and 76% in the NHR group were progression-free (p = 0.395) and 36% (43/120) were CR or better, of which 42% (18/43) had undetectable flow MRD <10-5. Altogether 95% of the patients with sustained MRD <10-5, 82% of the patients who turned MRD-positive, and 61% of those with positive MRD had no disease progression at two years on maintenance (p < 0.001). To conclude, prolonged maintenance with all-oral ixazomib plus lenalidomide might improve PFS in HR patients.

Idelalisib (PI3Kδ inhibitor) therapy for patients with relapsed/refractory chronic lymphocytic leukemia: A Swedish nation-wide real-world report on consecutively identified patients

OBJECTIVES

We examined the efficacy and toxicity of the PI3Kδ inhibitor idelalisib in combination with rituximab salvage therapy in consecutively identified Swedish patients with chronic lymphocytic leukemia (CLL).

METHODS AND RESULTS

Thirty-seven patients with relapsed/refractory disease were included. The median number of prior lines of therapy was 3 (range 1-11); the median age was 69 years (range 50-89); 22% had Cumulative Illness Rating Scale (CIRS) >6 and 51% had del(17p)/TP53 mutation. The overall response rate was 65% (all but one was partial response [PR]). The median duration of therapy was 9.8 months (range 0.9-44.8). The median progression-free survival was 16.4 months (95% CI: 10.4-26.3) and median overall survival had not been reached (75% remained alive at 24 months of follow-up). The most common reason for cessation of therapy was colitis (n = 8, of which seven patients experienced grade ≥3 colitis). The most common serious adverse event was grade ≥3 infection, which occurred in 24 patients (65%).

CONCLUSIONS

Our real-world results suggest that idelalisib is an effective and relatively safe treatment for patients with advanced-stage CLL when no other therapies exist. Alternative dosing regimens and new PI3K inhibitors should be explored, particularly in patients who are double-refractory to inhibitors of BTK and Bcl-2.

Carfilzomib and dexamethasone maintenance following salvage ASCT in multiple myeloma: A randomised phase 2 trial by the Nordic Myeloma Study Group

Objective

We investigated the efficacy and safety of carfilzomib‐containing induction before salvage high‐dose melphalan with autologous stem‐cell transplantation (salvage ASCT) and maintenance with carfilzomib and dexamethasone after salvage ASCT in multiple myeloma.

Methods

This randomised, open‐label, phase 2 trial included patients with first relapse of multiple myeloma after upfront ASCT who were re‐induced with four cycles of carfilzomib, cyclophosphamide and dexamethasone. Two months after salvage, ASCT patients were randomised to either observation or maintenance therapy with iv carfilzomib 27 → 56 mg/sqm and p.o. dexamethasone 20 mg every second week. The study enrolled 200 patients of which 168 were randomised to either maintenance with carfilzomib and dexamethasone (n = 82) or observation (n = 86).

Results

Median time to progression (TTP) after randomisation was 25.1 months (22.5‐NR) in the carfilzomib‐dexamethasone maintenance group and 16.7 months (14.4–21.8) in the control group (HR 0.46, 95% CI 0.30–0.71; P = .0004). The most common adverse events during maintenance were thrombocytopenia, anaemia, hypertension, dyspnoea and bacterial infections.

Conclusion

In summary, maintenance therapy with carfilzomib and dexamethasone after salvage ASCT prolonged TTP with 8 months. The maintenance treatment was in general well‐tolerated with manageable toxicity.

Somatic health in the Indigenous Sami population - a systematic review

The objective of this systematic review was to survey the current scientific knowledge regarding the state of somatic health among the Indigenous Sami people in Norway, Finland, Sweden and the Kola Peninsula in Russia; and assess the quality of the identified studies. A systematic search in the databases Pubmed, EBSCOhost (AMED, Medline, Cinahl) and Svemed was conducted from January 2000, through December 2017. This systematic search identified 399 articles. After screening abstracts, 93 articles were reviewed in full text, 32 of which met the inclusion criteria. The scientific quality of the evidence was rated according to the Newcastle–Ottawa scale. Based on the studies with moderate to high scientific quality, there is evidence for stating that the majority of the Sami included in this review experience good health. Mortality and life expectancy are similar, with only minor differences, to those of a non-Sami population. The cancer risk rate among Sami was lower than that of the general population of Norway, Sweden and Finland. Self-reported myocardial infarction prevalence was similar between Sami and non-Sami, but Angina pectoris was more prevalent among Sami. In Sweden, cardiovascular disease rates were similar between Sami and non-Sami. Musculoskeletal pain symptoms are common among the Sami population, as are obesity and overweight. To conclude, there are knowledge gaps in regard to the somatic health situation of the Indigenous Sami in the circumpolar area, especially in Russia, Finland and Sweden; as current knowledge is mainly based on publications from the SAMINOR study in Norway. No study obtained the highest quality score, suggesting a need to implement longitudinal prospective studies.

Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability have reduced rotational torque in the forearm

A total of 20 patients scheduled for wrist arthroscopy, all with clinical signs of rupture to the triangular fibrocartilage complex and distal radioulnar joint instability, were tested pre-operatively by an independent observer for strength of forearm rotation. During surgery, the intra-articular pathology was documented by photography and also subsequently individually analysed by another independent hand surgeon. Arthroscopy revealed a type 1-B injury to the triangular fibrocartilage complex in 18 of 20 patients. Inter-rater reliability between the operating surgeon and the independent reviewer showed absolute agreement in all but one patient (95%) in terms of the injury to the triangular fibrocartilage complex and its classification. The average pre-operative torque strength was 71% of the strength of the non-injured contralateral side in pronation and supination. Distal radioulnar joint instability with an arthroscopically verified injury to the triangular fibrocartilage complex is associated with a significant loss of both pronation and supination torque.

LEVEL OF EVIDENCE

Case series, Level IV.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.

Infant mortality of Sami and settlers in Northern Sweden: the era of colonization 1750-1900

The study deals with infant mortality (IMR) that is one of the most important aspects of indigenous vulnerability.

