Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions

As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients.

Clinical Relevance: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Is the shortened dental arch an underused treatment strategy in the Republic of Ireland?

OBJECTIVES: To determine the proportion of Republic of Ireland 35-44 and 65+ year-olds currently satisfying the criteria for a classic shortened dental arch (SDA) of 20 anterior teeth.

RESEARCH DESIGN: Secondary analysis of data collected in the 2000/02 epidemiological survey of the oral health of Irish adults.

CLINICAL SETTING: Participants underwent a clinical oral examination in health board dental clinics and completed a detailed interview pertaining to dental and general health.

PARTICIPANTS: The analysis is based on a random sample of adults, aged 35 to 44 years (n = 978), and 65 years and older (n = 714).

MAIN OUTCOME MEASURES: The SDA was measured as 20 teeth in the mouth in the positions normally described as from the left second premolar to the right second premolar in each arch.

RESULTS: Only one of the 35-44 year-olds and none of the 65+ year-olds had teeth in their mouths in positions normally described as a classic SDA. However, of the 35-44 year old age group only five patients who had at least a premolar dentition of 20 contiguous teeth had been provided with a removable denture compared to one patient from the 65+ years group.

CONCLUSIONS: Very few older patients in the Republic of Ireland have a SDA based on the measure used. However, very few have been provided with removable dentures where they already possess at least a premolar dentition of 20 contiguous teeth. Suggested reasons for this may include limitations of the data recorded, patient preferences and economic factors.

Impact of tooth replacement strategies on the nutritional status of partially-dentate elders

OBJECTIVE: To investigate the impact of tooth replacement on the nutritional status of partially dentate older patients, and, to compare two different tooth replacement strategies; conventional treatment using removable partial dentures and functionally orientated treatment based on the shortened dental arch.

BACKGROUND: Amongst older patients, diet plays a key role in disease prevention, as poor diets have been linked to numerous illnesses. Poor oral health and loss of teeth can have very significant negative effects on dietary intake and nutritional status for elderly patients. There is evidence that good oral health generally, has positive effects on the nutritional intake of older adults.

MATERIALS AND METHODS: A randomised, controlled clinical trial was designed to investigate the impact of tooth replacement on the nutritional status of partially dentate elders. Forty-four patients aged over 65 years completed the trial, with 21 allocated to conventional treatment and 23 allocated to functionally orientated treatment. Nutritional status was accessed at baseline and after treatment using the Mini Nutritional Assessment (MNA) and a range of haematological markers.

RESULTS: At baseline, relationships were observed between the number of occluding tooth contacts and some measures of nutritional status. As the number of contacts increased, MNA scores (R = 0.16), in addition to vitamin B12 (R = 0.21), serum folate (R = 0.32) and total lymphocyte count (R = 0.35), also increased. After treatment intervention, the only measure of nutritional status that showed a statistically significant improvement for both treatment groups was MNA score (p = 0.03). No significant between group differences were observed from analysis of the haematological data.

CONCLUSION: In this study, prosthodontic rehabilitation with both conventional treatment and functionally orientated treatment resulted in an improvement in MNA score. Haematological markers did not illustrate a clear picture of improvement in nutritional status for either treatment group.

Accelerated rehabilitation of an edentulous patient with an implant retained dental prosthesis: a case report

This case report details the successful rehabilitation of an edentulous patient using a complete upper prosthesis and a lower implant retained overdenture. The provision of care was split between a specialist centre and a primary care setting. This approach reduced inconvenience to the patient. Modern surgical and prosthodontic techniques also reduced the total delivery time. After initial consultation a new set of complete dentures was prescribed with changes in design to the originals. The patient was also planned for placement of two mandibular implants to stabilise and retain the mandibular denture. The first line of treatment involved provision of a new set of dentures constructed by the patient's general dental practitioner. Dental implants were then placed in a specialist centre and the patient returned to the dental practice for attachment of the lower denture to the dental implants. The benefits and success of mandibular implant retained dentures are well documented. With delivery of the overdenture, the patient reported increased satisfaction with his prostheses which allowed him to eat a greater range of foods and enabled him to feel confident when speaking and socialising.

