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Background: The study of regenerative therapy in the periodontal intrabony defect has relied upon surgical re-entry as the gold standard of outcome assessment. The search for a non-invasive method has led to the application of various radiographic techniques in evaluating post-treatment bone fill. Methods: The purpose of this study was to determine the ability of 2 forms of radiographic analyses (linear measurement and computer assisted densitometric image analysis, CADIA) to assess postsurgical bone fill as measured at a re-entry procedure. A method that incorporates linear measurements and CADIA (linear-CADIA) was developed and tested as well. Forty-five intrabony defects in 15 patients were treated with open flap debridement, demineralized freeze-dried bone allograft (DFDBA), or a combination of DFDBA and tetracycline. Standardized radiographs were obtained at baseline and at 1-year postsurgery. Results: A 12-month surgical re-entry provided clinical measurements for post-treatment bone fill. All radiographs were digitally scanned and analyzed on a computer. Fifty-three percent of the defects were excluded from the study due to poor standardization or poor defect quality. Forty percent of all pairs of radiographs were judged to have poor standardization. In the first analysis, standardized images were subtracted and quantitatively analyzed utilizing CADIA. It was found that CADIA had the highest correlation with clinical bone fill when a region of interest (ROI) was examined in the middle portion of the defect. This quantitative evaluation provided very little clinically relevant information regarding actual bone fill. For the second analysis, pre- and post-treatment linear radiographic measurements were obtained. In only 43% of the sites, did linear radiographic measurements determine post-treatment bone fill within 1.0 mm of the clinical measurements. Overall, linear measurements underestimated bone fill by 0.96 mm (+/-1.2). These differences were statistically significant (paired Student t-test, P = 0.0023). A method, which incorporates the use of both CADIA and linear radiographic measurements (linear-CADIA), was tested. The linear-CADIA method underestimated bone fill by 0.26 mm (+/-1.4), but these differences were not statistically significant (paired Student t-test, P = 0.41). Conclusion: Linear radiographic measurements significantly underestimate post-treatment bone fill when compared to re-entry data. The linear-CADIA method provided the highest level of accuracy of the 3 methods tested. This study also emphasizes the importance of developing a consistent method of radiographic standardization. [ABSTRACT FROM AUTHOR]

The nonhuman primate, Macaca fascicularis, was used to study the role of immunization with selected members of the periodontopathic microbiota in the longitudinal progression of ligature-induced periodontitis. Animals were immunized with cell envelope antigens prepared from Porphyromonas gingivalis and Prevotella intermedia, and a mixture prepared from Fusobacterium nucleatum, Campylobacter rectus, and Actinoimyces viscosus. Serum immunoglobulin G (lgG). IgM and IgA isotype antibodies increased significantly in all immunization groups and were specific for each of the immunogens. P. gingivalis and P. intermedia immunization resulted in a stabilization of the proportions of these species throughout most of the experiment. The high P. gingivalis antibody titer resulted in low P. gingivalis numbers being recovered. P. gingivalis immunization, while lowering recoverable viable P. gingivalis, resulted in significantly increased levels of Prevotella Ioescheii, Prevotella buccae, Bacteroides macacae and Prevotella melaninogenica compared with preligation and preimmunization levels. Actinohacillus actinoniyceterncomitans, Capnocytophaga spp. and Eikenella spp. remained at preligation levels postimmunization. Campylobacter spp. increased significantly during the course of the experiment in all groups, whereas the levels of Fusobacterium spp. decreased. Plaque indices and bleeding on probing showed significant increases in all groups following ligation, with the placebo group showing the greatest increase. Pocket depth measurements revealed that, whereas the placebo animals showed an approximate 5% increase, the P. gingivalis- and P. intermedia-immunized groups showed nearly a 20% increase in pocket depth. [ABSTRACT FROM AUTHOR]

Advances in periodontics with respect to disease activity, microbiology and immunology have demonstrated the multifactorial nature of periodontal diseases. This serves to underscore the need for an ideal animal model for periodontal research. Non-human primates are most similar to man in comparison to other animal models. The baboon is an Old World monkey that has infrequently been used in periodontal research. Periodontal exams were accomplished on 116 baboons (Papio anubis, P. cynocephalus) ages 5 to 30 years with one baboon year being roughly equivalent to 3 to 4 human years. The study population consisted of 29 males and 87 females. Clinical parameters including probing depth. attachment level, mobility, plaque index and gingival index were collected. Radiographs were taken on 25 animals and correlated to clinical findings. Results showed a significant increase in mean probing depth and mean attachment level with age (p=0.0001). Disease prevalence and severity were not significantly different between genders. Mobility was uncommon: however, the prevalence and severity of furcation involvement increased with age. Radiographs suggested horizontal and isolated vertical bone loss. Plaque and gingival indices were at sustained high levels for all age groups and showed a statistically significant increase with age. Some baboons were found to develop a naturally-occurring periodontitis that increased in severity with age. This primate may be a suitable model for studies in human periodontal disease. [ABSTRACT FROM AUTHOR]