Abandoning "the other": statistical enumeration of Swedish Sami, 1700 to 1945 and beyond

Sweden has one of the world's most eminent and exhaustive records of statistical information on its population. As early as the eighteenth century, ethnic notations were being made in parish registers throughout the country, and by the early nineteenth century a specific category for the Sami population had been added to the forms used to collect data for the Tabellverket (National Population Statistics). Beginning in 1860, the Sami were also counted in the first official census of the Swedish state. Nonetheless--and in contrast to many other countries--Sweden today lacks separate statistical information not only about its sole recognized indigenous population but also about other ethnic groups. The present paper investigates Sweden's attempts to enumerate its indigenous Sami population prior to World War II and the cessation of ethnic enumeration after the war. How have the Sami been identified and enumerated? How have statistical categories been constructed, and how have they changed over time? The aim of this essay is not to assess the validity of the demographic sources. Instead the paper will explore the historical, social, and cultural factors that have had a bearing on how a dominant administrative structure has dealt with the statistical construct of an indigenous population.

The northern population development; colonization and mortality in Swedish Sápmi, 1776-1895

OBJECTIVES

The aim of the Consequence of Colonization project is to study population development and mortality in Swedish Sápmi. This article, the first to be drawn from our research, compares these changes between Sami and non-Sami, South and North Sami. Study design. Longitudinal individual based data from computerized records ofthe Glillivare, Undersåker and Frostviken parishes, divided into 2 40-year periods: 1776-1815 and 1856-1895.

METHODS

The main source material used for the present study was a set of data files from the Demographic Data Base (DDB) at Umeå University, the largest historical database in Europe. A Sami cohort was created by indicators of ethnicity in the parish registers, and was later extended with automatic linkages to children and parents.

RESULTS

Sami mortality rates show great fluctuations during the period 1776-1815, almost always peaking at a higher rate than in the rest of Sweden. The non-Sami group had lower mortality rates compared with both Sweden as a whole and the Sami in the parish. Between 1856 and 1895, the non-Sami experienced a very small reduction in their mortality rates and the Sami experienced overall improvement in their health status. Significant differences in age-specific mortality appear when the South and North Sami are compared, showing that the South Sami had far lower child mortality rates.

CONCLUSIONS

The Sami population's health status improved during the nineteenth century. This indicates that they had advanced in the epidemiologic transition model. A corresponding change is not found for the non-Sami group.

The effect of a needs-related caries preventive program in children and young adults - results after 20 years

The risk for caries development in children varies significantly for different age groups, individuals, teeth, and surfaces. Thus from a cost-effectiveness point of view, caries preventive measures must be integrated and based on predicted risk from age group down to individual tooth surfaces. Based on this philosophy and experiences from continuously ongoing research on evaluating and reevaluating separate and integrated caries preventive measures, as well as methods for prediction of caries risk, a needs-related caries preventive program was introduced for all 0-19-year-olds in the county of Värmland, Sweden, in 1979. The goals for the subjects following the program from birth to the age of 19 years were: 1. To have no approximal restorations. 2. To have no occlusal amalgam restorations. 3. To have no approximal loss of periodontal attachment. 4. To motivate and encourage individuals to assume responsibility for their own oral health. The effect of the program is evaluated once every year on almost 100% of all 3-19-year-olds in a computer-aided epidemiologic program from 1979. Most of the individualized preventive program was carried out by dental hygienists or prophy dental assistants at clinics in the elementary schools. During the 20-year period the percentage of caries-free 3-year-olds increased from 51% to 97%. In 1999 as many as 86% of the 12-year-olds were caries free. Caries incidence was reduced more than 90% in all age groups. More than 90% did not develop any new caries lesions in 1999. As a consequence, caries prevalence was dramatically reduced. In 12- and 19-year-olds, the mean number of Decayed and Filled Surfaces (DFS) per individual was reduced from 6 to 0.3 and from 23 to 2 respectively. In 19-year-olds the mean number of approximal DFS was <1, and only 0.5 had to be filled. The mean number of occlusal DFS was <1. Since 1995 we have not been allowed to use amalgam in 1-19-year-olds in Sweden. As an effect of our high quality plaque program, approximal attachment loss was prevented, and by efficient education in self-care based on self-diagnosis, needs-related self-care habits were established. Thus it can be concluded that nearly 100% of our goals had been achieved.

The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance

BACKGROUND

The biofilm that forms and remains on tooth surfaces is the main etiological factor in caries and periodontal disease. Prevention of caries and periodontal disease must be based on means that counteract this bacterial plaque.

OBJECTIVE

To monitor the incidence of tooth loss, caries and attachment loss during a 30-year period in a group of adults who maintained a carefully managed plaque control program. In addition, a comparison was made regarding the oral health status of individuals who, in 1972 and 2002, were 51-65 years old.

MATERIAL AND METHODS

In 1971 and 1972, more than 550 subjects were recruited. Three hundred and seventy-five subjects formed a test group and 180 a control group. After 6 years of monitoring, the control group was discontinued but the participants in the test group was maintained in the preventive program and was finally re-examined after 30 years. The following variables were studied at Baseline and after 3, 6, 15 and 30 years: plaque, caries, probing pocket depth, probing attachment level and CPITN. Each patient was given a detailed case presentation and education in self-diagnosis. Once every 2 months during the first 2 years, once every 3-12 months during years 3-30, the participants received, on an individual need basis, additional education in self-diagnosis and self-care focused on proper plaque control measures, including the use of toothbrushes and interdental cleaning devices (brush, dental tape, toothpick). The prophylactic sessions that were handled by a dental hygienist also included (i) plaque disclosure and (ii) professional mechanical tooth cleaning including the use of a fluoride-containing dentifrice/paste.

RESULTS

Few teeth were lost during the 30 years of maintenance; 0.4-1.8 in different age cohorts. The main reason for tooth loss was root fracture; only 21 teeth were lost because of progressive periodontitis or caries. The mean number of new caries lesions was 1.2, 1.7 and 2.1 in the three groups. About 80% of the lesions were classified as recurrent caries. Most sites, buccal sites being the exception, exhibited no sign of attachment loss. Further, on approximal surfaces there was some gain of attachment between 1972 and 2002 in all age groups.

