Cleidocranial dysplasia: a review of the dental, historical, and practical implications with an overview of the South African experience

Cleidocranial dysplasia (CCD) is an uncommon but well-known genetic skeletal condition. Several hundred affected persons are members of a large extended family in the Cape Town Mixed Ancestry community of South Africa. The clinical manifestations are often innocuous, but hyperdontia and other developmental abnormalities of the teeth are a major feature and may require special dental management. Over the past 40 years, the authors have encountered more than 100 affected persons in Cape Town. Emphasis has been on dental management, but medical, genetic, and social problems have also been addressed. In this article, we have reviewed the manifestations of the disorder in the light of our own experience, and performed a literature search with emphasis on the various approaches to dental management and treatment options in CCD. Advances in the understanding of the biomolecular pathogenesis of CCD are outlined and the international and local history of the disorder is documented.Web of Scienc

Injectable local anaesthetic agents for dental anaesthesia

Background: Pain during dental treatment, which is a common fear of patients, can be controlled successfully by local anaesthetic. Several different local anaesthetic formulations and techniques are available to dentists. / Objectives: Our primary objectives were to compare the success of anaesthesia, the speed of onset and duration of anaesthesia, and systemic and local adverse effects amongst different local anaesthetic formulations for dental anaesthesia. We define success of anaesthesia as absence of pain during a dental procedure, or a negative response to electric pulp testing or other simulated scenario tests. We define dental anaesthesia as anaesthesia given at the time of any dental intervention. Our secondary objective was to report on patients' experience of the procedures carried out. / Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2018, Issue 1), MEDLINE (OVID SP), Embase, CINAHL PLUS, WEB OF SCIENCE, and other resources up to 31 January 2018. Other resources included trial registries, handsearched journals, conference proceedings, bibliographies/reference lists, and unpublished research. / Selection criteria: We included randomized controlled trials (RCTs) testing different formulations of local anaesthetic used for clinical procedures or simulated scenarios. Studies could apply a parallel or cross‐over design. / Data collection and analysis: We used standard Cochrane methodological approaches for data collection and analysis. / Main results: We included 123 studies (19,223 participants) in the review. We pooled data from 68 studies (6615 participants) for meta‐analysis, yielding 23 comparisons of local anaesthetic and 57 outcomes with 14 different formulations. Only 10 outcomes from eight comparisons involved clinical testing. We assessed the included studies as having low risk of bias in most domains. Seventy‐three studies had at least one domain with unclear risk of bias. Fifteen studies had at least one domain with high risk of bias due to inadequate sequence generation, allocation concealment, masking of local anaesthetic cartridges for administrators or outcome assessors, or participant dropout or exclusion. We reported results for the eight most important comparisons. / Success of anaesthesia: When the success of anaesthesia in posterior teeth with irreversible pulpitis requiring root canal treatment is tested, 4% articaine, 1:100,000 epinephrine, may be superior to 2% lidocaine, 1:100,000 epinephrine (31% with 2% lidocaine vs 49% with 4% articaine; risk ratio (RR) 1.60, 95% confidence interval (CI) 1.10 to 2.32; 4 parallel studies; 203 participants; low‐quality evidence). When the success of anaesthesia for teeth/dental tissues requiring surgical procedures and surgical procedures/periodontal