Christoph M. Ziegler

Periodontal Disease as a Risk Factor for Ischemic Stroke

Background and Purpose— Chronic infectious diseases may increase the risk of stroke. We investigated whether periodontal disease, including periodontitis and gingivitis, is a risk factor for cerebral ischemia. Methods— We performed a case-control study with 303 patients examined within 7 days after acute ischemic stroke or transient ischemic attack, 300 population controls, and 168 hospital controls with nonvascular and noninflammatory neurological diseases. All subjects received a complete clinical and radiographic dental examination. The individual mean clinical attachment loss measured at 4 sites per tooth served as the main indicator for periodontitis. Results— Patients had higher clinical attachment loss than population (P <0.001) and hospital (P =0.010) controls. After adjustment for age, sex, number of teeth, vascular risk factors and diseases, childhood and adult socioeconomic conditions, and lifestyle factors, the risk of cerebral ischemia increased with more severe periodontitis. Subjects with severe periodontitis (mean clinical attachment loss >6 mm) had a 4.3-times-higher (95% confidence interval, 1.85 to 10.2) risk of cerebral ischemia than subjects with mild or without periodontitis (≤3 mm). Severe periodontitis was a risk factor in men but not women and in younger (<60 years) but not older subjects. Periodontitis increased the risk of cerebral ischemia caused by large-artery atherosclerosis, cardioembolism, and cryptogenic etiology. Gingivitis and severe radiologic bone loss were also independently associated with the risk of cerebral ischemia, whereas caries was not. Conclusions— Our study indicates that periodontal disease, a treatable condition, is an independent risk factor for cerebral ischemia in men and younger subjects.

Association Between Acute Cerebrovascular Ischemia and Chronic and Recurrent Infection

BACKGROUND AND PURPOSE We performed a case-control study to investigate whether chronic or recurrent respiratory, ear-nose-throat (ENT), and dental infections are risk factors for cerebrovascular ischemia. METHODS Using a standardized questionnaire we investigated past infectious diseases in 166 consecutive patients with acute cerebrovascular ischemia and in 166 age- and sex-matched nonstroke neurological patient controls. In subgroups, we performed standardized ENT (69 patients, 66 control subjects) and dental examinations including orthopantomography (66 patients, 60 control subjects). Dental status was determined by a total dental index (TDI) that reflects caries, periapical lesions, periodontitis, and other dental lesions and by an orthopantomography index (OPGI) that was assessed blinded. RESULTS Frequent (> or = 2 episodes in each of the 2 preceding years) or chronic bronchitis was associated with cerebrovascular ischemia in age-adjusted multiple logistic regression analysis (odds ratio, OR, 2.2; 95% confidence interval, CI, 1.04 to 4.6). Groups were not different in ENT examination. Patients tended to have a worse dental status (TDI: P = .070; OPGI: P = .062) and had more severe periodontitis (P = .047) and periapical lesions (P = .027) than control subjects. In age-adjusted multiple logistic regression analysis with social status and established vascular risk factors, poor dental status (TDI) was independently associated with cerebrovascular ischemia (OR, 2.6; 95% CI, 1.18 to 5.7). CONCLUSION Recurrent or chronic bronchial infection and poor dental status, mainly resulting from chronic dental infection, may be associated with an increased risk for cerebrovascular ischemia.

Endoscopy: a minimally invasive procedure for diagnosis and treatment of diseases of the salivary glands. Six years of practical experience.

During a 6-year period we did a total of 72 videoendoscopies of the salivary glands and their associated ductal systems. This minimally invasive procedure is associated with little morbidity and discomfort. The main indication was sialolithiasis of the submandibular and parotid glands. Sialoendoscopy was used not only for diagnosis of radiolucent calculi but also for simultaneous removal of calculi. Sialoendoscopy was also of benefit in the diagnosis and treatment of other diseases of the salivary glands. Even patients with chronic sialadenitis could be helped with endoscopic dilatation of the causative sialostenosis, thereby enabling us to conserve the gland.