Clinical implementation of dynamic multileaf collimation for compensated bladder treatments.

BACKGROUND AND PURPOSE: To describe the clinical implementation of dynamic multileaf collimation (DMLC). Custom compensated four-field treatments of carcinoma of the bladder have been used as a simple test site for the introduction of intensity modulated radiotherapy.MATERIALS AND METHODS: Compensating intensity modulations are calculated from computed tomography (CT) data, accounting for scattered, as well as primary radiation. Modulations are converted to multileaf collimator (MLC) leaf and jaw settings for dynamic delivery on a linear accelerator. A full dose calculation is carried out, accounting for dynamic leaf and jaw motion and transmission through these components. Before treatment, a test run of the delivery is performed and an absolute dose measurement made in a water or solid water phantom. Treatments are verified by in vivo diode measurements and real-time electronic portal imaging. RESULTS: Seven patients have been treated using DMLC. The technique improves dose homogeneity within the target volume, reducing high dose areas and compensating for loss of scatter at the beam edge. A typical total treatment time is 20 min. CONCLUSIONS: Compensated bladder treatments have proven an effective test site for DMLC in an extremely busy clinic.

Rapid sympatric ecological differentiation of crater lake cichlid fishes within historic times

Background: After a volcano erupts, a lake may form in the cooled crater and become an isolated aquatic ecosystem. This makes fishes in crater lakes informative for understanding sympatric evolution and ecological diversification in barren environments. From a geological and limnological perspective, such research offers insight about the process of crater lake ecosystem establishment and speciation. In the present study we use genetic and coalescence approaches to infer the colonization history of Midas cichlid fishes (Amphilophus cf. citrinellus) that inhabit a very young crater lake in Nicaragua-the ca. 1800 year-old Lake Apoyeque. This lake holds two sympatric, endemic morphs of Midas cichlid: one with large, hypertrophied lips (~20% of the total population) and another with thin lips. Here we test the associated ecological, morphological and genetic diversification of these two morphs and their potential to represent incipient speciation.
Results: Gene coalescence analyses [11 microsatellite loci and mitochondrial DNA (mtDNA) sequences] suggest that crater lake Apoyeque was colonized in a single event from the large neighbouring great lake Managua only about 100 years ago. This founding in historic times is also reflected in the extremely low nuclear and mitochondrial genetic diversity in Apoyeque. We found that sympatric adult thin- and thick-lipped fishes occupy distinct ecological trophic niches. Diet, body shape, head width, pharyngeal jaw size and shape and stable isotope values all differ significantly between the two lip-morphs. The eco-morphological features pharyngeal jaw shape, body shape, stomach contents and stable isotopes (d15N) all show a bimodal distribution of traits, which is compatible with the expectations of an initial stage of ecological speciation under disruptive selection. Genetic differentiation between the thin- and thick-lipped population is weak at mtDNA sequence (FST = 0.018) and absent at nuclear microsatellite loci (FST < 0.001).
Conclusions: This study provides empirical evidence of eco-morphological differentiation occurring very quickly after the colonization of a new and vacant habitat. Exceptionally low levels of neutral genetic diversity and inference from coalescence indicates that the Midas cichlid population in Apoyeque is much younger (ca. 100 years or generations old) than the crater itself (ca. 1 800 years old). This suggests either that the crater remained empty for many hundreds of years after its formation or that remnant volcanic activity prevented the establishment of a stable fish population during the early life of the crater lake. Based on our findings of eco-morphological variation in the Apoyeque Midas cichlids, and known patterns of adaptation in Midas cichlids in general, we suggest that this population may be in a very early stage of speciation (incipient species), promoted by disruptive selection and ecological diversification.