treatment, respectively, was tested, 3% prilocaine, 0.03 IU felypressin (66% with 3% prilocaine vs 76% with 2% lidocaine; RR 0.86, 95% CI 0.79 to 0.95; 2 parallel studies; 907 participants; moderate‐quality evidence), and 4% prilocaine plain (71% with 4% prilocaine vs 83% with 2% lidocaine; RR 0.86, 95% CI 0.75 to 0.99; 2 parallel studies; 228 participants; low‐quality evidence) were inferior to 2% lidocaine, 1:100,000 epinephrine. Comparative effects of 4% articaine, 1:100,000 epinephrine and 4% articaine, 1:200,000 epinephrine on success of anaesthesia for teeth/dental tissues requiring surgical procedures are uncertain (RR 0.85, 95% CI 0.71 to 1.02; 3 parallel studies; 930 participants; very low‐quality evidence). Comparative effects of 0.5% bupivacaine, 1:200,000 epinephrine and both 4% articaine, 1:200,000 epinephrine (odds ratio (OR) 0.87, 95% CI 0.27 to 2.83; 2 cross‐over studies; 37 participants; low‐quality evidence) and 2% lidocaine, 1:100,000 epinephrine (OR 0.58, 95% CI 0.07 to 5.12; 2 cross‐over studies; 31 participants; low‐quality evidence) on success of anaesthesia for teeth requiring extraction are uncertain. Comparative effects of 2% mepivacaine, 1:100,000 epinephrine and both 4% articaine, 1:100,000 epinephrine (OR 3.82, 95% CI 0.61 to 23.82; 1 parallel and 1 cross‐over study; 110 participants; low‐quality evidence) and 2% lidocaine, 1:100,000 epinephrine (RR 1.16, 95% CI 0.25 to 5.45; 2 parallel studies; 68 participants; low‐quality evidence) on success of anaesthesia for teeth requiring extraction and teeth with irreversible pulpitis requiring endodontic access and instrumentation, respectively, are uncertain. For remaining outcomes, assessing success of dental local anaesthesia via meta‐analyses was not possible. / Onset and duration of anaesthesia: For comparisons assessing onset and duration, no clinical studies met our outcome definitions. Adverse effects (continuous pain measured on 170‐mm Heft‐Parker visual analogue scale (VAS)) Differences in post‐injection pain between 4% articaine, 1:100,000 epinephrine and 2% lidocaine, 1:100,000 epinephrine are small, as measured on a VAS (mean difference (MD) 4.74 mm, 95% CI ‐1.98 to 11.46 mm; 3 cross‐over studies; 314 interventions; moderate‐quality evidence). Lidocaine probably resulted in slightly less post‐injection pain than articaine (MD 6.41 mm, 95% CI 1.01 to 11.80 mm; 3 cross‐over studies; 309 interventions; moderate‐quality evidence) on the same VAS. For remaining comparisons assessing local and systemic adverse effects, meta‐analyses were not possible. Other adverse effects were rare and minor. / Patients' experience: Patients' experience of procedures was not assessed owing to lack of data. / Authors' conclusions: For success (absence of pain), low‐quality evidence suggests that 4% articaine, 1:100,000 epinephrine was superior to 2% lidocaine, 1:100,000 epinephrine for root treating of posterior teeth with irreversible pulpitis, and 2% lidocaine, 1:100,000 epinephrine was superior to 4% prilocaine plain when surgical procedures/periodontal treatment was provided. Moderate‐quality evidence shows that 2% lidocaine, 1:100,000 epinephrine was superior to 3% prilocaine, 0.03 IU felypressin when surgical procedures were performed. Adverse events were rare. Moderate‐quality evidence shows no difference in pain on injection when 4% articaine, 1:100,000 epinephrine and 2% lidocaine, 1:100,000 epinephrine were compared, although lidocaine resulted in slightly less pain following injection. Many outcomes tested our primary objectives in simulated scenarios, although clinical alternatives may not be possible. Further studies are needed to increase the strength of the evidence. These studies should be clearly reported, have low risk of bias with adequate sample size, and provide data in a format that will allow meta‐analysis. Once assessed, results of the 34 ‘Studies awaiting classification (full text unavailable)’ may alter the conclusions of the review