CONCLUSION

The present study reported on the 30-year outcome of preventive dental treatment in a group of carefully monitored subjects who on a regular basis were encouraged, but also enjoyed and recognized the benefit of, maintaining a high standard of oral hygiene. The incidence of caries and periodontal disease as well as tooth mortality in this subject sample was very small. Since all preventive and treatment efforts during the 30 years were delivered in one private dental office, caution must be exercised when comparisons are made with longitudinal studies that present oral disease data from randomly selected subject samples.

Betamethasone does not prevent nausea and vomiting induced by ipecacuanha

BACKGROUND

Corticosteroids reduce the incidence of PONV but the mode of action is not known. The purpose of this study was to evaluate if betamethasone has serotonin (5-HT) antagonistic effects. Ipecacuanha is known to release serotonin and therefore it was used to induce nausea and vomiting. The 5-HT3 antagonist ondansetron was used as a control substance.

METHODS

In a randomized, double-blind, cross-over, placebo-controlled study 10 healthy male and female volunteers (6 M/4F), mean age 19.5 (18-23) years, mean weight 69.7 (53-84) kg, were studied on three occasions separated by at least 1 week. They were randomly allocated to receive pretreatment with betamethasone 8 mg, ondansetron 8 mg, or normal saline 2 ml as placebo on each occasion, 15 min before oral ingestion of 30 ml of Ipecacuanha syrup. After ingestion of ipecacuanha, vomitings were recorded and the intensity of nausea was estimated with a visual analog scale during 2 h.

RESULTS

During the first 2 h after ingestion of ipecacuanha nine of the 10 volunteers vomited both after betamethasone and placebo. No volunteer vomited after ondansetron (P < 0.01 vs. betamethasone and placebo). The max VAS for nausea was significantly higher after betamethasone and placebo compared to ondansetron (P < 0.01). There were no statistically significant differences of the max VAS for nausea between betamethasone and placebo.

CONCLUSION

This study in volunteers has shown that betamethasone does not prevent nausea and vomiting induced by oral intake of ipecacuanha syrup. As ipecacuanha releases 5-hydroxytryptamin, it can be concluded that betamethasone does not have 5-HT3 antagonistic effects.

Some characteristics of 50/55-year-old individuals with various experience of destructive periodontal disease: a cross-sectional study

OBJECTIVE

To analyze the association between subject characteristics and degree of destructive periodontal disease in a randomly selected sample of 50/55-year-old individuals.

METHODS

A randomized and geographically stratified (urban/rural districts) subject sample composed of dentate 50-year-old (n = 190) and 55-year-old individuals (n = 359) from the county of Varmland, Sweden were examined. Data were collected through full mouth clinical and radiographic examinations and by the use of questionnaires. Based on the cumulative distribution of the individuals with respect to mean probing attachment loss (PAL), subgroups of subjects with the lowest (L20%) and highest (H20%) experience of PAL were identified. Similar classifications were made for never-smokers and current smokers. Correlation analyses and forward stepwise logistic regression models were performed.

RESULTS

The subgroup with the most extensive PAL loss (H20%) included a significantly higher proportion of (i) males (60 vs 33%), (ii) subjects with low educational level (65 vs 41%), (iii) smokers (49 vs 15%), and had (iv) less favorable lifestyle characteristics than the subgroup with minimal experience of PAL loss (L20%). The same pattern of differences was observed when the analysis was restricted to never-smokers, with the addition of a significantly lower proportion of subjects living in urban areas (40 vs 69%) in the H20% compared to the L20% subgroup. The stepwise logistic regression analysis revealed that number of teeth and smoking habits were significant factors in the identification of individuals in the L20% subgroup. For the H20% subgroup, number of teeth, gender, number of cigarettes/day and lifestyle index were significant explanatory variables.

CONCLUSION

Number of remaining teeth and smoking habits were identified as the main discriminating factors for classification of subjects with regard to degree of destructive periodontal disease.

Intra-oral pattern of tooth and periodontal bone loss between the age of 50 and 60 years. A longitudinal prospective study

OBJECTIVE

In a 10-year prospective study we analyzed (i) the intra-oral pattern of and (ii) potential risk factors for tooth and periodontal bone loss in 50-year-old individuals.

METHODS

A randomized subject sample of 50-year-old inhabitants in the County of Varmland, Sweden, was examined at baseline and after 10 years. Data from full-mouth clinical and radiographic examinations and questionnaire surveys of 309 (72%) of the individuals who were dentate at baseline were available for analysis. Non-parametric tests and binary logistic multiple regression models were used for statistical analysis of the data.

RESULTS

4.1% of the 7,101 teeth present at baseline, distributed among 39% of the subjects, were lost during the 10-year interval. The incidence of tooth loss was highest among mandibular molars (7.5%) and lowest among canines (1.8%). The relative risk (RR) for tooth loss for endodontically compromised teeth was 4.1 and for furcation-involved molars 2.4-6.5, depending on tooth position. Logistic regression analysis identified baseline alveolar bone level (ABL), endodontic conditions, CPITN score (Community Periodontal Index of Treatment Needs), tooth position, caries, and educational level as risk factors for tooth loss. The overall mean 10-year ABL change was -0.54 mm (S.E. 0.01). On a tooth level the ABL change varied between -0.35 mm (mandibular molars) and -0.79 mm (mandibular incisors). Smokers experienced a greater (20-131% depending on tooth type) mean bone loss than non-smokers. The logistic regression model revealed that tooth position, smoking, and probing pocket depth > or =4 mm were risk factors for bone loss of >1 mm. No pertinent differences were observed with respect to risk factors for ABL change in the subgroup of non-smokers compared to the results of the analysis based on the entire subject sample.

CONCLUSION

Tooth loss was more common in the molar than in the anterior tooth regions, while periodontal bone loss had a random distribution in the dentition. The predominant risk factors identified with regard to further radiographic bone loss were "probing pocket depth > or =6 mm" and "smoking".

Some risk factors for periodontal bone loss in 50-year-old individuals. A 10-year cohort study

OBJECTIVE

The aim of this 10-year prospective study of 50-year-old individuals was to analyze the incidence of periodontal bone loss and potential risk factors for periodontal bone loss.

