Early and late intraventricular hemorrhage: the role of obstetric factors. To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.


Prenatal diagnosis of dilated cava septi pellucidi et vergae: associated anomalies, differential diagnosis, and pregnancy outcome. To study the significance of dilated cava septi pellucidi et vergae diagnosed prenatally using ultrasonography. Sonographic examinations were performed on 11,200 pregnant women. Transabdominal sonographic examinations were done at 24 weeks or later on 3150 pregnant women and transvaginal sonographic examinations were done between 13-17 weeks on 8050 pregnant women. Eight cases of enlarged cava septi pellucidi et vergae were diagnosed prenatally during the second trimester of pregnancy by transvaginal sonography. In only one fetus did dilatation of cava septi pellucidi et vergae disappear during the third trimester. Associated anomalies, three of which were hydrocephalus, were observed in five fetuses. One fetus had chromosomal translocation 11/22 and one was growth-retarded. Pregnancy was terminated in four cases because of associated fetal anomalies or abnormal chromosomal analysis. One of four neonates died of unexplained metabolic acidosis. One neonate demonstrated cava septi pellucidi et vergae communication with the third ventricle and another had mild hydrocephalus on sonographic examination after birth. The three surviving fetuses had normal development during the first months of life. When dilated cava septi pellucidi et vergae are diagnosed prenatally, attention should be paid to the possible presence of associated fetal malformations. When a cyst of cava septi pellucidi et vergae is the only abnormal finding observed, termination of pregnancy is not justified.


First-trimester exposure to alprazolam.

First-trimester exposure to alprazolam. To assess prospectively pregnancy outcome associated with first-trimester exposure to alprazolam in order to monitor for early signals of potential drug-related risk to the fetus. Reports of first-trimester exposure to alprazolam from patients, physicians, or pharmacists were registered. Information regarding drug exposure, risk factors, and pregnancy outcome was requested at 4.5 and 9 months after registration. From June 1982 through December 1990, 542 pregnancies had been registered. Follow-up data were obtained on 411 registrants. There were 13 live births with congenital anomalies, 263 live births with no congenital anomalies, 47 spontaneous fetal losses, and 88 elective abortions. No pattern of defects or excess of defects or spontaneous abortions was apparent. Although these findings may provide some reassurance in counseling women following inadvertent prenatal exposure, the cases represent a sample of insufficient size for reaching reliable and definitive conclusions about the safety of alprazolam for pregnant women and their developing fetuses. The cases accumulated in this report represent a sample of insufficient size to confirm or refute previous reports of specific congenital anomalies linked to exposure to benzodiazepines.


A prospective comparison of terbutaline and magnesium for tocolysis. To compare the tocolytic efficacy and side effects of parenteral and oral magnesium and terbutaline. Ninety-eight patients in labor between 23-35 weeks were prospectively entered into a controlled trial of intravenous and oral magnesium versus subcutaneous and oral terbutaline. Tocolytic effectiveness was judged by delay of delivery for 48 hours or 1 week, and to 37 weeks or more. The need to change therapy to the alternate drug was identified, as were side effects. Entrance characteristics of the population, initial pelvic examination, and concomitant infection or cervicovaginal isolates were noted. Outcomes included gestational age at delivery, birth weights, and Apgar scores. Outcome analysis was based on initial tocolytic therapy. Significantly more patients in the magnesium group delivered at 37 weeks or more: 34 of 46 versus 27 of 52 (P < .05). No significant differences were found for delivery by 48 hours or 1 week. The interval between treatment and delivery was greater for magnesium: 7.1 +/- 3.9 versus 5.0 +/- 3.2 weeks (P < .005). Failure to achieve 37 completed weeks was more often due to obstetric complications than to preterm labor itself. Tocolytic effectiveness was reduced if secondary therapy or re-treatment was required or if the patient had cervical dilatation of 3 cm or greater. Infectious complications were common but were not associated with tocolytic effectiveness. Side effects were more noticeable with oral magnesium and subcutaneous terbutaline. For short-term tocolysis, no significant difference was found between magnesium and terbutaline. Magnesium was associated with a higher term delivery rate. Idiopathic preterm labor accounted for only a small part of the overall prematurity in the study population.


Morning sickness control in early pregnancy by Neiguan point acupressure. To evaluate the antiemetic effect of acupressure at the Neiguan point. Sixty women in early pregnancy were entered into a randomized, double-blind, cross-over, placebo-controlled trial. During a 12-day period, organized in four steps of 3 days each, the women were divided into two homogeneous groups to test the effectiveness of unilateral and bilateral acupressure. Use of acupressure resulted in a significantly lower frequency of morning sickness compared with placebo treatment. More than a 60% positive effect was found with unilateral and bilateral acupressure, compared with an approximately 30% positive effect of placebo acupressure. Changing from unilateral to bilateral pressure on the Neiguan point caused no significant statistical difference. No noteworthy side effects occurred. Acupressure on the Neiguan point relieves morning sickness.


Serum lipids, blood pressure, body weight, and serum chemistry in women using subcutaneous contraceptive implants releasing the progestin ST 1435. To study the changes in serum lipids, serum chemistry, blood pressure, and body weight in long-term users of subcutaneous contraceptive implants releasing the progestin ST 1435. The study was done in the outpatient clinic of the City Maternity Hospital, Helsinki, Finland. Subdermal implants releasing the progestin ST 1435 were inserted in 30 women for 2 years of use. Healthy women aged 19-35 used the implants for contraception. Measurements of body weight and blood pressure were made and blood samples for lipid analysis (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides) and serum chemistry were taken before insertion of the implants and every 6 months thereafter until removal. Results are reported for 30 subjects after 6 months of use, 25 subjects after 12 months, 13 after 18 months, and 12 after 24 months. Blood pressure and serum chemistry, ie, liver enzymes and electrolytes, remained unchanged. Slight weight gain occurred, but was not statistically significant. No statistically significant changes were found in lipids or lipid ratios when comparing the values during use of the implant with the pre-treatment values. The progestin ST 1435, used parenterally for contraception or progestin therapy, had no adverse effects on serum lipids, blood pressure, or body weight, which are known to be risk factors for coronary artery disease. The steroid had no effects on serum chemistry determinations in long-term use.


Sexual assault in postmenopausal women.

Sexual assault in postmenopausal women. To examine patient characteristics, patterns of injury, forensic evidence, and the frequency of sexual assault in postmenopausal rape victims from 1986-1991. Medical and forensic records were reviewed from 129 postmenopausal women (50 years of age or older) and 129 women from a comparison group (14-49 years of age) who reported having been sexually assaulted. Statistical analysis was performed by Student t test, chi 2, multiple logistic regression, or Fisher exact test. Postmenopausal women represented 2.2% of women reporting sexual assault in Dallas County. The postmenopausal victim was more often white (64%), whereas the younger victim was more often black (53%). Drug or alcohol use within the previous 24 hours was more common in the younger group. Trauma, in general, was common, occurring in 67% of the postmenopausal women and 71% of the younger group (P = not significant). Genital trauma was more common in the postmenopausal group (43 versus 18%; P < .001). Nearly one in three postmenopausal women had genital abrasions or edema. Almost one in five older women had genital lacerations, with one in four severe enough to require surgical repair. In contrast, the frequency of extragenital trauma was more common in younger victims (66 versus 49%; P < .01). Forensic findings were similar in both groups; however, in postmenopausal women motile spermatozoa were seen only in those examined within 6 hours of the assault. Postmenopausal women who have been sexually assaulted are more likely to sustain genital trauma than younger victims.


Prenatal programs: what the literature reveals. To review evaluations of prenatal health care programs, examine their methodologic features, and synthesize the findings of high-quality studies. We combined a computerized search of the literature and recommendations of experts to select evaluations published between 1981-1991. After reviewing the quality of each evaluation in relation to methods and clinical applicability, we selected the highest-quality evaluations and summarized their methods and findings. Trained researchers used a standardized abstraction form for information on main objectives and activities, setting, study design and sample, data collection methods, results, and conclusions. Seven of 22 evaluations met the review criteria. Maternal care coordination and visits by nurses, and specially targeted smoking and nutrition programs, were associated with optimized pregnancy outcomes for certain women, including the poor and very young. Longer participation in prenatal care was an important factor in achieving positive outcomes. Women receiving care from nurse-midwives did not differ in their pregnancy outcomes from women cared for by physicians. No evaluation met all the review criteria. Selection biases are likely, and thus positive findings may have reflected the types of women who were likely to comply with care rather than the effects of program participation. Many topics were not systematically evaluated. Carefully controlled evaluations of the content, number, and timing of prenatal care visits for women with differing medical and social risks are essential in identifying effective ways to achieve the nation's public health objectives regarding maternal and infant mortality.


Hemolytic disease of the fetus: a plea for restraint. The recent addition of fetal blood sampling and transfusion techniques to the management schemes for hemolytic disease of the fetus has expanded clinical options for patient care. Coincident with these techniques is a new aggressiveness toward sensitized pregnancies that, upon review of available data, selects more patients for early and invasive testing than appears necessary. This paper explores the issues of invasive testing and offers guidelines that are more conservative than those recommended in recent reports.


Sexual assault: review of a national model protocol for forensic and medical evaluation. New Hampshire Sexual Assault Medical Examination Protocol Project Committee. A national hospital/community model protocol was developed for the forensic and medical examination of victims of sexual assault. This review is designed to assist states in the development of sexual assault protocols. Controversial issues were addressed, including the collection of hair evidence, the importance of semen, mandatory reporting, pregnancy testing and prophylaxis, and sexually transmitted diseases including human immunodeficiency virus. The current role of DNA profiling is reviewed. These issues at the interface of medicine, forensic science, victim advocacy, and the law are analyzed. Representatives of the medical, legal, law enforcement, victim advocacy, and forensic science communities contributed to the development of the protocols at the national and state levels. The importance of a collaborative effort is emphasized. The broad protocol goals are to minimize the physical and psychological trauma to the victim while maximizing the probability of collecting and preserving physical evidence for potential use in the legal system.


Laparoscopic myomectomy.