Dental care of patients with dementia

Dental care of patients with dementia. Clinical and ethical considerations Gunilla Nordenram Department of Clinical Neuroscience and Family Medicine, Division of Geriatric Medicine Huddinge Hospital and School of Dentistry, Division of Geriatric Dentistry, Karolinska Institutet, Stockholm, Sweden, ISBN 91-628-2416-3 To establish guidelines for fair and proper oral care for patients with dementia, the following aims were specified: To develop an appropriate method for analysing ethical problems related to the provision of dental care for patients with dementia; to categorize spokesmen's perceptions of the concept of oral comfort for persons with dementia; to assess the potential benefit of dental treatment for persons with dementia; to determine the influence of stage of dementia on the feasible level of treatment; to reveal the patient's individual adaption to dental treatment, irrespective of the dementia-related impairments; to disclose ethical dilemmas in dental management of patients with dementia experienced by hospital dentists and their reasoning in conflict situations. As dental care for impaired patients includes both close human relationships and technically demanding treatment procedures, the wide range of research questions concerning dental care of patients with dementia reflects this complexity. Thus the thesis combines qualitative and quantitative research methods. The first theme concerns aspects of human behavioural science such as perception, interpretation of feelings, thoughts, evaluations, actions and behaviour (1, 11, Vl). The other theme is formulated in conventional dental scientific terms, such as oral function, oral status and nutritional status (III,IV, V). A safe treatment setting can be created, based on adequate knowledge and explicit ethical insight, realized as morals in action. The dentists' ethical reasoning were dependent on recognition of ethical components in specific situations located in a specific context and could develop understanding - both when the treatment succeeded and when it failed. Benefits of oral care for patients with dementia were identified: The basal benefits, freedom from oral pain and a safe oral environment with no risk of aspiration. Further benefits, a better choice of food and food consistency and a better function in ADL of eating. Realistic treatment need could be identified considering the stage of the dementia, the patient's personality and social circumstances and in consensus with spokesmen. Fair and proper oral care for demented patients requires 3 "T": Time in the treatment situation. To receive, understand and support the patient in the dental setting is time-consuming. Teamwork in the treatment planning. To determine and provide adequate oral care is a task that involves not only the dental team but also non-dental health care providers. Training to develop skill in dental management of patients with dementia. In our heterogenic world, with rapid changes in technology and economics, shifts in contemporary biomedical ethics are evident and an ongoing philosophical dialouge of biomedical ethics is therefore essential. It should be based on actual practice with authentic cases which augment and extend the notion of good and bad, right and wrong within professions as well as within society as a whole. Key words: Dementia, Alzheimer's disease, cognition, ethical reasoning, ethical principles, advocate, geriatnc dentistry, dental management, elderly, nutrition, treatment need