METHODS

The subject sample was generated from an epidemiological survey performed in 1988 of subjects living in the County of Värmland, Sweden. A randomized sample of 15% of the 50-year-old inhabitants in the county was drawn. At the 10-year follow-up in 1998, 320 (75%) of the 449 individuals examined at baseline were available for re-examination, out of which 4 had become edentulous. Full-mouth clinical and radiographic examinations and questionnaire surveys were performed in 1988 and 1998. Two hundred and ninety-five individuals (69%) had complete data for inclusion in the analysis of radiographic bone changes over 10 years. Non-parametric tests, correlations and stepwise multiple regression models were used for statistical analysis of the data.

RESULTS

The mean alveolar bone level (ABL) in 1988 was 2.2 mm (0.05) and a further 0.4 mm (0.57) (p=0.000) was lost over the 10 years. Eight percent of the subject sample showed no loss, while 5% experienced a mean bone loss of >/=1 mm. Smoking was found to be the strongest individual risk predictor (RR=3.2; 95% CI 2.03-5.15). When including as smokers only those individuals who had continued with the habit during the entire 10-year follow-up period, the relative risk was slightly increased (3.6; 95% CI 2.32-5.57). Subjects who had quit smoking before the baseline examination did not demonstrate a significantly increased risk for disease progression (RR=1.3; 95% CI 0.57-2.96). Stepwise multiple regression analysis revealed that smoking, % approximal sites with probing pocket depth >/=4 mm, number of teeth and systemic disease were significant explanatory factors for 10-year ABL loss (R(2)=0.12). For never smokers, statistically significant predictors were number of teeth, mean ABL, % periodontally healthy approximal sites and educational level (R(2)=0.20).

CONCLUSION

The inclusion of smokers in risk analysis for periodontal diseases may obstruct the possibility to detect other true risk factors and risk indicators.

[The history of polio in Sweden - from infantile paralysis to polio vaccine]

Although other epidemics declined due to improved hygiene and sanitation, legislation, and vaccination, polio epidemics appeared in Sweden in 1881 and at the turn of the 20th century the disease became and annual feature in the Swedish epidemiological pattern. Due to the vaccination starting in 1957 epidemics ceased to exist in Sweden around 1965. This article deals with the history polio epidemics in Sweden, 1880-1965 and gives a brief description of: the demographical influence of polio, how did the medical authorities investigate and try to combat it, and the different comprehensions of how polio affected its victims.A study of polio incidence in Sweden at the national level during 1905-1962 reveals that the disease caused major epidemics in 1911-1913 and 1953. At the beginning of the 20th century polio primarily attacked children up to 10 years of age, and at the end of the period victims were represented in all age groups, but mainly in the ages 20-39. Due to its enigmatic appearance, polio was not considered as an epidemic infectious disease during the 19th century. Sweden's early epidemics enabled Swedish medical science to act and together with American research institutes it acquired a leading role in international medical research on the disease. In the 1955 Jonas Salk produced the first successful vaccine against polio but also Sweden developed its own vaccine, different in choice of methods and materials from the widely used Salk-vaccine.

Association between level of education and oral health status in 35-, 50-, 65- and 75-year-olds

AIM

The aim of the present study was to evaluate the association between educational level and dental disease, treatment needs and oral hygiene habits.

MATERIAL AND METHODS

Randomized samples of 35-, 50-, 65- and 75-year-olds, classified according to the educational level: [low (LE): elementary school or higher (HE)], were identified. In 1091 subjects, a number of characteristics such as (i) number of teeth, (ii) periodontal attachment levels (PAL), (iii) caries and (iv) occlusal function were recorded. Educational level, oral hygiene and dietary habits were self-reported. Non-parametric variables were analyzed by chi2, Mann-Whitney U-Wilcoxon's rank sum tests, and parametric variables by Student's t-test (level of significance 95%). A two-way anova was performed on decayed, missing and filled surfaces to investigate the interaction between age and educational level. All statistical procedures were performed in the SPSS statistical package.

RESULTS

The number of remaining teeth was similar for LE and HE in the 35-year olds (25.8 versus 26.6), but in the older age groups LE had significantly a larger number of missing teeth. The LE groups (except in 65-year olds) exhibited significantly more PAL loss. LE had significantly fewer healthy gingival units in all but the 75-year age group. In all age groups, LE had fewer intact tooth surfaces and a significantly poorer occlusal function. The frequency of tooth cleaning measures and dietary habits did not differ between LE and HE.

CONCLUSION

Educational level was shown to influence the oral conditions and should be considered in assessing risk, and in planning appropriate preventive measures.

Isodicentric 7p, idic(7)(q11.2), in acute myeloid leukemia associated with older age and favorable response to induction chemotherapy: a new clinical entity?

Three adult de novo acute myeloid leukemias (AML M1, M2, and M4) with an isochromosome 7p are presented. No additional abnormalities were detected by G-band and multicolor, using combined binary ratio labeling, fluorescence in situ hybridization (FISH) analyses, indicating that the i(7p) was the sole, i.e., the primary, chromosomal aberration. Although the patients were elderly--68, 72, and 78 years old--they all responded very well to chemotherapy, achieving complete remission lasting more than a year. Further FISH analyses, using painting, centromeric, as well as 7q11.2-specific YAC probes, revealed that the i(7p) contained two centromeres and that the breakpoints were located in 7q11.2. Thus, the abnormality should formally be designated idic(7)(q11.2). The detailed mapping disclosed a breakpoint heterogeneity, with the breaks in 7q11.2 varying among the cases, being at least 1,310 kb apart. Furthermore, the breakpoints also differed within one of the cases, being located on both the proximal and the distal side of the most centromeric probe used. Based on our three patients, as well as on a previously reported 82-year-old patient with AML M2 and idic(7)(q11) as the only chromosomal change, we suggest that this abnormality, as the sole anomaly, is associated with AML in elderly patients who display a good response to induction chemotherapy and, hence, have a favorable prognosis. Furthermore, the heterogeneous breakpoints in 7q11.2 suggest that the important functional outcome of the idic(7)(q11.2) is the genomic imbalance incurred, i.e., gain of 7p and loss of 7q material, rather than a rearrangement of a specific gene.