Laparoscopic myomectomy. Fifty-six patients presenting with infertility (17); bleeding, pain, and pressure symptoms (32); and pelvic mass (seven) associated with leiomyomas were managed with laparoscopic myomectomy. Twenty-four second-look procedures were performed to evaluate healing and adhesion formation. Operative time ranged between 45-443 minutes (mean 157), estimated blood loss varied from 10-400 mL (mean 75), and the mean length of hospital stay was 1 day. Traditional morcellation was used initially but was abandoned because of long operating time; vaginal or abdominal removal (depending on size) proved more satisfactory. Three patients developed subcutaneous emphysema and one had febrile morbidity due to upper respiratory tract infection. There were no other complications. In 24 second-look procedures, adhesions were present in 16 subjects (66%). Twelve of 17 in the infertility group conceived (71%); all 39 patients with other complaints experienced satisfactory relief. There were no reoperations. When myomectomy is indicated, the laparoscopic approach appears to offer an alternative to abdominal surgery in selected patients.


Natural oocyte retrieval with intravaginal fertilization: a simplified approach to in vitro fertilization. To simplify in vitro fertilization (IVF), we have combined natural-cycle oocyte retrieval with intravaginal fertilization. Our subjects ranged in age from 28-40 years and were monitored by ultrasound and steroid hormone levels. Oocyte retrieval was carried out under vaginal ultrasound-guided aspiration 32-36 hours after the onset of the LH surge. The oocyte was identified and placed in a sealed capsule containing culture media and sperm. The capsule, in a sealed cryoflex envelope, was placed in the woman's vagina and removed 42-48 hours later. The embryo was then isolated and transferred to the woman's uterus. Fifty-one retrieval cycles were attempted in 45 patients. At least one oocyte was retrieved in 88% of cycles, and fertilization was achieved in 84% of oocytes. Of the five clinical pregnancies (10%), four have delivered and one is ongoing. The cost of this procedure is approximately one-third that of standard IVF. The advantages of our method are the elimination of the use of gonadotropins, the simplicity of monitoring and oocyte retrieval, and the lack of need for expensive laboratory equipment. Natural oocyte retrieval with intravaginal fertilization may prove appropriate for those women requiring IVF who fear multiple pregnancies, have side effects from controlled ovarian hyperstimulation, or cannot afford standard IVF.


Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery. We present a case in which a modified peribulbar anesthesia, administered with a 24-gauge (0.55 x 25 mm) sharp, disposable needle, induced an orbital hemorrhage, resulting in complete and permanent loss of vision. To our knowledge, this is the first report of severe complications following a peribulbar block.


An analysis of intraocular lens exchange. We present an analysis of 101 eyes of 98 consecutive patients who underwent intraocular lens (IOL) exchange. The period of follow up ranged from 6 to 71 months (mean, 23 months). Bullous keratopathy was the leading (86.7%) indication for IOL exchange in 45 eyes that had combined penetrating keratoplasty (PKP) and IOL exchange (PKP group). Lens dislocation (36%) and incorrect power (25%) were the most frequent indications for IOL exchange without PKP (56 eyes) (NPKP group). A final visual acuity of 20/40 or better was achieved in 50.5% of the 101 eyes, with 88% having two lines of improvement or remaining within one line of the pre-exchange acuity. The geometric mean visual acuity was significantly improved, from 20/273 preoperatively to 20/125 postoperatively, in the PKP group (P less than .001), and from 20/61 to 20/43 in the NPKP group (P = .001). The main reason for vision less than 20/200 in the 23 eyes in the PKP group was glaucoma (nine eyes) and bullous keratopathy (eight eyes). In the NPKP group, seven eyes (four due to cystoid macular edema, CME) had a visual acuity less than 20/200. Posterior chamber (PC) IOL implantation was associated with significantly better visual acuity than anterior chamber (AC) IOL implantation when performed at IOL exchange (P = .004). The most common complications encountered with IOL exchange were CME (17.8%), hyphema (15.8%), glaucoma (10.9%) and PC opacity (8.9%).


Devices for the control of laser transmission across the sclera during transscleral photocoagulation. Improving the reproducibility of transscleral photocoagulation necessitates controlling the transmission of the laser beam through the sclera. Two factors make such control problematic: the locally increased transparency of the sclera resulting from the contact procedure and the occurrence of time-related relaxation phenomena. Two instruments have been devised to help control these factors. The first is a mechanical compensation unit comprised of magnets and a spring that allows the force exerted on the sclera to be adjusted to between 0.1 and 0.4 N, the pressure being determined by the outer diameter of the contact tip. The second instrument monitors the portion of the aiming beam reflected by the sclera as a means of determining the exact level of power actually transmitted through it. This information theoretically could be fed back to the treatment laser, allowing the level of power being delivered to be adjusted accordingly.


A new instrument for controlling pressure exerted on the sclera during contact Nd:YAG laser cyclodestruction. We tested the device described by Rol et al in their article in this issue, designed to define and precisely control the pressure applied to the sclera during contact cyclodestruction with a cw-Nd:YAG laser. Since scleral transparency, and hence transmission of laser energy, depends on the pressure applied, control of this parameter represents an important advance toward the goal of standardizing the cyclodestructive procedure. In eight of nine cadaver pig eyes, pressure was exerted on the sclera using the pressure-controlling device, with a setting of 0.25 N for two of these eyes, and one of 0.4 N for the other six. In the remaining eye, pressure was controlled intuitively by an experienced surgeon. Applying forces of 0.25 or 0.4 N yielded similar success rates, although these fluctuated greatly even under constant pressure conditions (from 17% to 50% at 0.25 N; from 27% to 42% at 0.4 N). The highest success rate (55%) was achieved by the intuitively controlled pressure irradiations of the experienced surgeon. The variation in coagulation intensity that occurred despite constant pressure suggests that additional factors contribute to the results achieved. Nonetheless, this pressure-controlling probe represents an important achievement. It will permit not only the novice but even experienced operators to adhere unambiguously to a protocol of quantitative, reproducible parameters, and will also help researchers to better understand the relationship between energy delivered and intraocular pressure reduction achieved in contact cyclophotocoagulation.


Racial variation of optic disc parameters in children. The optic disc parameters of 66 children without ocular disease were analyzed in a prospective study. The vertical disc diameter, the disc area, and the cup-to-disc ratio were significantly larger in blacks than in whites. The race-based variation of optic disc size demonstrated previously in adults appears to be inherited, as it is also present in children.


Extrusion of enucleation implants: treatment with secondary implants and autogenous temporalis fascia or fascia lata patch grafts. We performed one autogenous fascia lata graft and 11 autogenous temporalis fascia grafts in eight patients with extrusion of an orbital enucleation implant and in four patients with a bulging implant who could not wear a prosthesis. Excluding one patient with inadequate follow up, 10 of the 11 patients (91%) successfully retained their implant. One patient had severe conjunctivitis followed by anterior migration of his implant 2 1/2 years after patch grafting, necessitating replacement of the implant. We conclude that autogenous temporalis fascia patch grafting is an effective treatment for orbital enucleation implant extrusion or a bulging implant.


Forming and teaching true knots for strabismus surgery. I describe a system for ensuring the formation of true knots in the locking bites in strabismus surgery. I also present a method for teaching this system to residents that makes use of a piece of cotton or nylon rope, a cotton mop refill, and the end of a garden rake.


Office probing of congenital nasolacrimal duct obstruction. We report the results of office nasolacrimal duct probing under topical anesthesia in 2369 eyes with symptomatic nasolacrimal duct obstruction. The overall success rate for cure by initial probing was 92%. In patients less than 9 months old, a 94% cure rate was achieved with one probing; in patients 9 months and older, the rate decreased to 84%. The decrease in success rate after 9 months was statistically significant (P less than .00001 by chi-square analysis). A majority of 180 parents of these patients surveyed said they were happy with the office procedure and preferred having the probing performed to resolve symptoms, even though they realized that the symptoms most probably would resolve by 1 year of age without it. We conclude that office probing for congenital nasolacrimal duct obstruction is a safe and effective method for treatment of symptomatic nasolacrimal duct obstruction, allowing the cost and risk of general anesthesia as well as the cost and inconvenience of prolonged medical management to be avoided.


Canaliculocystostomy combining microsurgery and fibrin sealing of the anastomosis. I present a method of using fibrin sealing for anastomosis in canaliculocystostomy. A microsurgical resection of the stenosis of the common canaliculus is followed by silicone intubation of the lacrimal apparatus and fibrin sealing of the anastomosis of the canaliculi and the lacrimal sac. The silicone tube is removed 6 months postoperatively. This technique obviates microscopic sutures, reduces operating time, and provides hemostasis. Of seven patients with monolateral stenosis of the common canaliculus in whom this technique was used and who were followed for a minimum of 3 years, only one had a restenosis.


Monopolar cautery for graft cartilage sculpting in reconstructive eyelid surgery. We describe a technique for using the monopolar cautery to sculpt ear cartilage to prepare it for use as a graft to reconstruct or support the posterior lamella of the eyelid in oculoplastic procedures. We have used this simple, rapid, and predictable technique in 16 patients with excellent results.


Microblepharon.

Microblepharon. We describe a child with microblepharon and corneal exposure secondary to lagophthalmos. Surgical reconstruction utilizing full-thickness skin grafts to all four lids corrected the lagophthalmos and relieved her symptoms.


A modified technique of transscleral suture fixation of posterior chamber lenses. I describe a modified technique of sulcus fixation of posterior chamber intraocular lenses (PC-IOLs) in which the anterior vitrectomy is restricted to the vitreous base and anterior chamber and a single-armed sling suture is used. These modifications reduce operating time and the risk of intraoperative and postoperative infection. This technique has been used successfully in the last 20 of the 96 patients in our institution who have had transscleral suture fixation procedures.


Peribulbar anesthesia in retinal reattachment surgery. We prospectively evaluated the effectiveness of peribulbar anesthesia in retinal reattachment surgery. Of the 24 patients studied, 2 required retrobulbar supplementation during the latter part of the surgery. Our results show that peribulbar anesthesia can be effectively used for retinal reattachment surgery and probably should be the preferred form of local anesthesia for this surgery, since the eyes involved have a relatively high incidence of axial myopia and posterior staphyloma.