Parsing parallel evolution:Ecological divergence and differential gene expression in the adaptive radiations of thick-lipped Midas cichlid fishes from Nicaragua

The study of parallel evolution facilitates the discovery of common rules of diversification. Here, we examine the repeated evolution of thick lips in Midas cichlid fishes (the Amphilophus citrinellus species complex) - from two Great Lakes and two crater lakes in Nicaragua - to assess whether similar changes in ecology, phenotypic trophic traits and gene expression accompany parallel trait evolution. Using next-generation sequencing technology, we characterize transcriptome-wide differential gene expression in the lips of wild-caught sympatric thick- and thin-lipped cichlids from all four instances of repeated thick-lip evolution. Six genes (apolipoprotein D, myelin-associated glycoprotein precursor, four-and-a-half LIM domain protein 2, calpain-9, GTPase IMAP family member 8-like and one hypothetical protein) are significantly underexpressed in the thick-lipped morph across all four lakes. However, other aspects of lips' gene expression in sympatric morphs differ in a lake-specific pattern, including the magnitude of differentially expressed genes (97-510). Generally, fewer genes are differentially expressed among morphs in the younger crater lakes than in those from the older Great Lakes. Body shape, lower pharyngeal jaw size and shape, and stable isotopes (dC and dN) differ between all sympatric morphs, with the greatest differentiation in the Great Lake Nicaragua. Some ecological traits evolve in parallel (those related to foraging ecology; e.g. lip size, body and head shape) but others, somewhat surprisingly, do not (those related to diet and food processing; e.g. jaw size and shape, stable isotopes). Taken together, this case of parallelism among thick- and thin-lipped cichlids shows a mosaic pattern of parallel and nonparallel evolution. © 2012 Blackwell Publishing Ltd.

Suspected giant cell arteritis:A study of referrals for temporal artery biopsy

Background: The purpose of this study is to describe the nature of cases undergoing temporal artery biopsy (TAB) for suspected giant cell arteritis (GCA). Methods: A retrospective review of case notes was undertaken for all patients on whom ophthalmologists had performed TAB in 2 teaching hospitals between 1995 and 2001. Presenting symptoms, referring specialty, TAB result, treatment, and discharge diagnosis were recorded. Results: Ophthalmologists performed TAB on 110 patients for suspected GCA. A variety of specialties referred patients to ophthalmology for TAB; presenting symptoms varied with referral source. Of the 110 TABs, 21 (19%) were reported as positive for GCA, 84 (76%) were negative, and 5 (4.5%) were reported as inadequate. The symptoms most commonly associated with a positive TAB were visual disturbance (15/21) and headache (15/21).The odds ratios for having a positive TAB result rather than a negative result were 1.0 for the presence of headache, 4.1 for visual disturbance, and 6.7 for jaw claudication. Interpretation: Physicians were faced with a different population of GCA suspects than ophthalmologists. While physicians should be alert to the significance of visual symptoms or jaw claudication, ophthalmologists should be ready to facilitate prompt TABs when appropriate. TAB should be performed promptly and an adequate length of artery taken for biopsy. An argument can be made that TAB is not needed in cases of suspected GCA. However, a positive result provides firm justification for the use of steroids. We feel that TAB has a useful role and we make reference to methods to maximize its usefulness.

Defocused transmission spectroscopy: a potential detection of sodium in the atmosphere of WASP-12b

We report on a pilot study of a novel observing technique, defocussed transmission spectroscopy, and its application to the study of exoplanet atmospheres using ground-based platforms. Similar to defocussed photometry, defocussed transmission spectroscopy has an added advantage over normal spectroscopy in that it reduces systematic errors due to flat-fielding, PSF variations, slit-jaw imperfections and other effects associated with ground-based observations. For one of the planetary systems studied, WASP-12b, we report a tentative detection of additional Na absorption of 0.12+/-0.03[+0.03]% during transit using a 2A wavelength mask. After consideration of a systematic that occurs mid-transit, it is likely that the true depth is actually closer to 0.15%. This is a similar level of absorption reported in the atmosphere of HD209458b (0.135+/-0.017%, Snellen et al. 2008). Finally, we outline methods that will improve the technique during future observations, based on our findings from this pilot study.