Erweiterte Diagnostik im Rahmen der operativen Weisheitszahnentfernung mittels digitaler Volumentomographie

Hintergrund. Die Verletzung des N. alveolaris inferior ist eine der schwerwiegendsten Komplikationen der operativen Weisheitszahnentfernung. Mit Einführung der digitalen Volumentomographie (DVT) wurde eine neue Aufnahmetechnik in die Zahn-, Mund- und Kieferheilkunde eingeführt, die dieselben Rekonstruktionsmöglichkeiten wie die Computertomographie (CT) bietet. Seit Mitte 2000 führen wir bei tief verlagerten dritten Molaren, die eine enge topographische Beziehung zwischen Nervenkanal und Weisheitszahn aufweisen, eine Bildgebung mittels DVT durch. Methode und Ergebnisse. Im Rahmen der hier vorgestellten Untersuchung wurden volumentomographische Darstellungen von insgesamt 81 unteren und 11 oberen Sapientes durchgeführt, bei denen keine diagnostisch eindeutige Darstellung im vorhandenen Panoramaschichtbild möglich war. In allen Fällen konnte eine detaillierte Darstellung der Sapientes in allen Schnittebenen ermöglicht werden, die exakte Rekonstruktion des Verlaufs des N. alveolaris inferior gelang in 93% der untersuchten Fälle. Resümee. Zusammenfassend lässt sich feststellen, dass die DVT ein diagnostisch wertvolles und praxisreifes Bildgebungsverfahren für die erweiterte Diagnostik im Rahmen der operativen Weisheitszahnentfernung ist. Background. Trauma to the inferior alveolaris nerve is one of the worst complications of the surgical removal of wisdom teeth. With digital volume tomography (DVT), a new imaging technique has been introduced to dentistry and oral and maxillofacial surgery, offering the same options for reconstruction as computer tomography (CT). Since mid-2000 we have been performing imaging via DVT in the case of deeply dislocated third molars sited very close to the nerve canal. Methods and results. In the present study DVT images were made for a total of 81 lower and 11 upper wisdom teeth; the existing orthopantomogram of these teeth had not been sufficiently clear to allow a diagnosis in these cases. Detailed visualization of the wisdom tooth concerned in all planes was possible in each case, and exact reconstruction of the course of the inferior alveolar nerve was successful in 93%. Discussion. In summary, DVT is an advantageous and practical imaging technique that can be used for to extend the diagnosis in surgery on third molars.

Analgesic effects of intra-articular morphine in patients with temporomandibular joint disorders: a prospective, double-blind, placebo-controlled clinical trial.

PURPOSE A number of reports have shown a direct analgesic effect of opioids by way of the peripheral receptors. Nevertheless, only a very few studies have reported using opioids in the temporomandibular joint (TMJ), and nearly all of them were connected to surgical patient groups. The present study was designed to evaluate the analgesic efficacy and safety of repeated intra-articular morphine applications compared with a local anesthetic and saline solution in the management of TMJ pain. PATIENTS AND METHODS A total of 48 patients with articular pain related to the TMJ were entered in a clinical, prospective, randomized, double-blind, single-center study. The analgesic effect of repeated intra-articular infiltration with morphine (5 or 10 mg morphine sulfite), bupivacaine 0.5% (Carbostesin; AstraZeneca, London, UK), and isotonic saline solution as a placebo in the TMJ was examined. The efficiency after 3 injections of the same substance with an interval of 48 hours between each application was measured using a pain relief scale, visual analog scale, pain intensity scale, and the potential need for accessory peripheral analgesics (paracetamol). RESULTS All patients showed, independent of the treatment group, pain relief within 60 minutes after the first injection. Patients with saline and Carbostesin reported almost complete pain recurrence before the second injection. At 1 week after the last and third injection, the 10-mg morphine group still showed a distinct effect, with 16.7% reporting complete (no pain) and 41.7% distinct pain relief. In addition, 33.3% had a poor response and 8.3% had no improvement. None of the other groups reported complete improvement; however, 25% of the patients who received 5 mg morphine had distinct pain relief, and 50% had at least poor pain relief. In the Carbostesin group, distinct improvement was reported by 8.3%, with a poor response in 41.7%, and no effect in the remaining 50%. Patients treated with saline had a poor response in 16.7%, but most (83.3%) reported no improvement 1 week after treatment. CONCLUSIONS Independent of the applied substances, initial pain relief can be registered in the TMJ: either from the arthrocentesis effect or at least the placebo effect. Morphine at a dosage of 10 mg showed the best and most long-lasting analgesic efficiency. Morphine, in general (5 and 10 mg), and, with limitations, Carbostesin were more or less efficient for postoperative pain control but without distinct effects in the long term. With regard to our results, we can recommend intra-articular morphine application at a dose of 10 mg for pain management. Carbostesin showed no promising long-term effects.