Sub-Tenon's anesthesia for trabeculectomy. Sub-Tenon's anesthesia for anterior segment surgery avoids the risks associated with retrobulbar and peribulbar injections. Localized injections over the appropriate rectus muscles ensure patient comfort as well as optimal exposure of the surgical field in eyes undergoing trabeculectomy. We have used this technique without significant complications in approximately 400 procedures.


Effect of vitamin E in the treatment of bovine-albumin-induced uveitis in rabbits. In order to assess the role of vitamin E, an antioxidant, in the treatment of uveitis, a controlled experimental study was carried out on 20 New Zealand albino rabbits with bovine-albumin-induced uveitis. In all vitamin-E-treated animals, clinical and histopathological study of the retina and uvea revealed no significant changes in comparison with those in untreated rabbits.


Similarities and differences between the Kelman phacoemulsification and extracapsular cataract extraction procedures in the spontaneous regression of corneal astigmatism from against-the-rule astigmatism. We perspectively examined the induction and spontaneous regression of corneal astigmatism from preoperative against-the-rule astigmatism [Kelman phacoemulsification (KPE), n = 618; extracapsular cataract extraction (ECCE), n = 192] among cataract extraction surgeries (KPE, n = 1,648; ECCE, n = 443). All data were set on a double-angle coordinate graph, from which the mean +/- SE of the axis and the amount of astigmatism were obtained simultaneously. In the KPE group, the surgically induced astigmatism was independent of preoperative state or age. In the ECCE group, surgically induced astigmatism shifted toward with-the-rule astigmatism, and postoperative recovery was delayed longer in patients over 80 years of age than in those under 70. Postoperative against-the-rule astigmatism was more frequent after KPE. Our first trial to calculate astigmatism from a double-angle coordinate graph was useful in showing astigmatism changes.


Intraocular kinetics of ceftazidime (Modacin). The concentration of ceftazidime was determined in the aqueous humor and the vitreous body of normal, vitrectomized and aphakic/vitrectomized eyes and in the serum of albino rabbits 1 h after intravenous injection of 100 mg/kg ceftazidime. The intravitreal ceftazidime concentration was low (0.1-0.2 microgram/ml) in normal eyes 1 h after intravenous injection, and high (8.7 +/- 8.5 micrograms/ml) in vitrectomized and aphakic/vitrectomized eyes when injected immediately after surgery. The ceftazidime concentration was also determined in the aqueous humor and the vitreous body of normal eyes and in the serum of albino rabbits 3, 6, 12, 24 and 48 h after intravitreal injection of 200 micrograms. The intravitreal ceftazidime concentration after intravitreal injection decreased exponentially for 12 h (half-life about 7.4 h). It decreased more slowly thereafter and remained at 13.0 micrograms/ml (mean) even 48 h after injection. This concentration exceeded the minimum inhibitory concentrations against common gram-positive and gram-negative organisms causing endophthalmitis.


Spindleform scleropathy: collagen changes of the sclera. A pathologic report. To our knowledge, this is the first pathologic report of interscleral collagen bundle changes occurring as well-defined spindleform lesions randomly interspersed within the sclera. The lesions were observed in an otherwise healthy 75-year-old man whose eye was enucleated because of a uveal malignant melanoma. There are few reports in the literature of focal scleral changes of a predominantly acid mucopolysaccharide nature. The entity we observed in this case differs from these reports by its spindleform appearance, random distribution (not overlying the melanoma) and predominantly vicinal glycol nature. Histopathologic, histochemical, and ultrastructural studies revealed that the lesions were not the result of mucoid degeneration of the scleral collagen and not an abnormal collagen structure.


Retino-choroidal changes in endotoxin-induced uveitis in the rat. A single injection of 100 micrograms of lipopolysaccharide from Salmonella typhimurium in the foot pads of Lewis rats induced acute inflammation of the eye. Clinically, the disease started as early as 0.5 h and peaked 18 h after the inoculation. The aqueous protein concentration was increased after the inoculation. Histopathologically, cellular infiltrates and proteinaceous exudates were observed in the anterior segment (anterior chamber, iris and ciliary body). In addition to those changes described in previous reports, the examination of the posterior segment showed retinal vasculitis, hemorrhagic exudates, focal destruction of photoreceptor cells and choroidal infiltration.


Argon laser photocoagulation of the pecten oculi of the domestic pigeon (Columba livia) using a specially designed contact lens. A specially designed -62-D polymethylmethacrylate contact lens for biomicroscopy of the fundus oculi of the pigeon is presented. The study shows the usefulness of the lens in argon laser photocoagulation of the pecten, a noninvasive technique for ablating the organ. In addition, previous studies on operative destruction of the pecten are reviewed. To our knowledge, this is the first time the macroscopic appearance of a photocoagulated pecten is documented.


Aqueous humor polyamines and alkaline phosphatase activity in endotoxin-induced uveitis: correlations to diverse leukocyte subsets. The polyamines putrescine, spermidine and spermine have been proposed to be a part of the acute phase inflammatory response. They have been shown to be useful markers for cellular kinetics and change with various pathological conditions. The hypothesis that aqueous humor polyamines could be used to follow the time course of an endotoxin-induced inflammation in the eye was investigated. Additional parameters studied were the amount of aqueous leukocytes, alkaline phosphatase activity, distribution of leukocyte subsets and breakdown of the blood-aqueous barrier. Aqueous leukocytes, protein, alkaline phosphatase activity, putrescine and acetylated spermidine increased significantly as a response to inflammation during the first days after uveitis induction. Spermidine decreased 24 h after injection and seemed to rise thereafter. The different polyamines, except spermidine, correlated to the diverse infiltrating leukocyte subsets. These observations indicate that aqueous polyamines may be applied as valid markers for inflammation in the eye.


Quantification of angiogenesis due to basic fibroblast growth factor in a modified rabbit corneal model. The rabbit corneal angiogenesis assay was modified to allow quantification of the neovascular response induced by growth factors. Basic Fibroblast Growth Factor (bFGF) was used for this experiment. bFGF was diluted in phosphate buffer solution (PBS) in such a way that 2 microliter of solution contained concentrations ranging from 17 to 1,200 ng. Each drop was absorbed by a 1 x 2 mm particle of a dried 70% hydratable hydrogel and implanted into a mid-stroma corneal pocket, 2 mm from the limbus. Iodinated bFGF was used to measure growth factor diffusion in the cornea, which was found to be isotropic. Autoradiography showed that bFGF was stored in the cornea at both epithelial and endothelial level. Corneal neovascularization occurred on the second day after implantation and was maximal on the 7th day. At this time the neovascular surface was measured by planimetry on corneal photographs and compared with controls. This method allows precise definition of the dose of any substance to be implanted into the cornea and induces a rapid neovascular response, thus allowing quantitative evaluation of neovascularization within one week. A neovascular response was detectable for doses as low as 35 ng of bFGF and increased proportionally to the dose of bFGF implanted.


Pars plana vitrectomy in the Early Treatment Diabetic Retinopathy Study. ETDRS report number 17. The Early Treatment Diabetic Retinopathy Study Research Group. The Early Treatment Diabetic Retinopathy Study (ETDRS) enrolled 3711 patients with mild-to-severe nonproliferative or early proliferative diabetic retinopathy in both eyes. Patients were randomly assigned to aspirin 650 mg/day or placebo. One eye of each patient was assigned randomly to early photocoagulation and the other to deferral of photocoagulation. Follow-up examinations were scheduled at least every 4 months, and photocoagulation was initiated in eyes assigned to deferral as soon as high-risk proliferative retinopathy was detected. Aspirin was not found to have an effect on retinopathy progression or rates of vitreous hemorrhage. The risk of a combined end point, severe visual loss or vitrectomy, was low in eyes assigned to deferral (6% at 5 years) and was reduced by early photocoagulation (4% at 5 years). Vitrectomy was carried out in 208 patients during the 9 years of the study. This report presents baseline and previtrectomy characteristics and visual outcome in these patients. Information collected at baseline and during follow-up as part of the ETDRS protocol was supplemented by review of clinic charts for visual acuity and ocular status immediately before vitrectomy. Vitrectomy was performed in 208 (5.6%) of the 3711 patients (243 eyes) enrolled in the ETDRS. The 5-year vitrectomy rates for eyes grouped by their initial photocoagulation assignment were as follows: 2.1% in the early full scatter photocoagulation group, 2.5% in the early mild scatter group, and 4.0% in the deferral group. The 5-year rates of vitrectomy (in one or both eyes) were 5.4% in patients assigned to aspirin and 5.2% in patients assigned to a placebo. The indications for vitrectomy were either vitreous hemorrhage (53.9%) or retinal detachment with or without vitreous hemorrhage (46.1%). Before vitrectomy, visual acuity was 5/200 or worse in 66.7% of eyes and better than 20/100 in 6.2%. One year after vitrectomy, the visual acuity was 20/100 or better in 47.6% of eyes, including 24.0% with visual acuity of 20/40 or better. With frequent follow-up examinations and timely scatter (panretinal) photocoagulation, the 5-year cumulative rate of pars plana vitrectomy in ETDRS patients was 5.3%. Aspirin use did not influence the rate of vitrectomy.


Outcome and cost analysis of scheduled versus emergency scleral buckling surgery. Retinal detachments are usually considered to be a surgical emergency. However, there are additional risks and costs for unnecessary emergency surgeries. The purpose of this study is to evaluate whether the conventional wisdom for treating all retinal detachments as emergencies needs to be re-examined. Forty-eight patients who had an emergency scleral buckle and 89 patients who had a scheduled procedure were randomly selected from 884 consecutive patients who had a primary scleral buckling procedure during a 4 1/2-year period. The medical records of each patient were used to obtain detailed information related to prognosis. The visual acuity measurements of each patient, taken 6 months after the procedure, were obtained from the records of the ophthalmologist following the patient. Linear regression analysis was used to compare the final visual outcome for patients who had emergency surgery with patients who had scheduled surgery after taking into account patient factors related to prognosis. Patients selected for emergency surgery had better visual prognoses than scheduled patients but had the same risk of systemic complications and the same extent of detachment if the macula was not involved. None of the 18 patients with an attached macula experienced macular involvement while awaiting scheduled surgery. There were no differences between emergency and scheduled patients in ocular or systemic complications, rate of reattachment, rate of decreased visual acuity after surgery, visual outcome adjusted for prognosis, or, since 1985, length of hospital stay. A greater cost was incurred for the patients having emergency surgery due to difference in pay scales for support personnel. Because the study is not large and the patients were not randomized to treatment, the results are not definitive. However, they suggest that emergency surgery is unnecessary for many patients with a detached retina.