Models for solid waste and its management in Stockholm metropolitan area

In the transition from a linear economy to a sustainable circular economy, waste management is critical. This thesis approaches the management of Municipal Solid Waste (MSW) from the perspective of a mathematical modelling. Within the scope of the thesis, three mathematical models were developed. The first is a probability theory-based model that makes reliable projections of MSW amounts and composition from a relatively large number of small datasets using regressional estimates, by treating the regression parameters of individual municipalities (small sets) as samples from a single distribution. A tailored two-step method for outlier detection is also used. This model shows that the amount of mixed waste is decreasing rapidly, as more waste is separated in the households. It also shows that less food waste is being produced but more is being sorted separately, resulting in a rapid increase in available sorted organic waste. The predictions of this model are used as input data for the two other models. These area multi-objective linear programming model which provides Pareto optimal solutions for the Stockholm MSW management system and a stochastic model which simulates the current MSW management system from the perspective of the procurement process. The models take both Economic Benefits (EB) and emissions of Greenouse Gases (GHG) into account, where the latteris measured in CO2 equivalent. Therefore, a set of Pareto optimal solutions are obtained, ranging from maximized EB to minimized emissions of GHG with compromise solutions in between, rather than just one solution (e.g. minimum emissions). Each Pareto optimal solution is characterized by where waste flows are allocated, as well as which facilities should be operating and which facilities should be closed. One solution was subjectively chosen as the best compromise, as it saves Stockholm around 150 million SEK per year, while slightly decreasing emissions to a level very close to the minimum, as compared to the simulation of currenttreatment. This solution indicated that one of the MSW treatments, waste compression, is not economically viable, and should be removed from the system. This result was also seen in the procurement simulation, which was run both with compression facilities active and inactive. The cost for running these facilities had to be decreased to 1/10 of the estimated value before their economic impact became net zero for the simulation, but even at this level remained unfeasible in the optimization model. Another major indication of the models was that Anaerobic Digestion(AD) plant capacity will at the very latest be surpassed by the amount of separated organicwaste in 2024, so to make use of the benefits this process has compared to incineration, AD capacity should be expanded.Avfallshantering är en avgörande faktor i övergången från en linjär till en hållbar cirkulär ekonomi. Denna kandidatuppsats undersöker hanteringen av restavfall ur ett systemperspektiv genom matematisk modellering. I arbetet har tre matematiska modeller utvecklats. Den första är en sannolikhetsbaserad modell som uppskattar både mängd avfall och dess komposition. Modellen gör goda uppskattningar från ett större antal små dataset genom att behandla regressionsparametrar från enskilda kommuner (litet dataset) som stickprov från en fördelning. En tvåstegsmetod anpassad till datan används för att hitta felaktiga datapunkter. Modellen visar att uppkommet blandat restavfall väntas minska snabbt, till följd av ökad avfallssortering i hushållen. Även mängden uppkommet matavfall minskar, men eftersom en större andel av detta sorteras separat ökar den tillgängliga mängden utsorterat matavfall drastiskt. Uppskattningarna från denna modell användes som indata till två andra modeller: en linjärprogrammeringsmodell med två målfunktioner, som ger Paretooptimala lösningar till Stockholms avfallshanteringsystem, samt en stokastisk modell för simulering av dagens avfallshantering från perspektivet av offentliga upphandlingar. De kriterier som i dessa modeller betraktas är ekonomisk nytta och utsläpp av växthusgaser, där det senare mäts i koldioxidekvivalent. Genom att beakta båda kriterierna erhålls Paretooptimala lösningar, utspridda från maximal ekonomisk vinning till minimala växthusgasgasutsläpp med kompromisslösningar däremellan, snarare än en enskildlösning (exempelvis minimala växthusgasutsläpp). Varje Paretooptimal lösning karaktäriseras av hur avfallsflödena fördelas samt vilka anläggningar som är verksamma och vilka som är stängda. En av lösningarna valdes subjektivt som den bästa kompromissen, då denna sparar Stockholm cirka 150 miljoner SEK årligen, samtidigt som växhusgasutsläppen minskar något till en nivå nära minimum, jämfört med simuleringen av dagens hantering. Den valda lösningen indikerade att en av avfallsbearbetningarna, omlastning och komprimering, inte är ekonomisk försvarbar och bör exkluderas från avfallshanteringssystemet. Samma resultat erhölls i simuleringen av offentliga upphandlingar, som både genomfördes med och utan omlastning och komprimering. Anläggningskostnaderna för denna avfallsbearbetning behövde minskas till 1/10 av den uppskattade kostnaden innan dess ekonomiska påverkan blev netto noll i simuleringsmodellen, men även vid denna nivå förblev de ekonomiskt ohållbara i optimeringsmodellen. Ytterligare en indikation från modellerna är att kapaciteten hos Stockholms rötningsanläggningar överskrids av mängden utsorterat matavfall senast från och med år 2024. För att utnyttja fördelarna rötning av matavfall har i jämförelse med förbränning bör kapaciteten för dessa anläggningar därmed ökas