Is there increased intervertebral mobility in isthmic adult spondylolisthesis? A matched comparative study using roentgen stereophotogrammetry

STUDY DESIGN

By roentgen stereophotogrammetric technique, the intervertebral mobility of the spondylolytic segment in eight patients was measured and compared with the mobility of eight nonspondylolytic patients matched according to sex, afflicted segment, and grade of disc degeneration.

OBJECTIVES

To compare the intervertebral mobility of a spondylolytic segment with the mobility of a segment without spondylolysis in adult patients with back pain.

SUMMARY OF BACKGROUND DATA

Evidenced by the resulting olisthetic deformity and supported by the outcome from prior investigations, spondylolysis is assumed to induce spinal segmental instability/hypermobility.

METHODS

After percutaneous application of tantalum indicators for roentgen stereophotogrammetric technique, the intervertebral translations of the spondylolytic fifth lumbar vertebra were measured in eight adult patients with low back pain and low-grade olisthesis. Eight other patients without spondylolysis but with low back pain presumably on degenerative basis were chosen for comparison and had an identical measuring procedure using roentgen stereophotogrammetric technique. The two groups were matched in pairs according to sex, afflicted segment, and grade of disc degeneration.

RESULTS

No significant difference was registered considering the intervertebral mobility for matched pairs in the two groups neither along the sagittal nor the vertical axis. The transverse translations were mostly negligible in both groups.

CONCLUSION

The spondylolytic defect in pars interarticularis does not cause permanent instability/hypermobility detectable in the adult patient with low back pain and low-grade olisthesis.

External pedicular fixation of the lumbar spine: outcome evaluation by functional tests

We analyzed the pain-relieving effect and the functional outcome during external pedicular fixation of the lumbar spine. Twenty patients were included, and the diagnoses were disc degeneration with or without facet joint arthrosis in eight patients, pain after decompression in six patients, spondylolysis/olisthesis in two patients, other types of lumbar anomalies in three patients, and pseudarthrosis after prior uninstrumented fusion in one patient. Before application of the external frame, the pain level on the Visual Analogue Scale was registered at rest, as a mean level for the preceding week, and at seven different functional tests. Maximum walking capacity and walking time needed for a standardized distance were also measured. The same test procedure was repeated 1 week postoperatively with the external frame applied in locked position. With stabilization, 11 patients reported pain relief at rest and 14 when approximating the mean pain level for the week. Both these measured levels correlated to the pain level at all of the seven functional tests. Thus, the patients selected for a subsequent fusion based on pain relief during extended functional provocation would not differ from the patients selected by using only the pain-relieving effect at rest. The patients reporting pain relief tended to increase their walking distance (p = 0.06, t test) but not the speed of walking.

Stability of lumbar fusion with transpedicular fixation determined by roentgen stereophotogrammetric analysis

STUDY DESIGN

An evaluation of the intervertebral stability of transpedicular instrumentation in posterolateral lumbar fusions by roentgen stereophotogrammetric analysis.

OBJECTIVES

To determine the in vivo intervertebral stability of posterolateral lumbar fusions augmented with transpedicular screws and plates.

SUMMARY OF BACKGROUND DATA

Transpedicular bone screw systems have been found to be as safe and clinically effective as other types of devices in stabilizing surgery of the spine. Many experimental studies have yielded basic data on the stabilizing implant effect in vitro, but the exact in vivo stabilizing effect on human lumbar vertebrae has not been presented previously.

METHODS

In 12 patients, the intervertebral stability of posterolateral fusion in the lower lumbar spine augmented with transpedicular screws and plates was evaluated by serial roentgen stereophotogrammetric analysis with the patients in supine and erect positions 1 year after surgery.

RESULTS

Screws in each fused vertebra yielded stable fixation or permitted sagittal intervertebral translations smaller than 1 mm induced by the positional change. A widely decompressed and destabilized vertebra without screw fixation yielded persisting intervertebral translations.

CONCLUSIONS

The current study demonstrated the adequacy of in vivo stability of lumbar fusions augmented with transpedicular screws and plates. Sagittal translation seems easier to elicit than movements along the other three-dimensional axes. A widely decompressed and destabilized vertebra without screw fixation increases the risk for persisting intervertebral translations. The roentgen stereophotogrammetric analysis technique described seems to be a good way of comparing the in vivo behavior of different implant systems.

Relationship between smoking and dental status in 35-, 50-, 65-, and 75-year-old individuals

The aim of the present study was to examine the dental status and smoking habits in randomized samples of 35-, 50-, 65-, and 75-year-old subjects (n = 1093), recruited for a cross-sectional epidemiological study in the County of Värmland, Sweden. The following clinical variables were recorded by 4 well-calibrated dentists: number of edentuolous subjects, number of missing teeth, probing attachment level, furcation involvement, CPITN scores, DMF surfaces, plaque and stimulated salivary secretion rate (SSSR). In addition, the subjects reported in a questionnaire their tobacco habits, oral hygiene habits, dietary habits etc. The percentage of smokers in 35-, 50-, 65-, and 75-year-olds was 35%, 35%, 24% and 12%, respectively. In 75-year-olds, 41% of the smokers were edentulous compared to 35% of non-smokers. The difference in number of missing teeth between smokers and non-smokers was 0.6 (p=0.15), 1.5 (p=0.013), 3.5 (p=0.0007) and 5.8 (p=0.005) in the 4 age groups. Smokers had the largest mean probing attachment loss in all age groups. The differences between smokers and non-smokers in mean attachment level were 0.37 (p=0.001), 0.88 (p=0.001), 0.85 (p=0.001) and 1.33 mm (p=0.002) in the 35-, 50-, 65-, and 75-year-olds, respectively. Treatment need assessed by CPITN was in all age groups greatest among smokers. The number of intact tooth surfaces was fewer in 35-, 50-, and 75-year-old smokers than in non-smokers. The number of missing surfaces (MS) was higher in 50-, 65-, and 75-year-old smokers than in non-smokers. In addition, 35-year-old smokers exhibited a significantly larger number of decayed and filled tooth surfaces (DFS) than non-smokers. Male smokers had significantly higher SSSR than non-smoking males (p=0.012). Plaque index and oral hygiene were similar in smokers and non-smokers. Smokers reported a more frequent intake of sugar containing soft drinks (p=0.000) and snacks (p=0.003) than non-smokers. The opposite was reported for consumption of fruit (p=0.003). It was concluded that smoking is a significant risk indicator for tooth loss, probing attachment loss and dental caries.