Proliferative vitreoretinopathy. Lymphocytes in epiretinal membranes. To investigate the potential contribution of inflammatory and immune-mediated processes contributing to the pathogenesis of proliferative vitreoretinopathy (PVR), an immunohistochemical study was undertaken to characterize the infiltrating inflammatory cells in epiretinal membranes surgically removed from the eyes of patients with PVR. Twenty-one epiretinal membranes obtained surgically from eyes with PVR complicating rhegmatogenous retinal detachment were studied immunohistochemically using the ABC technique and a panel of monoclonal and polyclonal antibodies. T lymphocytes were found in 18 of the 21 specimens and generally constituted a small percentage of the total cell number. CD4+ T cells were found in 14 of the 18 membranes containing T cells. Three of six frozen membranes contained T cells that were positive for the interleukin-2 receptor. In 5 of 16 membranes studied, cells positive for the macrophage/monocyte marker were found. No B lymphocytes or neutrophils were identified, and there were no deposits of complement or immunoglobulins. Positive staining for the class II MHC antigen HLA-DR was found in 7 of the 21 membranes, a result that was more consistent in frozen than in fixed tissues. The study suggests that T lymphocytes are present in PVR epiretinal membranes and may be activated. These cells have the potential to play a role in the pathobiology of PVR.


Ultrastructural immunocytochemistry of subretinal neovascular membranes in age-related macular degeneration. The authors studied various cellular and extracellular matrix components of subretinal neovascular membranes (SRNVM) from patients with age-related macular degeneration (ARMD). Electron microscopic immunocytochemistry was used on the subfoveal neovascular membranes surgically removed from three patients with disciform lesions due to ARMD. The SRNVMs always contained large "feeder" vessels along with many new capillaries in different stages of maturation. Capillaries were sparse and embedded in an abundant stroma. The majority of the nonvascular cells were either retinal pigment epithelial (RPE) cells or fibroblast-like cells. The RPE cells formed single or multiple layers on one side of the membranes. The stroma was composed mainly of collagen types I and IV and fibronectin, with small amounts of collagen types III, V, and VI. The absence of Bruch's membrane suggests that a splitting may occur between the RPE cells and Bruch's membrane with the new vessels growing into this cleft. A thickened layer of collagen type IV was often present under the RPE cells. The basement membranes of the newly formed capillaries were morphologically ill-defined, and contained substantial amounts of collagen type IV and fibronectin, but, unlike the basement membranes of normal capillaries, they lacked laminin or heparan sulfate proteoglycan. These results on the ultrastructural components of the SRNVMs may be useful in clarifying the nature of the disciform process in ARMD.


Dominantly inherited cystoid macular edema. A histopathologic study. Dominantly inherited cystoid macular edema was described as a clinically distinct form of macular dystrophy with an onset at approximately age 30 years with slow progression over the ensuing decades. This is the first report of the light and electron microscopic findings in two donor eyes of one of the patients with this clinical entity. Both eyes were obtained after death and fixed within 24 hours in a buffered 4% formaldehyde-1% glutaraldehyde solution. For light microscopy, tissue was embedded in paraffin and stained with hematoxylin-eosin, periodic acid-Schiff, colloidal iron for mucopolysaccharides, and an antibody to glial fibrillar acidic protein. For ultrastructural investigation, several blocks of choroidal/retinal tissues from the posterior pole, including both maculae, were embedded in epoxy resin and processed for transmission electron microscopy. Major findings included large retinal cysts in the macula, atrophy and marked disorganization of the inner nuclear layer, advanced degeneration of Müller cells with nodular aggregates of basement membrane-like material, and a preretinal membrane. The retinal vasculature did not show excessive endothelial alterations but was surrounded by deposits of multilayered basement membrane in the perivascular space. The authors believe that the pathologic features of dominantly inherited cystoid macular edema are different from those of macular edema caused by other disease processes. The predominant pathologic changes affected mainly the inner nuclear layer. The possibility of a primary disease of the Müller cell is suggested.


Low-dose methotrexate therapy for ocular inflammatory disease. Methotrexate is a second-line anti-inflammatory agent used in the treatment of rheumatic diseases. At low doses (12.5 mg/week), it is associated with few serious side effects. Twenty-two patients (5 men, 17 women) with chronic noninfectious ocular inflammatory disease, who had not responded to or who had become intolerant of corticosteroid or alternate cytotoxic agents, were treated weekly with oral low-dose, pulse methotrexate. Treated diseases included chronic uveitis-vitreitis (9), scleritis (4), inflammatory pseudotumor (3), orbital myositis (3), and retinal vasculitis (3). Follow-up ranged from 2 to 39 months (mean, 11 months). Response time ranged from 3 to 9 weeks (mean, 5 weeks) after implementation of methotrexate therapy. Sixteen of 22 patients had reduction of inflammatory activity. Fourteen of these 16 patients were able to taper or discontinue corticosteroid therapy. Five patients had complete remission of their disease; six patients did not respond to methotrexate. Treatment with low-dose methotrexate appears to be effective therapy for steroid-resistant ocular inflammatory disease.


Ocular findings associated with neurofibromatosis type II. Neurofibromatosis has been recently acknowledged as consisting of a number of different diseases. Neurofibromatosis (NF) type I and NF type II are the most clearly defined. Type II is characterized by bilateral acoustic neuromas and is rare (its incidence is 1/50,000). The previously reported ocular associations of NF type II are posterior subcapsular cataracts, Lisch nodules, and combined hamartomata of the retinal pigment epithelium and retina. In this study, the authors attempt to define further the ocular manifestations of NF type II. The authors prospectively examined 9 patients who met the diagnostic criteria for NF type II (age, 18 to 38 years; mean, 25 years). Seven of nine patients had epiretinal membranes in the posterior pole. None of these epiretinal membranes were visually significant. In addition, five patients had central posterior cortical cataracts and five had peripheral wedge-shaped cortical cataracts. The presence of epiretinal membranes in young patients may represent another clinical finding associated with NF type II. Epiretinal membranes, central posterior cataracts, peripheral cortical cataracts, or combined hamartoma of the retinal epithelium and retina in young patients should alert the ophthalmologist to include NF type II in the differential diagnosis in patients with stigmata of NF type II.


Atypical presentation of fungal dacryocystitis. A report of two cases. Candida albicans has only rarely been implicated in nasolacrimal duct obstruction. Its association with dacryoliths is well known, but it is unclear whether it is an etiologic factor or is present as a result of the obstruction. The authors report 2 cases of fungal dacryocystitis that were not associated with dacryolith formation and where Candida species appear to be the primary etiologic agent. The possibility of a fungal infection should be considered in the evaluation of "routine" chronic dacryocystitis, particularly in the presence of corneal ulceration or postoperative endophthalmitis, as prompt initiation of appropriate therapy may be crucial.


Miniplate reconstruction of the lateral orbital rim after orbital decompression for Graves disease. Removal of lateral orbital bone with or without simultaneous removal of the lateral orbital rim is an accepted method of orbital decompression for Graves disease. Once removed, the bone is no longer available for reconstruction and secondary complications such as rounding of the canthal angle, canthal dystopia, and globe dystopia may result. The authors replaced the excised bone with a titanium miniplate to protect the globe and fixate the lateral canthal tendon in 18 patients (33 orbits). The orbital rim and lateral orbital wall were completely removed, and the inner aspect of the orbit was enlarged with a cutting burr. A standard titanium miniplate was then anchored to remaining bone, and soft tissue was secured to the miniplate to reconstruct the lateral canthus. The results, as manifest by appearance of the lateral canthus and position of the eyelid in apposition to the globe, were graded as excellent in all patients and orbits. There were no early or late complications. Miniplate reconstruction of the lateral orbital rim after decompression for Graves disease allows the beneficial affect of lateral decompression and preserves the functional aspect of the lateral orbital wall.


Multidisciplinary approaches to complicated vascular lesions of the orbit. Hemodynamically active vascular lesions of the orbit are often clinically challenging to treat, both because of the complexity of the vascular anatomy and the delicacy of the cardinal structures that are involved and vulnerable to damage. Attempts to achieve complete embolization of such vascular lesions may result in damage to vital visual structures. Conversely, incomplete closure of the feeders or vascular shunts will usually result in recanalization and, therefore, recurrence of such lesions. Surgical excision after selective optimal embolizations may convert dynamic lesions into static ones with controlled surgical risks and could provide a solution to these problems. Cyanoacrylic polymerization was used to embolize the lesions, which were then excised with careful microsurgical and microvascular techniques. The authors present four cases of different hemodynamically active orbital vascular lesions (a post-traumatic arteriovenous fistula, a complex venous anomaly, a cavernous hemangioma of bone, and an arteriovenous malformation), which were treated successfully with the combination of presurgical embolization and surgery. The authors believe that, from their experience with these cases, a multidisciplinary approach to complicated orbital vascular lesions is ideal and practical.


Microanatomy of the orbital apex. Computed tomography and microcryoplaning of soft and hard tissue. The anatomy of the orbital apex is characterized by a complex interplay between critical bony and neural structures. Traditional methods used to study this region include dissection, static sections, and computed tomography (CT). Tomographic techniques are very useful in understanding these complex relationships, but the resolution of conventional CT and magnetic resonance imaging (MRI) is not sufficient to recognize the intricate details of the optic nerve canal and associated structures. The purpose of this study is to determine the value of microcryoplaning and computer reconstruction in visualizing the orbital apex in detail not previously possible, at any orientation in three-dimensional space. Microcryotomy of the orbital apex area was performed on cadaver specimens, and images of each cryosection were digitized. Subsequently, the lesser wing of sphenoid bone and optic nerve were outlined to allow for spatial manipulation and three-dimensional visualization of the orbital apex. The authors present reconstructed computer images of the orbital apex in coronal and axial planes with CT correlation. Clinically important anatomic points and landmarks as well as potential pitfalls are demonstrated. Microcryoplaning and computer reconstruction are useful techniques in viewing the detailed anatomy of the orbital apex. Although microcryoplaning has the limitation of poor soft tissue detail, the resolution of captured images is much greater than those obtained from CT or MRI scans; the improved resolution allows for accurate CT correlations. The technique has utility in education, surgical planning, and quantitative analysis of orbital apical anatomy.