OrbitabodenrekonstruktionVergleich einer neuen perforierten 0,15 mm dicken PDS-Folie mit etabliertem Titanium-Dynamic-Mesh

ZusammenfassungHintergrund. In der operativen Versorgung der Orbitabodenfraktur steht seit kurzem eine neue perforierte resorbierbare PDS-(Poly-p-dioxanon-)Folie der Dicke 0,15 mm zur Verfügung. Ziel der folgenden prospektiv randomisierten interdisziplinären Studie, die gleichermaßen Patienten aus der HNO- und MZKG-Klinik der Universität Heidelberg rekrutierte, war die klinische Evaluation der neuen PDS-Folie im Vergleich zum etablierten Titanium-Dynamic-(TD-) Mesh der Stärke 0,3 mm in der Versorgung der Orbitabodenfraktur. Patienten und Methodik. Neben der üblichen Diagnostik wurde präoperativ (U1), am 4. postoperativen Tag (U3), 1 Monat postoperativ (U4) und 1/2 Jahr postoperativ (U5) eine ausgedehnte ophthalmologische Untersuchung durchgeführt und der Verlauf dokumentiert. Ergebnisse. Die Eingriffe wurden in allen Randomisationsgruppen gut toleriert. Die perforierte PDS-Folie erwies sich intraoperativ hinsichtlich der glatten Schnittkanten als leichter zu verarbeiten. Sowohl die PDS- als auch die TD-Gruppe zeigten eine diskrete Zunahme des präoperativen Exophthalmus (im Mittel 0,5 mm). Schlussfolgerung. Die neue perforierte PDS-Folie ist funktionell, insbesondere hinsichtlich der Stabilität und des kosmetischen Ergebnisses dem Titan-Mesh in der Versorgung von Orbitabodenfrakturen bis 20 mm Durchmesser gleichwertig und erscheint darüber hinaus aufgrund der Bioresorption vorteilhaft.AbstractIntroduction. For surgical reconstruction of the orbital floor after blow-out fractures, a new perforated PDS (poly-p-dioxanon) foil (0.15 mm thickness) has recently become available. The main target of this prospective and randomized interdisciplinary clinical study was to compare this new PDS foil with the proven titanium dynamic mesh (0.3 mm thickness). Patients/Methods. Aside from the common diagnostic procedures, an extensive ophthalmologic examination was performed and documented preoperatively (U1), 4 days (U3), 1 month (U4), and 6 months (U5) postoperatively. Results. In both groups the surgical procedure was tolerated well. The new perforated PDS foil turned out to be easier to handle intraoperatively because of smooth and clean cutting edges. The surgical treatment was well tolerated in all randomized groups. In contrast to the control group, the PDS and TD groups showed postoperatively a slight increase of the preoperative exophthalmos (mean 0.5 mm). Conclusion. The new perforated PDS foil is comparable concerning cosmetic and functional aspects. Especially with regard to stability after blow-out fractures, the new perforated PDS foil is equal to titanium dynamic mesh up to 20 mm in diameter. PDS foil is felt to be superior regarding bioresorption and due to the more convenient handling.

The current state of facial prosthetics – A multicenter analysis

Even though modern surgical techniques are dominating reconstructive facial procedures, the capability to use facial epitheses for reconstruction is still an important skill for the maxillofacial surgeon. We present an international multicenter analysis to clarify which techniques are used to fixate facial prostheses. We contacted all maxillofacial departments in Germany, Austria, Switzerland and Norway which were registered with the German society for oral and maxillofacial surgery (DGMKG). These centers were asked via electronical mail to provide information on the type of epithesis fixation systems currently in use. The return rate from 58 departments was 43.1% (n = 25). Overall, implant fixation was the preferred fixation system (92%). Plates were the second most common fixation technique (32%). No centers reported the standard use of non-invasive fixation techniques for permanent epithesis fixation. The main retention systems in use were magnets (24/25), other retention systems are used much less often. The current preferred fixation technique for facial epitheses consists of implant-based, magnet-fixated epitheses. For nasal prostheses, a plate-based, magnet-fixated system is often used.

Digital tomosynthesis-experiences with a new imaging device for the dental field.

Based on the principles of classic film tomography, a new digital X-ray device for dental sites was developed and clinically evaluated. The tomosynthesis process produces several slices from a finite number of radiographs taken from different projection angles, obtaining a three-dimensional image of the jaws and teeth. During evaluation of an industrial prototype, a total of 52 tomosynthesis data sets were made covering different anatomic areas. Of those, 32 sets were assessed by ten radiologically experienced dentists. Anatomic regions not shown on conventional intraoral dental films were displayed due to the extraoral sensor. Diagnostic images of high value were mainly achieved within the scope of lateral views and transverse views in the frontal region. Even small structures such as the periodontal ligament could be shown in several planes, resulting in superposition-free representation. The elimination of metal artefacts caused by dental restorations was facilitated. However, improvements can be made in definition and resolution. Views in the sagittal plane and incomplete blurring of the contralateral jaw are difficulties that remain. The tomosynthesis process combined with a planned 3D representation is likely to be well suited for dental radiology. The use of such a device could be much less expensive than computed tomography (CT). Furthermore, it offers higher spatial resolution, exposes patients to less radiation, and could be easily used in daily practice, even chairside.

