Vivek Shetty

Use of sodium hyaluronate in treating temporomandibular joint disorders: A randomized, double-blind, placebo-controlled clinical trial

This study assessed the efficacy of high-molecular-weight sodium hyaluronate as a treatment for certain intracapsular temporomandibular joint (TMJ) disorders. One hundred twenty-one patients were studied at three test sites using a randomized, double-blind, placebo-controlled experimental design. Patients were selected on the basis of 1) confirmed diagnosis of either degenerative joint disease (DJD), reducing displaced disc (DDR), or nonreducing displaced disc (DDN); 2) nonresponsiveness to nonsurgical therapies; and 3) severe dysfunction as established by the Helkimo indices (HI), visual analog scales (VASs), and physical measurements of joint movement and joint noise (arthrophonometry [APM]). Subjects received a unilateral upper joint space injection of either 1) 1% sodium hyaluronate in physiologic saline (MedChem Products, Woburn, MA) or 2) USP physiologic saline. Clinical evaluations were performed using HI, VAS, and APM at weekly intervals for the first month and then at monthly intervals up to 6 months postinjection. Statistical analyses for both categorical and continuous variables were performed for each diagnostic category at each examination interval. For DJD, no difference in outcome was seen between treatment groups. For DDN, significant between-group differences were seen through 1 month; however, beyond this time point, the number of DDN patients was insufficient to draw meaningful conclusions concerning efficacy. For DDR, statistically significant within-group and between-group improvement in all three measures (HI, VAS, APM) was seen for the hyaluronate group compared to the saline group throughout the 6-month test period. At the month-2 and month-3 examination intervals, twice as many patients treated with hyaluronate (90%) showed improvement compared to patients given placebo. Further, only 3% of patients with DDR who were treated with hyaluronate relapsed compared with 31% of patients with DDR given placebo.

Biomechanical Rationale for Surgical- Orthodontic Expansion of the Adult Maxilla

OBJECTIVE To develop a biomechanical rationale for surgical-orthodontic correction of transverse maxillary deficiencies in adults by clarifying the internal stress responses to rapid palatal expansion in a photoelastic model. MATERIALS AND METHODS A three-dimensional photoelastic analog of an adult human skull was constructed by fabricating the individual facial bones from a photoelastic material and fixing them along their anatomic sutural areas. After determining the force-activation characteristics of a Hyrax expansion appliance in a straining frame, the appliance was applied to the analog and incrementally activated. The stresses developing at the different craniofacial areas were visualized and photographed in the field of a circular polariscope. Sequential cuts were performed to simulate midpalatal, zygomatic buttress, and pterygomaxillary osteotomies, and the alterations in the internal stress responses were recorded after each individual cut. RESULTS The force-activation characteristics of the Hyrax appliance are in the orthopedic range (500 g). The magnitude and distribution of the stresses induced by appliance activation differed notably between the simulated osteotomies. Analysis of fringe patterns showed that the midpalatal and pterygomaxillary articulations were the primary anatomic sites of resistance to expansion forces. The patterns of distribution and the increase in the magnitude of the stresses at superior sutural location were particularly pronounced after the pterygomaxillary cuts. The forces produced by the Hyrax appliance had deep anatomic effects, with internal stresses also manifesting at regions distant from the site of force application. CONCLUSIONS Based on photoelastic observation, it may be concluded that complete midpalatal and pterygomaxillary osteotomies are essential for predictable skeletal expansion in adults. Exclusive use of bilateral zygomatic buttress osteotomies appears to be inadequate. The expansion forces exerted by the Hyrax appliance are orthopedic in nature and produce deep anatomic effects. Clinicians should be aware that the craniofacial stresses produced by appliance activation may be experienced by the patient as pain or discomfort.

The role of hyperarousal in the manifestation of posttraumatic psychological distress following injury.

The authors examined the temporal relation among posttraumatic stress disorder symptom clusters, using data derived from a longitudinal study of survivors of orofacial injury (N = 264). They conducted cross-lagged panel analyses, with self-reported symptom data collected at 1, 6, and 12 months postinjury. Results demonstrate that hyperarousal was a potent predictor of subsequent symptoms of reexperiencing and avoidance as well as hyperarousal. By contrast, neither reexperiencing nor avoidance was significantly related to other symptom clusters other than themselves over time. These findings underscore the distinctive nature of hyperarousal in the manifestation of posttraumatic psychological distress over time. Implications for theory, clinical intervention, and future research are discussed.

The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital.

PURPOSE Psychologic distress is a common outcome among trauma survivors. This report examines both the development and predictors of acute post-traumatic stress disorder (PTSD) symptoms in a sample of US inner-city orofacial trauma survivors seeking treatment in a publicly funded hospital. PATIENTS AND METHODS Baseline data were collected from 336 patients seeking urgent care for an oral injury (mandibular or midfacial fracture). Participants were predominantly unemployed, unmarried, African American or Hispanic men in their 30s. One-month follow-up assessments of PTSD symptoms were conducted on the available 84% of the sample. RESULTS Absolute levels of PTSD symptoms were high at 1 month; 25% of the sample appeared to meet diagnostic criteria for acute PTSD, based on a self-report of symptoms. Variables associated with self-reports of higher rates of PTSD symptoms included older age, being female, prior psychologic disturbance as reflected in lifetime and current mental health and social service need and use, exposure to and distress at a prior trauma as well as overall high rates of stressful life events in the past year, injury pain, psychologic distress at hospital discharge, and unmet social support needs during the recovery phase. CONCLUSIONS A substantial subsample of these traumatized medical patients had negative psychologic outcomes at 1 month. Results underscore the potential use of screening survivors of orofacial injury at urban trauma centers for PTSD and developing systems of care that facilitate referral to appropriate psychologic treatment.