Color Doppler imaging of the ocular ischemic syndrome. This study describes hemodynamic characteristics of the ophthalmic, central retinal, and posterior ciliary arteries in 16 eyes of 11 patients with the ocular ischemic syndrome. Understanding the hemodynamic characteristics of the retrobulbar circulation may elucidate the natural history and pathophysiology of the ocular ischemic syndrome and perhaps form the basis for rational treatment of this condition. Color Doppler imaging, a procedure that permits rapid noninvasive imaging of the ophthalmic, central retinal, and posterior ciliary arteries, was used to quantitate peak systolic blood flow velocities and vascular resistance (pulsatility index) within these vessels in study group eyes and in an age-matched control population. We demonstrated markedly reduced ocular ischemic syndrome central retinal and posterior ciliary artery peak systolic velocities compared with control group eyes. Central retinal and posterior ciliary artery vascular resistance (pulsatility index) was greater in ocular ischemic eyes versus control group eyes. Reversal of ophthalmic artery blood flow was detected in 12 of 16 ocular ischemic syndrome eyes. Study group eyes with poor vision had no detectable posterior ciliary arterial blood flow. Color Doppler imaging quantitates hemodynamic characteristics of the retrobulbar circulation in the ocular ischemic syndrome. There is markedly reduced peak systolic velocity and increased vascular resistance in ocular end arteries such as the central retinal and posterior ciliary arteries. Ophthalmic artery reversal of flow seems to represent collateral blood flow to lower resistance vascular beds. Posterior ciliary artery hypoperfusion may correlate with poor vision in the ocular ischemic syndrome.


Acute promyelocytic infiltration of the optic nerve treated by oral trans-retinoic acid. Oral trans-retinoic acid has recently been shown to be an effective treatment modality for acute promyelocytic leukemia. This type of drug differs from traditional tumoricidal agents by promoting differentiation of the malignant, immature cells. The authors describe a patient with optic nerve infiltration by acute promyelocytic leukemia documented ophthalmoscopically and confirmed by standardized echography and magnetic resonance imaging. High-resolution chromosome banding revealed the patient had a 15;17 chromosomal translocation known to be associated with acute promyelocytic leukemia. Treatment was instituted with oral all trans-retinoic acid without adjuvant radiotherapy or intrathecal chemotherapy. Results of serial bone marrow examination showed progressive differentiation of malignant cells with complete bone marrow remission. Results of serial ophthalmic examinations showed complete resolution of the leukemic optic nerve head infiltration. All trans-retinoic acid alone can be an effective treatment for optic nerve head infiltration in acute promyelocytic leukemia. This case suggests that radiation therapy may not be necessary in acute promyelocytic leukemia with optic nerve infiltration.


Intraocular pressure reduction in normal-tension glaucoma patients. The Normal Tension Glaucoma Study Group. In a collaborative study, patients with untreated normal-tension glaucoma were randomly assigned to a marked intraocular pressure reduction group or to a no therapy group. It was anticipated that medical therapy and laser trabeculoplasty would generally not achieve adequate pressure lowering and that fistulizing surgery would be required. This hypothesis was examined using current observations in the study. Patients randomized to the therapy group had a pressure reduction of at least 30% from their last prerandomization level. This was achieved within 6 months by means of fistulizing surgery or with pilocarpine and/or laser trabeculoplasty. Beta-blockers and adrenergic agonists were excluded from both eyes. Of 30 patients with documented stable 30% pressure reduction, 17 (57%) achieved this with topical medication and/or laser trabeculoplasty: 8 with pilocarpine alone, 2 with laser trabeculoplasty alone, and 7 with laser trabeculoplasty after initial topical medication. The remaining 13 (43%) patients required a single fistulizing procedure. There was no statistically significant difference between the mean follow-up time for the nonfistulized group (533.8 +/- 437.6 days) and for the fistulized group (502.7 +/- 344.7 days). Both treatment groups had similar baseline profiles. Marked pressure reduction can be achieved and maintained on a long-term basis by means other than fistulizing surgery in a large proportion of patients with untreated normal-tension glaucoma.


Effect of brief exposure to mitomycin C on viability and proliferation of cultured human Tenon's capsule fibroblasts. The purpose of this study is to determine why a single intraoperative dose of mitomycin C (MMC) appears to promote the success of glaucoma filtration surgery. Human Tenon's capsule fibroblasts were exposed to MMC and 5-fluorouracil (5-FU) in vitro at the concentrations and durations of exposure used clinically. Cell proliferation was assessed by quantification of 3H-thymidine uptake. Cell viability was studied using a sulfarhodamine B cell protein stain and by trypan blue exclusion. Neither MMC (0.4 mg/ml) nor 5-FU (40 mg/ml) were cytocidal. Both 1- and 5-minute exposures to MMC were antiproliferative. A 1-minute exposure to 0.4 mg/ml inhibited 3H-thymidine uptake by 77%. For the 5-minute exposure, 3H-thymidine uptake was inhibited by 50% at 0.06 mg/ml and by 90% at 0.4 mg/ml. For 5-FU, 3H-thymidine uptake was inhibited by 50% at 10 mg/ml and by 64% at 40 mg/ml. Mitomycin C probably does not improve the success of filtration surgery by killing fibroblasts. The ability of a brief exposure to MMC to improve filtration surgery may be due to an almost complete inhibition of proliferation. Alternatively, it may be due to sustained tissue binding, effects on other components of wound healing, such as cell migration and extracellular matrix production, or effects on the vasculature. A 1-minute exposure may be as effective as a 5-minute exposure.


Temporomandibular joint diskectomy. No positive effect of temporary silicone implant in a 5-year follow-up. The purpose of this study was to evaluate the long-term clinical and radiologic effects of a temporary silicone implant after diskectomy of the temporomandibular joint. Forty-three temporomandibular joints in 43 patients with painful disk displacement underwent a diskectomy. A sheet of medical-grade silicone was temporarily placed in 22 patients; 21 patients did not receive an implant. The patients were clinically and radiologically examined 5 years after surgery. On the basis of symptoms and jaw function, they were classified as having good (30 patients), acceptable (8 patients), and bad (5 patients) results. All the patients with bad results and five of the eight patients with acceptable results had received implants. Erosive changes of the condyle or fossa were seen radiographically at follow-up in eight patients, each of whom had received an implant. No positive clinical or radiologic effects of the implants could be identified. The use of a temporary silicone implant after diskectomy of the temporomandibular joint in patients with internal derangement should be seriously questioned.


HIV parotid gland lymphoepithelial cysts. Review and case reports. Lymphoepithelial cysts of the parotid gland are frequently associated with cervical lymphadenopathy. These unique cysts have recently been recognized as another manifestation of HIV disease. Proliferation of lymphocytes and salivary gland tissue contained within intra-parotid lymph nodes is observed. The lymphoepithelial cyst is the end product. Ultrasound imaging serves as an excellent technique to demonstrate the existence of these cysts.


Steroid acne after orthognathic surgery. Steroid acne is a common unwanted effect in patients undergoing corticosteroid therapy. Eight women in a series of 1276 adult patients had acne after orthognathic surgery in which short-course parenteral corticosteroid therapy was used to reduce postoperative swelling. Steroid-induced acneiform eruption is different from acne vulgaris in that the former usually resolves on its own, without scar formation, after withdrawal of the drug.


Idiopathic trigeminal neuralgia complicated by lingual nerve dysesthesia. The treatment of facial pain disorders has become a multifaceted discipline that involves numerous scientific fields. Diagnostic and treatment modalities may be beneficial to the patient but at times may also complicate the problem and compromise the outcome. We present an interesting case of left trigeminal neuralgia complicated by unassociated lingual nerve dysesthesia.


Failure of an endodontic implant. Complications of removal and treatment. The principal goal in the development of endodontic implants is to improve the stability of periodontally and traumatically compromised teeth. When excessive forces exist and periodontal conditions are suboptimal, however, the system breaks down and ultimately fails. We report such a failure, a sequela of which contributed to subsequent fracture of the mandible. The patient's hospital course and complications of treatment are discussed.


Salivary gland involvement in autoimmune thyroiditis, with special reference to the degree of association with Sjögren's syndrome. From a total of 63 patients with autoimmune thyroiditis, 19 cases were further investigated to determine the degree of concomitant morphologic and functional salivary gland changes. For comparison, 21 of a total of 28 cases of primary Sjögren's syndrome were also examined. Of the 19 cases of autoimmune thyroiditis, 11 showed various degrees of salivary gland involvement on the basis of an analysis of lower lip salivary gland biopsy specimens, scintigraphy of the parotid, and unstimulated whole sialometry. Six of these cases fulfilled the criteria of primary Sjögren's syndrome. A remarkably high proportion of dark-staining acini was observed in the lower lip biopsy specimens of our patients with thyroiditis (8 of 19, 42%) and less among our patients with primary Sjögren's syndrome (5 of 21, 24%). We conclude that significant involvement of salivary glands may occur in cases of autoimmune thyroiditis, which indicates that common mechanisms may frequently be operative in the development of thyroid and salivary gland immune disease.