Models for solid waste and its management in Stockholm metropolitan area

In the transition from a linear economy to a sustainable circular economy, waste management is critical. This thesis approaches the management of Municipal Solid Waste (MSW) from the perspective of a mathematical modelling. Within the scope of the thesis, three mathematical models were developed. The first is a probability theory-based model that makes reliable projections of MSW amounts and composition from a relatively large number of small datasets using regressional estimates, by treating the regression parameters of individual municipalities (small sets) as samples from a single distribution. A tailored two-step method for outlier detection is also used. This model shows that the amount of mixed waste is decreasing rapidly, as more waste is separated in the households. It also shows that less food waste is being produced but more is being sorted separately, resulting in a rapid increase in available sorted organic waste. The predictions of this model are used as input data for the two other models. These area multi-objective linear programming model which provides Pareto optimal solutions for the Stockholm MSW management system and a stochastic model which simulates the current MSW management system from the perspective of the procurement process. The models take both Economic Benefits (EB) and emissions of Greenouse Gases (GHG) into account, where the latteris measured in CO2 equivalent. Therefore, a set of Pareto optimal solutions are obtained, ranging from maximized EB to minimized emissions of GHG with compromise solutions in between, rather than just one solution (e.g. minimum emissions). Each Pareto optimal solution is characterized by where waste flows are allocated, as well as which facilities should be operating and which facilities should be closed. One solution was subjectively chosen as the best compromise, as it saves Stockholm around 150 million SEK per year, while slightly decreasing emissions to a level very close to the minimum, as compared to the simulation of currenttreatment. This solution indicated that one of the MSW treatments, waste compression, is not economically viable, and should be removed from the system. This result was also seen in the procurement simulation, which was run both with compression facilities active and inactive. The cost for running these facilities had to be decreased to 1/10 of the estimated value before their economic impact became net zero for the simulation, but even at this level remained unfeasible in the optimization model. Another major indication of the models was that Anaerobic Digestion(AD) plant capacity will at the very latest be surpassed by the amount of separated organicwaste in 2024, so to make use of the benefits this process has compared to incineration, AD capacity should be expanded.Avfallshantering är en avgörande faktor i övergången från en linjär till en hållbar cirkulär ekonomi. Denna kandidatuppsats undersöker hanteringen av restavfall ur ett systemperspektiv genom matematisk modellering. I arbetet har tre matematiska modeller utvecklats. Den första är en sannolikhetsbaserad modell som uppskattar både mängd avfall och dess komposition. Modellen gör goda uppskattningar från ett större antal små dataset genom att behandla regressionsparametrar från enskilda kommuner (litet dataset) som stickprov från en fördelning. En tvåstegsmetod anpassad till datan används för att hitta felaktiga datapunkter. Modellen visar att uppkommet blandat restavfall väntas minska snabbt, till följd av ökad avfallssortering i hushållen. Även mängden uppkommet matavfall minskar, men eftersom en större andel av detta sorteras separat ökar den tillgängliga mängden utsorterat matavfall drastiskt. Uppskattningarna från denna modell användes som indata till två andra modeller: en linjärprogrammeringsmodell med två målfunktioner, som ger Paretooptimala lösningar till Stockholms avfallshanteringsystem, samt en stokastisk modell för simulering av dagens avfallshantering från perspektivet av offentliga upphandlingar. De kriterier som i dessa modeller betraktas är ekonomisk nytta och utsläpp av växthusgaser, där det senare mäts i koldioxidekvivalent. Genom att beakta båda kriterierna erhålls Paretooptimala lösningar, utspridda från maximal ekonomisk vinning till minimala växthusgasgasutsläpp med kompromisslösningar däremellan, snarare än en enskildlösning (exempelvis minimala växthusgasutsläpp). Varje Paretooptimal lösning karaktäriseras av hur avfallsflödena fördelas samt vilka anläggningar som är verksamma och vilka som är stängda. En av lösningarna valdes subjektivt som den bästa kompromissen, då denna sparar Stockholm cirka 150 miljoner SEK årligen, samtidigt som växhusgasutsläppen minskar något till en nivå nära minimum, jämfört med simuleringen av dagens hantering. Den valda lösningen indikerade att en av avfallsbearbetningarna, omlastning och komprimering, inte är ekonomisk försvarbar och bör exkluderas från avfallshanteringssystemet. Samma resultat erhölls i simuleringen av offentliga upphandlingar, som både genomfördes med och utan omlastning och komprimering. Anläggningskostnaderna för denna avfallsbearbetning behövde minskas till 1/10 av den uppskattade kostnaden innan dess ekonomiska påverkan blev netto noll i simuleringsmodellen, men även vid denna nivå förblev de ekonomiskt ohållbara i optimeringsmodellen. Ytterligare en indikation från modellerna är att kapaciteten hos Stockholms rötningsanläggningar överskrids av mängden utsorterat matavfall senast från och med år 2024. För att utnyttja fördelarna rötning av matavfall har i jämförelse med förbränning bör kapaciteten för dessa anläggningar därmed ökas

Är korta tandbågar förenligt med god oral funktion hos äldre

Eftersom tandhälsan förbättras och dagens äldre kan förväntas få behålla fler tänder kommer det att ställas större krav på äldretandvården i framtiden. Samtidigt kommer tandvården att ha en begränsad tillgång på tandläkare som förväntas balansera samhällets allt mer restriktiva ekonomiska ersättning till tandvården mot patientens och de anhörigas ökade och därmed kostsammare krav på god funktionell tandvård. Mot denna bakgrund genomfördes en litteraturgenomgång i syfte att närmare kunna presentera sda-konceptet (”The shortened dental archkonceptet”) och dess möjliga kliniska applikation inom äldretandvården. En försiktig extrapolering som baserats på resultat från studier som rör patienter i yngre åldrar visar att ”the shortened dental arch-konceptet” även är tillämpbart inom tandvården för äldre