Posterolateral lumbar fusion using facet joint fixation with biodegradable rods: a pilot study

Roentgen stereophotogrammetric analysis (RSA) was used to assess whether there is a potential for biodegradable rods crossing the denuded facet joints to increase the stability and healing rate of lumbar posterolateral fusions. Eleven consecutive patients with lumbosacral disc/facet joint degeneration had a posterolateral fusion augmented with 2- or 3.2-mm biodegradable rods passing perpendicularly through the center of the denuded facet joints. The patients were followed-up with RSA in supine and erect positions monthly from the 2nd to the 6th postoperative month, and again 1 year postoperatively. All seven L5-S1 fusions healed. Four cases were stable as defined by RSA within 3 months, two within 6 months, and one within 1 year. One L4-S1 fusion could not be evaluated by RSA. None of the remaining three L4-S1 fusions fully healed. In all three cases 1- to 3-mm intervertebral translations remained at 1 year. None of the 11 fusions showed any radiographic signs of osteolysis around the biodegradable rods. The promising results of this pilot study indicate that posterolateral L5-S1 fusion augmented with transarticular biodegradable rods crossing the denuded facet joints may yield rapid intervertebral stabilization and a high healing rate without any adverse rod effects. This may be due to enhanced initial fusion stabilization and/or increased ossification induced by the rods.

The spondylolytic vertebra and its adjacent segment. Mobility measured before and after posterolateral fusion

STUDY DESIGN

By using roentgen stereophotogrammetric analysis in six patients having tantalum indicators implanted at a preoperative external fixation test, the mobility in the spondylolytic lumbosacral level and its adjacent segment could be studied before fusion and during the course of postoperative fusion consolidation.

OBJECTIVE

To study the mobility effects on the segment adjacent to a lumbar fusion over time from the preoperative situation until fusion healing as defined by roentgen stereophotogrammetric analysis.

SUMMARY OF BACKGROUND DATA

In vitro studies indicate that the altered biomechanical situation after lumbar fusion increases the intradiscal pressure and changes the kinematics in the juxtafused segment.

METHODS

Six patients with low grade spondylolysisolisthesis were scheduled for fusion of the spondylolytic lumbosacral segment after a preoperative external fixation test. The latter procedure also included implantation of tantalum markers for spinal roentgen stereophotogrammetric analysis. Each patient was examined by roentgen stereophotogrammetric analysis at four separate occasions: before fusion (2 months after removal of the external frame) and 3, 6, and 12 months after surgery. The translatory movements of the L5 vertebra in relation to sacrum and of the L4 vertebra in relation to the L5 vertebra were calculated at each examination.

RESULTS

For the juxtafused L4-L5 level, increased and decreased mobility patterns could be identified. Transformation of the preoperative mobility in the lumbosacral segment to the adjacent segment during fusion consolidation was verified in two patients but was not a general phenomenon.

CONCLUSION

Fusion of the lumbosacral segment can alter the kinematics of the adjacent segment, redistributing the mobility toward relative hypermobility in the juxtafused segment.

Mechanics of the external fixation test in the lumbar spine. A roentgen stereophotogrammetric analysis

STUDY DESIGN

By implanting tantalum indicators percutaneously during application of pedicular screws, lumbosacral mobility could be studied with roentgen stereophotogrammetric analysis in seven patients having a diagnostic external fixation test.

OBJECTIVES

To determine the mechanical effects on the segmental mobility during an external fixation test of the lumbar spine.

SUMMARY OF BACKGROUND DATA

External pedicular fixation test of the lumbar spine has been reported a valuable prognostic instrument in fusion for low back pain.

METHODS

A Magerl external fixation device was applied in seven patients with low-grade spondylolysis-olisthesis. By using roentgen stereophotogrammetric technique, the intervertebral translations in the lumbosacral segment were determined. Each patient had three separate examinations; with the frame fixed, with the frame loosened, and without frame 6 weeks after screw removal.

RESULTS

With the external frame fixed, the sagittal intervertebral translations were significantly reduced, in three cases to a level beneath the accuracy of the measuring method. One patient had the same immobilizing effect even with the frame loosened while for the others loosening of the frame meant regained mobility of the segment.

CONCLUSION

The properties of the external fixator give an adequate mechanical basis for the prognostic external fixation test in lumbar fusion.

Orthosis as prognostic instrument in lumbar fusion: no predictive value in 50 cases followed prospectively

To evaluate pain relief in a lumbar orthosis as a predictor for good clinical results after solid fusion, all patients scheduled for such a surgical procedure were preoperatively encouraged to use an orthosis, soft or rigid, for 3 weeks. Grade of back pain relief as a percent using the orthosis was assessed by the patients and was registered before surgery. After surgery, at 1-year follow-up, patients with nonunion demonstrated radiographically were excluded from the series. Thus, 50 patients with solid fusion could be identified and followed for at least 2 years prospectively. At follow-up these 50 patients graded the pain relief induced by the fusion. In the preoperative corset test, 31 patients experienced significant back pain relief, meaning a reduction of at least 50%. No applicable correlation was found, however, between outcome in this corset test and the eventual clinical result expressed as improvement/no improvement after solid fusion. The two types of orthoses did not differ in this aspect. We conclude that the orthosis, rigid or soft, is not a useful instrument when selecting patients for lumbar fusion.