Clinical response to levamisole in thirty-nine patients with erythema multiforme. An open prospective study. Patients with erythema multiforme (EM) often have chronic or recurring oral lesions that cause intense pain and interfere with a variety of functions including eating and speech. Previous studies suggest that levamisole restores to normal the function of phagocytes and T lymphocytes, and activates the inflammatory response. In our previous double-blind study 8 of 13 patients with EM had a decrease in severity and frequency of attacks. The purpose of this open prospective study was to evaluate short-term and long-term clinical efficacy of levamisole in patients with mucocutaneous EM. Thirty-nine patients with mucocutaneous EM seen in the Oral Medicine Clinic, School of Dentistry, University of California-San Francisco, comprised our study group. Levamisole was used alone in 17 patients or in combination with prednisone in 22 patients and was given as a single dose of 150 mg/day for 3 consecutive days. Thirty-one patients showed a complete response from levamisole (alone in 13 and in combination with prednisone in 18). Four showed a partial response of signs and symptoms, and four others had no benefits from levamisole whether alone or in combination. The most common side effects from levamisole were skin rash, tiredness, weakness, myalgia, taste change, and insomnia.


Jaw and other orofacial pain in patients receiving vincristine for the treatment of cancer. This prospective cohort study investigated orofacial pain occurring as a manifestation of vincristine neurotoxicity. Forty cancer patients (28 to 63 years of age) receiving vincristine were given baseline interviews and orofacial examinations, which were repeated weekly for 7 weeks of treatment. Twenty-two patients (55%) had neurotoxicity manifesting as orofacial pain. Onset was usually 3 days after vincristine administration; mean duration was 2 days. Twenty patients (50%) were affected in the first week: nine (22%) with severe and five (12%) with moderate pain. Symptoms were mild and infrequent in subsequent weeks. Eighteen control patients receiving chemotherapy without vincristine had no comparable orofacial symptoms. Multiple sites in the distribution of the trigeminal and glossopharyngeal nerves were affected: primarily the temporomandibular joint, mandible, throat, ears, and mandibular teeth. The frequency of orofacial pain increased with younger age. Pain was significantly associated with smaller body surface area (p less than 0.05), indicating a dose-related toxicity, and with sociodemographic variables including smoking (p less than 0.05).


Dental and oral findings in patients with familial dysautonomia. Familial dysautonomia is an inherited autosomal recessive disease found almost exclusively in Ashkenazi Jews. It is characterized by selective damage to the sensory, motor, and autonomic peripheral nervous system. The main clinical features include decreased pain sensation, impaired temperature and blood pressure regulation, lack of tearing, absent tendon reflexes, and fungiform papillae on the tongue. The purpose of this study was to explore in depth and to verify the oral and dental status in familial dysautonomia. Twenty-two patients and 44 match-paired healthy persons of Ashkenazi descent were examined. Patients and parents had only little concern for their oral condition. Caries prevalence was lower than normal and plaque accumulation increased in all patients. Dental trauma was found in 59% of the patients, and 32% showed orodental self-mutilation. Dental age was within normal range, and dental arch measurements implied proportionally small jaws and little crowding. The low caries rate may be related to the known "hypersalivation" in familial dysautonomia and/or a possible change in the salivary composition and content, caused by chronic autonomic denervation.


Chronic candidiasis, enamel hypoplasia, and pigmentary anomalies. This report describes a young male patient who had enamel hypoplasia, persistent oral candidiasis, skin hyperpigmentation, and vitiligo, and was thus suspected of having candidiasis endocrinopathy syndrome. The clinical and laboratory investigations employed to confirm the diagnosis are detailed.


Epithelioid angiosarcoma of the maxilla. A case report and review of the literature. Epithelioid angiosarcoma is a rare vascular tumor composed of a proliferation of cytologically malignant epithelioid endothelial cells. These tumors are fully malignant and can pursue a rapidly progressive course. A case of primary epithelioid angiosarcoma of the maxilla is presented. Also discussed is a review of the literature with emphasis on the concept of epithelioid endothelial cell tumors.


Natural history of HIV-associated salivary gland disease. To describe the natural history of HIV-associated salivary gland disease, which is characterized by enlarged major salivary glands and/or xerostomia in HIV-infected persons, we assessed 22 patients at an initial and follow-up examinations (median span of examinations, 15 months). Sixteen patients (73%) had bilateral parotid gland enlargement, 17 had symptoms of dry mouth, and 11 had both conditions. Parotid gland enlargement remained unchanged in 10 patients, it progressed in 2, and it regressed in 4 during treatment with zidovudine or steroids. Those patients with parotid gland enlargement had a significantly lower mean stimulated parotid flow rate (0.27 ml/min/per gland) than a control group of HIV+ persons without salivary gland disease (0.48 ml/min/per gland) (p less than 0.05), whereas the mean unstimulated whole salivary flow rates did not did not differ significantly between the two groups. The mean salivary flow rate of the study group did not change during the observation period. When HIV-associated salivary gland disease was diagnosed, 5 patients (23%) had AIDS, and at follow-up 10 (46%) had AIDS. Seven of these had Kaposi's sarcoma. The mean peripheral blood CD4 cell count was 280 and 225 per mm3 at the initial and follow-up examinations, respectively. The corresponding CD8 counts were 1138 and 900. The pathogenesis of HIV-associated salivary gland disease may include hyperplasia of intra-parotid lymphoid tissue. Because HIV-associated salivary gland disease can clinically resemble Sjögren's syndrome, the differential diagnosis of bilateral parotid enlargement should include HIV infection.


A non-Hodgkin's lymphoma in the buccal mucosa. A case report. Non-Hodgkin's lymphomas are tumors of the immune system that uncommonly evolve as primary lesions of the oral cavity. A case of a primary lymphoma in the right cheek that had invaded the surrounding tissues is presented.


B-cell lymphoma presenting as a midfacial necrotizing lesion. A case of midfacial necrotizing lesion (midline nonhealing granuloma) is reported. Paraffin- and frozen-section immunocytochemistry suggested a tumor of B-cell lineage and was confirmed by Southern blot analysis that disclosed an immunoglobulin heavy chain gene rearrangement with no evidence of T-cell receptor genetic aberration. The tumor was of B-cell lineage despite the tumor site and the angiocentric pattern, which are typically seen with peripheral T cell lymphoma with this presentation.


Vascular changes in the dental pulp in the hypercholesterolemic miniature swine. The aim of this study was to evaluate the effect of hypercholesterolemia and a cholesterol-lowering diet on the blood vessels of dental pulp. Eighteen miniature swine were assigned to three different groups on the basis of their diets: hog finisher; hog finisher with added fat and cholesterol, or hog finisher with added fat and cholesterol supplemented with grapefruit pectin. The cholesterol levels were monitored monthly for the duration of the experiment. Biopsy specimens of the aorta, coronary arteries, kidneys, and mandibular incisor teeth were prepared for histologic examination. The degree of narrowing of the central pulpal arterioles was measured with a Bioquant II digitizer attached to an Apple IIe computer and a Nikon Labophot light microscope. A few (9.8%) of the pulpal arterioles of the swine on a high-cholesterol diet had atheromatous plaques, but no complete vascular obstructions were observed. No degenerative changes were observed in any of the dental pulps examined.


Bone and root resorption. Effects of the force developed during periodontal ligament injections in dogs. The purpose of this study was to determine the role of the pressure generated during the intraligamentary injection technique on the occurrence of root and bone resorptions in dogs. Five beagles were used in the study, and interventions were scheduled to provide observation periods at 7, 25, and 45 days. One hundred five sites on the dogs were divided into three groups: (1) those subjected to needle penetration; (2) those subjected to saline solution injection; and (3) the control sites. Injections were made with a specially designed syringe equipped with a miniaturized force transducer. The dogs were then killed, and block sections of the sites were made and treated in accord with standard histologic procedures. The mean number of osteoclasts and odontoclasts was calculated for each group, and the mean value of bone and tooth resorption angle was measured. Data were then analyzed statistically. Results showed that, at 7 days, needle penetration and saline solution injection caused osteoclastic activity and bone resorption; the number of osteoclasts and the extent bone resorption were greater in the group that received the injection of saline solution. No difference was found for the odontoclastic activity and tooth resorption. A correlation was found between the force developed during injection, the mean number of osteoclasts, and the mean angle of bone and tooth resorption. At 25 and 45 days, healing had occurred. These findings suggest that fluid pressure within the periodontal ligament is sufficient to initiate osteoclastic, reversible bone resorption.


The significance of idiopathic osteosclerosis found in panoramic radiographs of sporadic colorectal neoplasia patients and their relatives. Osteosclerotic lesions in the mandible are reported with increased frequency in patients with colorectal neoplasia. Panoramic radiography has been suggested to detect high-risk patients among relatives of patients with hereditary adenomatous disease and sporadic colorectal cancer. The present study was undertaken to compare the incidence of idiopathic osteosclerotic lesions in patients with sporadic colorectal cancer and their first-degree relatives with the incidence in the general population and to determine whether panoramic radiographs are a reliable method to screen for early detection of risk of colorectal cancer. A total of 283 patients were interviewed and radiographically examined. Idiopathic osteosclerosis appeared in significantly increased incidence only in patients with colorectal cancer or adenomas and a first-degree relative with CRC (chi 2 = 7.214; p less than 0.01, and chi 2 = 4.1827; p less than 0.05 respectively). The incidence was not increased in first-degree relatives of patients with colorectal cancer or adenoma. Therefore panoramic radiographs cannot be the only screening tool for early detection of patients at high risk of colorectal cancer.


Carcinoma arising in a dentinogenic ghost cell tumor. A 13-year-old black girl was referred for evaluation of a nonhealing extraction site of 2 years' duration. Radiographs revealed a large, irregularly shaped, mixed radiolucent/radiopaque lesion that occupied almost the entire left area of the maxilla and crossed the midline. Microscopic examination revealed irregular dentinoid material with odontogenic epithelium that exhibited ghost cell keratinization and anaplastic changes. The patient underwent a hemimaxillectomy, and 7 years after surgery she appears to be free of disease.


Evaluation of radiopaque denture liner.

Evaluation of radiopaque denture liner. Radiopacity is needed in polymeric biomaterials to facilitate noninvasive detection. Permanent denture liner material with barium sulfate filler is nearly as radiopaque as aluminum and would be useful in radiographic identification. If 1 mm to 3 mm thicknesses are used, it should be easily observable radiographically.