Odontogener Fokus als Ursache zerebraler Ischämien

Frühere Studien haben gezeigt, daß akute Infektionen, insbesondere der Atemwege, einen wichtigen Risikofaktor für zerebrale Ischämien darstellen. Weiterhin wissen wir, daß chronische odontogene Infektionen ein Risiko für myokardiale Infarkte und Arteriosklerose sein können. Der Zusammenhang zwischen zerebralen Insulten und dentalen Infektionen wurde jedoch bislang kaum untersucht. Daher führten wir eine Fall-Kontroll-Studie unter Anwendung eines standardisierten Erhebungsbogens und Untersuchungsprotokolls durch. Es wurden 66 Patienten mit einer akuten zerebralen Ischämie/Insult sowie 60 weitere alters- und geschlechtsentsprechende neurologische Patienten als Kontrollgruppe untersucht. Der Zahnstatus wurde durch einen sog. Total-Dental-Index (TDI), welcher in erster Linie Karies, Parodontitis, periapikale Läsionen, devitale und fehlende Zähne berücksichtigt, sowie durch einen Panoramaschichtindex (PI) erfaßt. Speziell ältere Patienten mit einer zerebralen Ischämie wiesen tendenziell einen signifikant schlechteren Zahnstatus auf und besaßen deutlich öfter Parodopathien und apikale Läsionen als Kontrollpersonen. Ein vorbestehender schlechter Zahnstatus war verknüpft mit einer zerebrovaskulären Ischämie unabhängig von anderen vaskulären Risikofaktoren und dem sozialen Status. Zusammenfassend gesagt, kann eine schlechte Zahngesundheit, v.a. aus chronischen odontogenen Infektionen resultierend, mit einem erhöhten Risiko für zerebrovaskuläre Ischämien verbunden sein. Die Ergebnisse müssen nun in größeren Folgestudien verifiziert werden. Da chronische dentale Infektionen weit verbreitete und ebenso leicht therapierbare Faktoren darstellen, würde ihre Identifikation als Risikofaktor für einen Insult eine ziemlich wichtige Rolle im Bereich der Präventivmedizin spielen. Recent studies have shown that acute infections, especially of the respiratory tract, are an important risk factor for cerebral ischemia. Additionally we know that chronic dental infections may be a risk for myocardial infarction and artherosclerosis. However, the connection between stroke and dental infections has hardly been examined so far. Therefore we performed a case-control study using a standardized questionaire and examination. We investigated 66 patients consecutive to a acute cerebral ischemia/stroke and 60 age- and sex-matched nonstroke neurological patients as a control group. Dental status was determined by a so called total dental index (TDI) which reflects primarily caries, periodontitis, periapical lesions, devital and missing teeth as well as by a panoramic index (PI). Specifically, older patients with cerebrovascular ischemia tended to have a significantly worse dental status and had more severe periodontitis and periapical lesions than control subjects. A predefined poor dental status was associated with cerebrovascular ischemia independent from other vascular risk factors and social status. In conclusion, poor dental health, mainly resulting from chronic dental infections, may be associated with an increased risk for cerebrovascular ischemia. The results must now be verified in larger studies. As chronic dental infections are a common and also easily treatable factor, their identification as a risk factor for stroke would be quite important in the field of preventive medicine.

Plattenepithelkarzinom bei einer 27jährigen Patientin mit zellulärem Immundefekt

Plattenepithelkarzinome im Bereich der Mundhöhle treten meist bei älteren Patienten oder bei Patienten mit Alkohol- oder Nikotinabusus auf. Bei jüngeren Patienten werden diese selten beschrieben. Es wird über die Kasuistik einer 27jährigen Patientin mit einem Plattenepithelkarzinom im Bereich der rechten Wange berichtet. Bei fehlenden Risikofaktoren wird ein zellulärer Immundefekt und eine langjährig persistierende Candidainfektion für die Karzinogenese verantwortlich gemacht. Squamous cell cancer of the oral cavity mainly occurs in older patients or in patients with alcohol or nicotine abuse. Younger patients are seldom involved. The case of a 27-year-old woman with a squamous cell cancer of the right cheek will be presented. Without any risk factors, an immune defect resulting in chronic Candida infection of the oral cavity seems to be responsible for the carcinogenesis.