Teeth in the line of fracture: A review

The management of teeth in the line of fracture is still controversial. This lack of consensus about what is appropriate therapy led to a review of the literature. The various opinions expressed are reappraised in the context of the new treatment modalities available today, and recommendations are made to help the surgeon in his decision making.

Solitary Lag Screw Osteosynthesis in the Treatment of Fractures of the Angle of the Mandible: A Retrospective Study

Various methods have been advocated for the treatment of fractures of the angle of the mandible, emphasizing the complexity of the problem. A functionally stable osteosynthesis can be achieved in such fractures with a solitary lag screw. This technique meets the principles of rigid internal fixation and achieves maximum stability with a minimum of implant material. It obviates the need for maxillomandibular fixation, as well as the morbidity associated with the conventional methods of treatment. A review is presented of 50 patients who were treated by this method. The data show that the procedure is an effective and predictable modality of treatment with a low rate of morbidity.

Torsion-axial force characteristics of SR-PLLA screws.

The torsion axial-force characteristics of biodegradable screws are central to their ability to generate interfragmentary compression when used as lag screws. The purpose of this investigation was to compare the torsion-axial force characteristics of prototype self-reinforced poly-L-lactide (SR-PLLA) screws with conventional titanium screws. Axial forces developed by incremental increases in the torque applied to the individual screws were measured in a test apparatus incorporating an Instron machine. For the SR-PLLA screws, the relationship between applied torque and axial force development was non-linear with a marked relaxation throughout the test range. The axial forces reached a maximum with increasing torque, after which failure of the screws occurred. The response curve for titanium screws of the same length demonstrated a steeper slope. No failures or force relaxation were observed with the titanium screws. The results of this investigation suggest that, at this time, the use of SR-PLLA screws for lag screw fixation should be restricted to low stress bearing areas.

Developmental validation of a point-of-care, salivary α-amylase biosensor.

The translation of salivary alpha-amylase (sAA) to the ambulatory assessment of stress hinges on the development of technologies capable of speedy and accurate reporting of sAA levels. Here, we describe the developmental validation and usability testing of a point-of-care, colorimetric, sAA biosensor. A disposable test strip allows for streamlined sample collection and a corresponding hand-held reader with integrated analytic capabilities permits rapid analysis and reporting of sAA levels. Bioanalytical validation utilizing saliva samples from 20 normal subjects indicates that, within the biosensors linear range (10-230 U/ml), its accuracy (R(2)=0.989), precision (CV<9%), and measurement repeatability (range -3.1% to +3.1%) approach more elaborate laboratory-based, clinical analyzers. The truncated sampling-reporting cycle (<1 min) and the excellent performance characteristics of the biosensor has the potential to take sAA analysis out of the realm of dedicated, centralized laboratories and facilitate future sAA biomarker qualification studies.

Label-free, chemiresistor immunosensor for stress biomarker cortisol in saliva

Salivary cortisol is commonly used as a bioindicator of the psychobiologic response to environmental and psychological stressors. Current analytical approaches rely on immunoassays performed at distant, centralized laboratories and involve an elaborate specimen collection-processing-transportation-storage-analysis-reporting cycle. To facilitate point-of-use measurement of salivary cortisol levels, we describe the development and proof-of-concept testing of an ultrasensitive, label-free immunosensor based on a single-walled, carbon nanotube-based chemiresistive transducer. Carbon nanotubes were functionalized with a cortisol analog [cortisol-3-CMO-NHS ester] and a monoclonal anti-cortisol antibody was ligated to this receptor. Addition of phosphate buffer as well as artificial saliva spiked with varying cortisol concentrations displaced the anti-cortisol antibody producing corresponding decreases in the resistance/conductance of the nanotube-biomolecule hybrid. The immunosensor demonstrated an ultralow detection limit of 1 pg/ml and excellent binding selectivity for cortisol even in the presence of structurally similar steroids such as 21-hydroprogesterone. The nanotube immunosensor offers attractive prospects for the development of highly sensitive biosensor for rapid, label-free measurement of salivary cortisol in a variety of clinical and research settings.

Alcohol abuse and illegal drug use among Los Angeles County trauma patients: Prevalence and evaluation of single item screener

BACKGROUND The misuse of alcohol and illicit drugs is implicated with injury and repeat injury. Admission to a trauma center provides an opportunity to identify patients with substance use problems and initiate intervention and prevention strategies. To facilitate the identification of trauma patients with substance use problems, we studied alcohol abuse and illegal substance use patterns in a large cohort of urban trauma patients, identified correlates of alcohol abuse, and assessed the utility of a single item binge-drinking screener for identifying patients with past 12-month substance use problems. METHODS Between February 2004 and August 2006, 677 patients from four large trauma centers in Los Angeles County were interviewed. The sample was broadly representative of the entire Los Angeles County trauma center patient population. RESULTS Twenty-four percent of patients met criteria for alcohol abuse and 15% reported using an illegal drug other than marijuana in the past 12 months. Male gender, assaultive injury, peritrauma substance use, and history of binge drinking were prominent risk factors. A single item binge drinking screen correctly identified alcohol abuse status in 76% of all patients; the screen also performed moderately well in discriminating between those who had or had not used illegal drugs in the past 12 months, with sensitivity estimates reaching 0.79 and specificity estimates reaching 0.74. CONCLUSIONS A large proportion of urban trauma patients abuse alcohol and use illegal drugs. Distinct sociodemographic and substance use history may indicate underlying risky behaviors. Interventions and injury prevention programs need to address these causal behaviors to reduce injury morbidity and recidivism. In the busy trauma care setting, a one-item screener could be helpful in identifying patients who would benefit from more thorough assessment and possible brief intervention.