Evaluation of prognosis and survival of the HIV-infected patient. HIV disease, once considered an acute disease with a 100% mortality rate but a very short symptomatic stage, has begun to emerge as a preventable, treatable, chronic disease. Interactions between patients, dentists, and physicians are essential to gain the information necessary to provide appropriate dental care for both short-term and long-term survivors. The prognosis and survival time of the dental patient may influence treatment protocols and necessitate modified dental procedures. Certain clinical and laboratory parameters, which may be useful indicators of disease progression, need to be recognized by the dental clinician. These parameters include systemic signs, symptoms, and serologic data as well as intraoral manifestations associated with HIV disease. Although a perfect classification system for progression of HIV disease does not exist, trends among larger cohorts may enable health care providers to estimate the prognosis and survival of HIV-infected patients on an individual basis. This article presents clinical and laboratory parameters that indicate HIV disease progression. Providers who care for HIV-infected patients need to consider these parameters to establish an appropriate and flexible treatment plan based on changes in the patient's medical status.


Computer-aided analysis of intraoral ulcerative lesions. At the present time there is no objective method to evaluate oral ulcerative lesions for degree of inflammation, surface area, or other parameters of healing. The capability of infrared photography to uniquely image the inflammatory process associated with oral lesions and the use of image-processing technology for parameter analysis was investigated. Lesions were compared cross-sectionally and over time for area of tissue degeneration, active inflammation, and intensity of inflammation with respect to adjacent tissue. Eight subjects were available for study. Standard black and white, color, and black and white infrared photographs were taken in accord with study protocols. A reflectance standard was included in each photograph to normalize the background intensity. A video camera was used to enter the data into a microcomputer image processing system. Quantitative data obtained included area of ulceration and erythematous halo, inflammatory intensity changes over time, and intensity with respect to adjacent tissue. This computer-aided photographic technique was able to quantify healing progression and intensity parameters associated with intraoral inflammatory lesions.


Survey of the medical history questionnaire. The purpose of this study was to examine and to compare the type of information requested on representative health history questionnaires commonly used by the dental profession. Samples of medical history questionnaires were obtained from American and Canadian dental schools, commercial vendors, and the American Dental Association. Results indicated that more than 140 questions have been included on questionnaires and more than 92% of these appeared in some type of yes-or-no format. The number of questions per form ranged from 32 to 88, with an average of 58 items. Although there was wide variation in the range of information requested, the 25 most frequently asked questions occurred in 70% of the forms. The majority of questions focused on noninfectious disease conditions that affect the cardiovascular system and major organ functions, allergies, and blood disorders; infectious diseases such as hepatitis, tuberculosis, mumps, and venereal disease; and health care status and special treatment considerations.


Squamous cell carcinoma of the upper aerodigestive tract in patients 40 years of age and younger. Oral squamous cell carcinoma in patients 40 years of age and younger has been noted to be infrequent. The incidence is not as noticeable because the majority of oral cancers are diagnosed during the later decades of life. This study was undertaken to evaluate the incidence, site predilection, etiologic factors, and modes of treatment and to compare these results with available data on this topic. Of 1387 cases of oral and pharyngeal squamous cell carcinoma diagnosed from 1968 to 1989 at University Hospital and affiliated institutions, 28 occurred in patients under 40 years of age. When these lesions were staged according to the American Joint Committee for Cancer Staging, we found 6 stage I lesions, 3 stage II, 2 stage III, and 11 stage IV. Six lesions could not be staged from information available in the patient records. Present data corroborate the national average of 1% to 3% of cases of oral squamous cell carcinoma found within the 40 and under age group.


Multicenter evaluation of temporomandibular joint Proplast-Teflon disk implant. Seven oral and maxillofacial surgeons from all U.S. American Association of Oral and Maxillofacial Surgeons districts participated in a retrospective study of Proplast II Teflon interpositional implants that were placed after meniscectomy in 680 TMJs (465 patients) and followed from 6 to 76 months. At longest follow-up a relatively high number (85.9%) 584 of 680 implants were in place with an average weighted follow-up of nearly 32 months. Of these 584 joints, a very high number, 540, (92.4%) were asymptomatic, however, 224 asymptomatic and 25 symptomatic joints with the implants in place exhibited some degree of condyle resorption that included 45 with malocclusion. In the worst case scenario, if condylar resorption is indicative of a worn Proplast II Teflon interpositional implant, then 364 (54%) of the 680 implants may fail. Failure rates per year range from Vitek's reported 3% to an average 18% clinician report in the literature. Higher rates are reported by individual clinicians, and our recent in vitro wear tests of Proplast II Teflon interpositional implants suggest an in vivo service life of only 3 years. Because no one has reported follow-up beyond 5 years, the long term performance and survival of any of these implants is doubtful. Asymptomatic patients should be evaluated yearly with tomography, CT, or MRI. Symptomatic patients should be evaluated every 4 to 6 months. Implant removal should be recommended if occlusal changes or condyle/fossa articular bone changes are active past the time of expected remodeling from surgery. This report summarizes the success/failure incidence from the literature and makes recommendations on follow-up, removal, and repair surgery.


Cerebrospinal fluid leak associated with proplast implant removal from the temporomandibular joint. Severe bone erosion within the temporomandibular joint reconstructed with polytetrafluoroethylene implants is a well-recognized phenomenon. Although erosion into the middle cranial fossa has been reported, we know of no report of dural disruption with cerebrospinal fluid leakage. We report a case of cerebrospinal fluid leak noted at the time of PTFE implant removal and its subsequent management. Perforation of the contralateral glenoid fossa and its reconstruction is also reported.


Healing after dental extractions in men with HIV infection. To determine the incidence of delayed healing after dental extractions in men with HIV infection, a retrospective audit was conducted of all extractions performed in a dedicated dental clinic over a 26-month period. The incidence of delayed healing in patients with HIV was compared with the incidence in those patients without HIV. Eighty men with HIV had 163 teeth extracted, which resulted in five dry sockets (3.01%). Thirty-six men thought not to have HIV had 70 extractions and three dry sockets (4.28%). All three dry sockets in the control group occurred in men who had tested negative for HIV antibodies in the year before their extraction. There were no other incidents of delayed healing. These findings contrast with other reports since they reveal no increase in delayed healing after extractions in men with HIV and do not support recommendations that prophylactic antimicrobials are required for extractions in this group of patients.


Effect of extraction of partly erupted third molars on subgingival microorganisms. This study was made to investigate the effect of extraction of third molars on subgingival microbes in 39 generally and gingivally healthy men with an average age of 20.2 years (SD 0.9). Microbial samples were taken from the pericoronal space of symptom-free partly erupted lower third molars and from the adjacent gingival pockets of the second molars. The samples were cultivated anaerobically. All partly erupted third molars were extracted from 20 subjects. A control group of 19 subjects was left untreated. Microbe sampling was repeated 2 and 5 months postoperatively with highly significant results. It was shown that at baseline the number of black-pigmented gram-negative bacteria and Fusobacterium species was more frequent in third molar than in second molar sites. The total bacterial count decreased significantly at the second molar sites after extraction of the third molars when compared with the control group. Before the extractions, black-pigmented gram-negative bacteria were detected in 45% of the test subjects and Actinobacillus actinomycetemcomitans in 20%. The respective postoperative figures were 30% for black-pigmented gram-negative bacteria and 10% for Actinobacillus actinomycetemcomitans. Capnocytophaga species were not affected by the extractions. The findings suggest that erupting third molars may harbor harmful bacteria that can be reduced by eradicating the foci.


Drugs used in the management of trigeminal neuralgia. Management of trigeminal neuralgia, a severe facial pain, remains difficult. All patients are initially treated with drugs. Since the seventeenth century more than 40 different preparations have been used; some of these, although effective, had toxic side effects. The most useful drugs at present are carbamazepine, phenytoin, baclofen, and clonazepam. A new drug, oxcarbazepine, is showing therapeutic promise. The most common reason for therapeutic failure with antineuralgic drugs is inadequate dosage. We review here the pharmacokinetics, side effects, possible drug interactions, plasma and serum therapeutic concentrations, and the available formulations of each drug. On the basis of these considerations and clinical reports describing the use of these drugs, we make dosage recommendations to enable the practitioner to individualize therapeutic regimens.


Immunodiagnosis in oral candidiasis. A review. Detection of anti-Candida antibodies in sera and saliva of patients with oral candidiasis has been regarded as a valuable laboratory technique in the diagnosis of the lesion. However, despite considerable research, the value of candidal immunodiagnosis remains controversial. Conflicting conclusions about the sensitivities and specificities of these techniques as applied to human sera and saliva have appeared. These controversies have arisen because of the use of different antigen preparations and immunologic techniques. For the present, the use of purified cytoplasmic protein antigen of Candida albicans and the ELISA technique seems to be the most reliable laboratory method.


Close association of HLA-B51 in persons with recurrent aphthous stomatitis. The HLA typing profile of 26 Israeli subjects with recurrent aphthous stomatitis (RAS) was examined and compared with that of 100 healthy control subjects. HLA-B51 was found in six subjects (23%) with RAS and in nine control subjects (9%) (p < 0.05). HLA-Cw7 was found in six subjects with RAS (23%) and in five control subjects (5%) (p < 0.01). Eleven subjects had first-degree relatives who had RAS. Because a high frequency of HLA-B51 has been found in Behcet's syndrome and aphthous stomatitis is part of this syndrome, it is suggested that in some subjects with RAS the entire syndrome may actually develop in the future.


Gram-negative enteric bacteria in the oral cavity of leukemia patients. We examined changes in the bacterial flora in hospitalized patients with leukemia. This study placed special emphasis on enteric microorganisms and their relation to the general status of the patient. One hundred thirty bacterial cultures from 16 leukemia patients and 16 control subjects, were obtained. The organisms were isolated on MacConkey agar and identified by the API-20E system. Enteric microorganisms were isolated from 62.2% of the leukemia patients as compared with 28% from the control group (p < 0.001). The enteric positive cultures were identified as Klebsiella (42.7%), Enterobacter (18.8%), and Pseudomonas (15.6%). In contrast to the negative cultures (1342), enteric microorganisms were cultured from 2948 specimens (p < 0.005).