An analysis of the attitudes of dental patients attending general dental practice in Galway

AIM: To describe the patterns of dental attendance and attitudes towards tooth loss of general dental practice patients in Galway.

OBJECTIVES: 1. To determine the pattern of adult dental attendance in general practices in Galway; and, 2. To examine the oral health attitudes of these patients.

METHOD: Questionnaires were distributed to 311 consecutive adult patients in the waiting rooms of ten general dental practices in Galway, which were randomly selected from the telephone directory.

RESULTS: A total of 254 of the 311 questionnaires distributed were fully completed, returned and included in the results, giving a response rate of 81.7%. A total of 59% of dentate participants attended their dentist for annual or biannual examinations compared to 23% of edentate patients. Some 10.5% of medical card holders and 0.5% of non-medical card holders were edentulous.

CONCLUSIONS: The data from the survey indicated that medical card holders in Galway were more likely to be edentulous than nonmedical card holders. Edentate patients were less likely to be regular dental attenders than dentate patients.

Do removable dental prosthesis have an impact on tooth loss?

DESIGN: A multi-centre randomised controlled study in 14 dental schools. This report is an interim analysis at 3 years.

INTERVENTION: Patients were allocated to either the Removable dental prosthesis group (RPD)-109 patients or the no prosthesis group (SDA) -106 patients. Patients had to be older than 35 years with no molars in the study jaw. Follow-up visits were scheduled at 4 to 8 wks (baseline), at 6 months, and at 1, 2, 3, 4, and 5 yrs after treatment.

OUTCOME MEASURE: Time to loss of first tooth following intervention or no intervention.

RESULTS: 81 patients received a RDP and 69 patients received no treatment in the end. This is a reduction of 26% and 35% respectively from the time when they were randomised to the two groups. Tooth loss occurred in 13 of the RDP group (16% of those who received the RDP, 12% of those allocated to the group at the start) with 5 of these being in the study jaw and 8 in the opposing jaw. Tooth loss occurred in 9 of the SDA group (13% of those who received SDA, 9% of those who were allocated to the group at the start) with 5 in the study jaw and 4 in the opposing jaw. The respective Kaplan-Meier survival rates at 38 months were 0.83 (95% CI: 0.74-0.91) in the RDP group and 0.86 (95% CI: 0.78-0.95) in the SDA group.

CONCLUSIONS: The difference in tooth loss at three years between patients treated with RDP and those not treated with RDP was not significant.

Nutritional Status of older patients attending Cork University Dental School and Hospital

Objectives: This study aimed to gather data on the nutritional status of older patients attending Cork University Dental School and Hospital for treatment in the Restorative Department. Information was also collected about the medical status of the patients including the prevalence of self-reported xerostomia.
Methods: Data was collected by a self-completion questionnaire followed by a brief clinical examination. Nutritional Status was measured using the short version of the Mini Nutritional Assessment (MNA) which recorded patients’ Body Mass Index (BMI). The MNA consists of 6 parameters (including questions relating to patients’ history and anthropometric data) with a maximum total of 14 points. Scores of 12-14 indicate “normal nutritional status” whilst those between 8 and 11 indicate a patient “at risk of malnutrition”. Scores lower than 8 are an indication a patient who is “malnourished”. All patients attending Cork University Dental School and Hospital aged 65 years and older were invited to participate in the study.

Results: A total of 22 subjects participated in this study. Twelve patients were partially dentate with 10 edentulous. The results from the MNA indicate that 11 patients were of “normal nutritional status” with 11 patients identified as being “at risk of malnutrition”. None of the subjects were “malnourished”. Edentate patients generally recorded lower MNA scores than partially dentate patients. In total, 9 patients reported experiencing xerostomia with 8 indicating that they needed to sip liquids to aid swallowing but only 3 had difficulty swallowing food.

Conclusion: This small study indicates that a number of the older patients attending Cork University Dental School and Hospital for dental care may be “at risk of malnutrition”. These findings suggest that nutritional advice and dental care should both be included in an overall package of care for older patients.