Caries lesions and dental restorations as predisposing factors in the progression of periodontal diseases in adolescents. A 3-year longitudinal study

The present study used a novel approach to assess the relationship between untreated caries lesions and defective and non-defective dental restorations and the incidence of gingival inflammation and the progression of chronic inflammatory periodontal diseases at the approximal surfaces of posterior teeth and at the adjacent surface of the neighboring tooth in adolescents over a period of 3 years. Two hundred-twenty-seven (227) 13-year-old schoolchildren were examined clinically and radiographically at baseline and annually at three subsequent occasions. At each site the alveolar bone height and presence of gingival bleeding were assessed. Incipient caries lesions, manifest caries, and defective and non-defective restorations were identified at the same site and also at the adjacent approximal tooth surface at all examinations, both clinically and radiographically. The data were analyzed by the multi-level logistic regression and variance components analyses. On average, 32, 8.5, 7, and 10% of the sites, respectively, were diagnosed as having incipient caries, manifest caries, and defective and non-defective restorations. There was a significant association between the presence of untreated manifest caries lesions, non-defective and defective dental restorations, and the progression of periodontal support loss. Also there was an association between presence of defective restorations and manifest caries and the incidence of gingival inflammation. Consistently, factors detected at the involved site and at the adjacent site had significant effects. The present study indicates that untreated cavities and dental restorations are predisposing factors with a significant negative effect on periodontal health in adolescents.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of effect of oral hygiene training on periodontal disease progression over 3 years in adolescents

A comprehensive new oral hygiene training program has lately been described and found effective in controlling dental plaque formation and in significantly reducing the incidence of approximal dental caries and gingivitis in adolescents. This study investigated the long-term effect of plaque control on the progression of periodontal diseases in adolescents. A group of 227 Brazilian schoolchildren were followed up over a period of 3 years. The children were divided randomly into 3 groups. The first group was given a needs-related intensive program which combined detailed information to parents and children pertaining to the etiology and prevention of dental diseases, instructions in self-diagnosis of plaque and gingivitis, and a detailed oral hygiene training based on individual needs, together with continued feedback and motivation during the entire 3 years. The second group was given a similar program, but through shorter sessions and with no motivation and feedback and no training in self-diagnosis. A control group received no motivation sessions or oral hygiene training. The 3 groups were examined radiographically at baseline and annually at 3 subsequent occasions. The data were analyzed with a multi-level variance analysis. The frequency of subjects showing sites with alveolar bone loss increased steadily during the entire period in all groups. Neither of the training programs had a significant effect on the alveolar bone level during 3 years compared to the control group. Generally, girls demonstrated higher proportions of approximal tooth surfaces showing radiographic bone loss, though not statistically significant. In this population the supragingival plaque control lacked any significant effect on periodontal disease progression.(ABSTRACT TRUNCATED AT 250 WORDS)

Plaque formation at healthy and inflamed gingival sites in young individuals

The present investigation was performed to evaluate the influence of gingivitis on the amount of de novo plaque that forms during a 24-h period of no oral hygiene. 292 fully dentate subjects participated in the study. The condition of the gingiva and the presence of supragingival plaque were examined at 4 surfaces of each tooth at a baseline examination. Following this examination, the participants were subjected to a comprehensive mechanical tooth cleaning and instructed to refrain from tooth cleaning measures during the subsequent 24 h. The plaque examinations were repeated at the end of the 24-h period. The results from the clinical trial revealed that during a 24-h period of no tooth cleaning, subjects with naturally occurring overt gingivitis, in general, formed more plaque than young individuals with healthy gingivae. Furthermore, plaque in all parts of the dentition, formed more frequently on tooth surfaces adjacent to sites with gingivitis than at healthy sites. It was concluded that the condition of the gingiva plays an important role for de novo plaque formation.

The effect of a new oral hygiene training program on approximal caries in 12-15-year-old Brazilian children: results after three years

This study evaluated the effects of a new oral hygiene training program on approximal caries in a population of 12-13-year-old Brazilian schoolchildren with a well-established habit of daily toothbrushing with a F dentifrice. Two hundred twenty-two children were randomly allocated into two test groups (I and II) and one control group (III). Group I subjects were trained to establish needs-related oral hygiene habits based on self-diagnosis and a new behavioral principle, the 'linking method', for establishment of habits. The first three visits (20 minutes each) were scheduled at two-day intervals. They were recalled for a monthly check-up during the first 4 months, and then every 3 months for reevaluation of the results based on self-diagnosis. Group II subjects were recalled at the same intervals for detailed oral hygiene instruction on how to clean every tooth surface using dental tape, toothbrush, and fluoride dentifrice. Group I developed significantly fewer (p < 0.001) new approximal manifest (dentin) caries lesions than groups II and III. The mean values (SEM) were 2.3 (0.29), 4.7 (0.59), and 5.3 (0.68), respectively. The conclusions from our study are: In a toothbrushing population using fluoride dentifrices and fluoridated drinking water, the oral hygiene training program with behavioral modification significantly reduced caries incidence on approximal surfaces. Frequent repetition of training in meticulous oral hygiene is almost redundant.

Long-term effect of two preventive programs on the incidence of plaque and gingivitis in adolescents

The efficacy of two oral hygiene training programs on the control of plaque and the prevention of gingival inflammation in adolescents was evaluated during a 3-year period. A population of 227 Brazilian schoolchildren were divided into 3 groups. The first group received a comprehensive program based on individual needs and included information sessions pertaining to the etiology and prevention of dental diseases together with extensive training in self-diagnosis and oral hygiene. In addition, an information session was arranged for parents and teachers of these children. The second group received a less comprehensive program consisting of conventional oral hygiene training. The third group (control) received no preventive program. The programs were presented through frequent initial training sessions ensued by infrequent follow-up visits. During the experimental period, the two oral hygiene training programs involved 3.5 and 1.5 hours per child, respectively. The children were examined clinically at baseline and annually over the next 3 years to assess plaque and gingival bleeding and the data were analyzed by a multi-level variance component analysis. All children showed a perpetual improvement in their oral hygiene and gingival state during the course of the study. However, the improvements observed in the comprehensive group were significantly better than that of the control group. Results from the less comprehensive group were not significantly different from the control group. Longer exposure to the programs appeared to produce more improvement; children with higher plaque and gingivitis scores prior to the program showed less favorable results; girls exhibited better results than boys.(ABSTRACT TRUNCATED AT 250 WORDS)

Posterolateral lumbar fusion. Outcome of 71 consecutive operations after 4 (2-7) years

We report the outcome of 71 consecutive posterolateral lumbar fusions without spinal instrumentation. The indication for the operation was spondylolysis-olisthesis, degenerative disc disease/facet joint arthrosis, or pain after prior laminectomy. Concerning pain relief, 29/43 patients with spondylolysis-olisthesis were classified as good. The corresponding figures in the group with degenerative disc disease and/or facet joint arthrosis were 8/16 patients and in the group with pain post-laminectomy, 6/12 patients. No surgical complications were noted. In the total material 54 patients had a solid fusion, as defined by radiographic osseous trabecular bridging at all intended levels. One-level fusions tended to heal solidly in a higher frequency than two-level fusions. For the spondylolysis-olisthesis group, healed fusion correlated with a good clinical result. Such a correlation could not be verified for the other diagnostic groups. We conclude that non-instrumented posterolateral lumbar fusion is a valid method for treating low-grade spondylolysis-olisthesis, especially when the aim is to fuse a single level. Improved patient selection methods are required in fusion for degenerative disc disease and pain after laminectomy.