Smokeless tobacco use prevents aphthous stomatitis. Aphthous stomatitis is a common, recurrent, painful ulcerative condition of the oral mucosa. Cigarette smoking has been reported to protect against aphthous ulcers. To determine whether smokeless tobacco use also protects against aphthous ulcers, we examined the oral mucosa in 1456 professional baseball players, about half of whom were smokeless tobacco (ST) users. After controlling for the confounding effects of age, race, cigarette smoking, alcohol consumption, and dental hygiene practices, ST use was found to significantly reduce the risk of aphthous ulcers among these healthy young men (odds ratio = 0.4; p = 0.04). It has been suggested that cigarette smoking prevents aphthous ulcers by causing increased keratinization of the oral mucosa, and ST may protect by the same mechanism. Alternatively, a component of tobacco that is systemically absorbed might be responsible for protecting against aphthous ulcers. If the mechanism that protects ST users against aphthous ulcers is systemic, then nicotine is the likely protective factor.


Invasive maxillary aspergillosis after dental extraction. Case report and review of the literature. Paranasal sinus aspergillosis has usually been considered a rare disease, but it is seen more frequently in both immunocompromised and immunocompetent persons. Invasion may reach the sinuses via the nose or from the mouth after dental procedures. Even though the infection is usually limited to one or more sinuses, it may in certain cases extend to vascular or intracranial structures with a fatal outcome. In these cases, aggressive treatment is justified. We report a case of maxillary sinus aspergillosis that developed after dental extraction. Attention should be given to this possibility even after an apparently uncomplicated dental extraction.


Immunohistochemical detection of ras 21 in oral squamous cell carcinomas. The expression of the ras p21 in oral squamous cell carcinoma was examined immunohistochemically with the use of a monoclonal antibody NCC-RAS-001 with the avidin-biotin-peroxidase complex method. The expression of ras p21 product was detected in 65.7% (44 of 67 cases) of cancer patients. On the basis of the degree of histologic differentiation of the cancer cells, the incidence of ras p21 was found to be as follows: 63.4% (26 of 41 cases) were well differentiated; 86.7% (13 of 15 cases) were moderately differentiated; and 45.5% (5 of 11 cases) were poorly differentiated. The highest incidence was found in patients in their sixties--80.0% (16 of 20 cases). The incidence decreased to 40% in patients over 80 years of age. The incidence of ras p21 on the basis of location was as follows: 81.8% (9 of 11 cases) involved the buccal region, 70.6% (12 of 17 cases) were in the gingiva, and 55.0% (11 of 20 cases) were in the tongue.


Evaluation of the carcinogenic potential of toluidine blue O in the hamster cheek pouch. Toluidine blue O has been shown to have clastogenic and mutagenic effects when tested in vitro, suggesting that it may be a carcinogen. Because this might compromise its use for cancer screening, the carcinogenic potential of this dye was investigated in the hamster cheek pouch, an established in vivo carcinogenesis model. Male hamsters were divided into seven groups at age 5 weeks. The right pouches of four groups were painted three times weekly with 2% toluidine blue or the vehicle for toluidine blue, in conjunction with submaximal applications of 9,10-dimethyl-1,2-benzanthracene (DMBA) (groups II and III, 0.5% twice weekly), and groups IV and V, 0.1% three times weekly). The right pouches of two groups received DMBA only (group I, 0.5% three times weekly, the standard maximal amount, and group VI, 0.1% three times weekly). Group VII received toluidine blue (right pouches) and toluidine blue vehicle (left pouches) three times weekly. The extent of carcinomas and other abnormalities (scored histologically) did not differ among groups receiving the same amount of DMBA with and without toluidine blue or vehicle, and no abnormalities were seen in the pouches from group VII. These results demonstrate no effect of toluidine blue as a carcinogen, cocarcinogen, or promoter.


Silver-binding nucleolar organizer region proteins as a possible prognostic indicator in oral submucous fibrosis. Silver-binding nucleolar organizer region proteins (AgNORs) were counted in sections from formalin-fixed, paraffin-embedded tissue blocks of oral submucous fibrosis (OSMF) and oral squamous cell carcinoma (SCC). Moderately advanced and advanced cases OSMF, and well-differentiated and poorly differentiated cases of SCC, were studied with respect to the relation between AgNOR counts and histologic grading. Normal oral mucosa collected from age- and sex-matched subjects constituted the control group. The pooled mean (+/- SD) AgNOR counts were as follows: normal mucosa, 2.50 +/- 0.52 (n = 5); moderately advanced OSMF, 5.24 +/- 1.23 (n = 10); advanced OSMF, 7.26 +/- 1.12 (n = 10); well-differentiated SCC, 8.29 +/- 1.47 (n = 5); and poorly differentiated SCC, 9.49 +/- 0.74 (n = 5). The pooled mean AgNOR counts in advanced OSMF were higher than in moderately advanced cases (t = 3.84; p < 0.005) and those in poorly differentiated SCC were higher than those of well-differentiated SCC, although the comparison was not significant in the latter (t = 1.63, p > 0.10). AgNOR counts could hold promise for predicting the biologic behavior of OSMF because this study demonstrated a correlation with clinical and histologic grading.


Simple bone cyst. A clinical and histopathologic study of fifteen cases. Nineteen simple bone cysts found in 15 patients were studied by classifying them into younger and older age groups. The clinical, radiographic, and histopathologic features of 11 cysts in the younger group of 10 patients were consistent with those of previous reports. Among patients in the older age group, female predominance (80% vs 30%), involvement of the maxilla (25% vs 0%), multiple occurrence (60% vs 10%), simultaneous presence of radiopaque fibro-osseous lesions or hypercementosis (63% vs 0%), and loss of lamina dura of related teeth (83% vs 14%) resulting in exposure of their roots on surgical intervention were the characteristic features.


Effects of chronic Candida albicans in the hamster cheek pouch. Sixty-four adult male hamsters had a suspension of either C. albicans (UO1) or C. albicans (ATCC 10261) placed in their cheek pouches once a week for up to 9 months. Four hamsters from both experimental groups, along with two untreated control hamsters, were killed at monthly intervals after the initial inoculation. Sections taken from the hamsters and examined in the light microscope showed that all experimental pouches had some or all of the following localized changes: inflammation and increased vascularity of the connective tissue; epithelial inflammation and microabscesses; hyperkeratosis; and isolated rete ridges similar to those in control pouches. C. albicans, usually the yeast form, was present on the exposed surface and between hyperplastic keratin squames. There was no hyphal invasion of the epithelium. Rather than being a true long-term study of chronic infection by C. albicans, the changes seen were probably the result of repetitive, more short-term responses after multiple inoculations.


Another look at root canal instrumentation. Several aspects of root canal instrumentation need additional research. Various factors must be considered in an analysis of instrumentation of the root canal system: the dentin that is cut; the technique used to cut it; the design of the instruments; the material and manufacturing process used to make the instruments; the irrigant used during the procedure; and the anatomic configuration of the root canal system. An analysis of these factors clearly indicates that existing root canal instruments and techniques are less than ideal and, in fact, do not accomplish what is expected of them. Root canals must be properly, but, at the same time, destructive and unnecessary removal of dentin should be kept to a minimum. The Flex-R and Canal Master instruments were developed to address some of the shortcomings of existing instruments and techniques. More scientifically based research is needed to fully evaluate these new instruments and techniques and to develop future instruments.


Dual wavelength spectrophotometry as a diagnostic test of the pulp chamber contents. The purpose of this in vitro study was to determine the feasibility of using dual wavelength spectrophotometry to identify teeth with pulp chambers that are either empty, filled with fixed pulp tissue, or filled with oxygenated blood. In phase I of the experiment, a human third molar was prepared so that its pulp space could be filled with oxygenated blood and later emptied. In phase II, the lower jaw of a beagle dog was removed and placed in formalin, thereby fixing the pulps of the teeth. The pulp of the right canine was removed via an apical approach, and attachments were placed in a similar position to those on the human tooth, to allow filling and emptying of the pulp space. Cavit was placed over the exposed fixed pulp in the left canine. Ten readings, which were separated by light source and detector removal and replacement, were taken of the right canine pulp space when it was empty or filled with oxygenated blood, or the left canine pulp space when it was filled with fixed tissue. Distinct and reproducible changes were measured for pulp spaces filled with air, tissue, or oxygenated blood. In phase III, simulated pulp testing on a dog tooth model was performed. Blood was introduced into the root canal space, the chamber was rinsed with water and replaced with air, according to a predetermined code. Spectrophotometer readings were recorded. The identification of pulpal contents was correctly determined in all 20 of the predetermined conditions. The findings indicate that continuous wave spectrophotometry may become a useful pulp testing method.


Magnetic resonance spectroscopy of inflammation associated with the temporomandibular joint. Noninvasive early recognition and treatment of temporomandibular joint dysfunction remains a diagnostic challenge. This pilot study evaluated the use of phosphorus 31 magnetic resonance spectroscopy with magnetic resonance imaging to measure alterations in pH and high-energy phosphate metabolite ratios of muscle that is adjacent to an inflamed temporomandibular joint. Ten New Zealand white rabbits were used in this study. Two animals were used to develop signal acquisition protocols and to ensure that stable baseline data could be measured. In each of the eight animals used in the experiment, one temporomandibular joint was injected with a suspension of silica particles and the contralateral joint served as a control. Data were collected from control and experimental joints on days 0, 7, 14, 21, and 28, after the injection. At the end of the study, temporomandibular joints were block resected and histologically examined to confirm the presence of an inflammatory response. Results indicated that pH and metabolite ratios could be obtained by 31P-magnetic resonance spectroscopy. Changes in pH and some metabolite ratios in experimental joints showed statistical significance (p < 0.001). Differences were seen on day 2 and day 7 (p = 0.040 and p = 0.008, respectively) in the phosphocreatine/alpha-adenosine triphosphate ratios. This contrasts with phosphocreatine/beta adenosine triphosphate ratios that showed significance that began at day 7 (p = 0.022) and continued to day 14 (p = 0.025). Histologic examination indicated that the tissue response within the joint capsule was less than the granulomatous reaction expected.(ABSTRACT TRUNCATED AT 250 WORDS)