Effect of two preventive programs on oral health knowledge and habits among Brazilian schoolchildren

The effect upon dental health knowledge and dental health behavior of a comprehensive and a less comprehensive preventive program was compared in a 3-yr follow up study. The comprehensive program included active participation of the students and parental involvement. The study group consisted of 186 Brazilian schoolchildren 13 yr of age at the start of the program. A reference group from another school of similar socioeconomic level was included in the analyses. The data were collected from questionnaires filled in by the children under surveillance after the completion of the program. Significant differences in knowledge as well as in reported behavior were observed. The children enrolled in the comprehensive program in general scored higher in dental health knowledge than did those in the less comprehensive program. However, the latter group of children seemed to have acquired more correct knowledge during the period than had the control and reference children. Similar results were obtained concerning reported dental health behavior.

Current role of pharmaceuticals in prevention of caries and periodontal disease

Epidemiological studies, based on the tooth surface as a unit of reference, confirm a strong correlation between dental plaque and the initiation of dental caries and periodontal disease. Therefore, prevention of caries and periodontal disease must be based on plaque control. Dental plaque can be controlled both mechanically and chemically. Both methods can be achieved by self-care, or professionally by dentists and dental hygienists. Chemical antimicrobial products are used for non-specific plaque control, as well as against specific microbes associated with the aetiology of caries and periodontal disease. Most products are applied topically (mouthrinses, gels, dentifrices and varnishes). The use of fluoride is generally accepted specifically for caries prevention. It is evident that the caries preventive effects of fluorides are mainly post-eruptive due to fluoride in drinking water, milk, salt and tablets. Dentifrices are the major, most widespread commercial product for topical use, followed by mouthrinses, gels, prophy pastes and slow-release fluoride products such as varnishes and glass ionomers. Dentifrices, mouthrinses and gels containing both fluorides and antimicrobial agents are also available. Products, methods and programmes for all individuals and selected risk individuals are discussed.

How Swedish dental hygienists apply their training program in the field

The purpose of this study was to evaluate how clinical practice by Swedish dental hygienists was related to type of dental delivery system, period of training, educational institution attended and patient category. Dental hygienists from 14 different dental hygiene schools were represented. Of these schools, 11 are still in operation. A specially designed questionnaire was posted to all dental hygienists in Sweden (n = 1857). A total of 1399 questionnaire (75.3%) were completed and returned, providing data on 15,546 dental appointments. 37.2% of the Swedish dental hygienists are presently working in private practices, 45.8% in the public dental health service and 6.2% in both. Of the patients treated by hygienists, 88.7% were adults: 99.5% in private practice and 78.4% in the public dental health service. 42.0% of all dental hygienists were trained in 1980-84. The mean treatment time per appointment in private practice was 49.7 min and 45 min in the public dental health service. Scaling, root-planning and removal of overhangs took 27 min per visit in private practice and 22 min in the public dental health service. However, there were no significant differences in methods in the two delivery systems with respect to examinations, self-care training, professional mechanical toothcleaning (PMTC), topical fluoride application, or salivary and oral microbiology tests. The adult patient categories were periodontal risk (45.1%), caries risk (9.1%) and hygiene (34.6%). In periodontal risk patients, scaling, root-planning and removal of overhangs took 28 min per appointment and 14 min in caries risk patients.

New ideas and advancing technology in prevention and non-surgical treatment of periodontal disease

Analytical, oral epidemiological studies in adult 'toothbrushing' populations show that the highest prevalence of missing teeth is for molars and maxillary premolars ('key-risk' teeth). The highest prevalence of subgingival microflora, gingivitis (CPITN-1), plaque retentive factors, such as subgingival calculus and restoration overhangs (CPITN-2), and diseased pockets > 3 mm (CPITN-3-4) is found on the approximal surfaces of the same teeth ('key-risk' surfaces). Primary and secondary prevention, as well as treatment of periodontal disease should be focused on these 'key-risk' surfaces. One single, well-executed subgingival scaling and root-planning procedure in deep, diseased periodontal pockets, followed by oral hygiene training and professional mechanical tooth-cleaning (PMTC) at need-related intervals, will prevent further loss of periodontal attachment. However, if the root cementum is removed during instrumentation, and the post-treatment plaque control programme fails, microorganisms will recolonize and invade the rough exposed root dentine, resulting in recurrence of periodontitis and possibly, root caries and pulpitis. Some of these problems may be overcome by the application of new instruments and methods for self-care, PMTC, removal of overhangs, scaling and root-planing without removing 'non-diseased' cementum.

Lumbar orthosis with unilateral hip immobilization. Effect on intervertebral mobility determined by roentgen stereophotogrammetric analysis

To determine the additional stabilizing effect of unilateral hip fixation on external lumbar supports, nine patients with a posterolateral lumbosacral fusion without internal fixation were examined by roentgen stereophotogrammetric analysis. The roentgen stereophotogrammetric analysis was performed with the patients in supine and erect positions 1 month after surgery, that is, before fusion consolidation. Each patient was examined without lumbar support and with a molded, rigid thoracolumbosacral orthosis with extension to one thigh, thus immobilizing one hip. The additional hip immobilization had no consistent or significant stabilizing effect on the sagittal, vertical, or transverse intervertebral translations in the lower lumbar spine. This study using roentgen stereophotogrammetric analysis gave no support for including hip immobilization when using lumbar orthoses after spinal fusion in patients adequately cooperating to minimize gross body motions.