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to alter periodontitis in both animals and humans. This study was initiated in the nonhuman primate (Nhp) model to determine the effect of two NSAIDs on preexisting gingivitis, the conversion of gingivitis to periodontitis, the associated subgingival microbiota, and the gingival PMN response. Eighteen cynomolgus monkeys were divided into three groups and treated on a blind basis with ibuprofen 8%, meclofenamic acid 5%, or placebo applied topically 5 days/week for 20 wk. After 4 wk of treatment, periodontitis was initiated in one quadrant by the placement of silk ligatures. Clinical parameters, bone loss by densitometric analysis of radiographs (CADIA). and cultural microbiology of subgingival plaque were monitored. In situ PMN chemotaxis was assessed by quantitating the PMNs which entered the sulcus in response to a challenge with n-formyl-methionyl-leucyl-phenylalanine (FMLP). No significant differences in the clinical parameters were noted by treatment groups. Radiographic bone toss was detected in all experimental sites in placebo animals as compared with 67% and 44% for ibuprofen and meclofenamic acid animals, respectively. Mean CADIA scores/animal showed a significant loss in bone density for placebo at 6 and 16 wk, no change for ibuprofen animals, and a significant increase in density for meclofenamic acid animals. The microbiota of all groups changed with ligation consistent with previous reports of disease initiation in the Nhp. Similar patterns of PMN response to FMLP were elicited in the gingiva of the ibuprofen and placebo groups. with minimal change in PMN levels detected during disease induction: however, sulcular PMNs were significantly higher than placebo in meclofenamic acid animals at all time periods. In this study, ibuprofen inhibited significant bone loss and meclofenamic acid not only inhibited bone loss but produced a significant increase in bone density in the non-human primate model. These effects were achieved without eliminating clinical gingivitis and without significant effects on the subgingival microbiota. In the meclofenamic acid-treated animals this was accompanied by a significant increase in PMNs in the local area. Based on this report it appears that topical ibuprofen and meclofenamic acid do not affect the progression of alveolar bone loss equally. In addition, the local increase in PMNs at sites which did not exhibit bone loss may provide insights to the mechanisms involved in the initiation of periodontitis in the cynomolgus monkey. [ABSTRACT FROM AUTHOR]

As the availability of extracorporeal membrane oxygenation (ECMO) expands, so has the need for interfacility transfer to ECMO centers. However, the impact of these transfers is unknown. We hypothesized that interfacility transfers would be associated with increased complications and mortality. This retrospective cohort study includes adult patients treated with venovenous (VV) ECMO at all four adult ECMO centers comprising our statewide registry. Complications, mortality, ECMO duration, length of stay, and disposition were compared based on cannulation at an ECMO center versus outside hospital and transferred by air versus ground after adjusting for baseline covariates/parameters. The study included 420 adult patients, 36% of whom were cannulated at an outside institution before transfer. Of these, 63% were transported by ground and the remainder by air. Risk adjusted logistic regression revealed similar odds of mortality between those cannulated at ECMO centers versus referring hospital and then transported (odds ratio [OR] = 0.77, confidence interval [CI] = 0.49-1.22). This study supports the practice of interfacility ECMO transfer., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2024.)

Background: Patients with fungal pneumonias sometimes progress to acute respiratory distress syndrome (ARDS). Mortality has been reported as high as 60% to 90% in this group. Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support such patients, however, outcomes are not well understood. Patients and Methods: This was a retrospective study across the four adult ECMO centers in Minnesota for one decade (2012-2022). The outcomes of interest were duration of ECMO, survival rate, and complications. Data were extracted from the electronic medical record and analyzed using descriptive statistics. Results: Fungal pneumonia was the etiology of ARDS in 22 of 422 (5%) adults supported with VV-ECMO during the 10-year study period. Median patient age was 43 years (interquartile range [IQR], 35-56) and 68% were male. By type of fungal infection, 16 (72%) had blastomycosis, five (22%) had pneumocystis, and one (5%) had cryptococcus. Of the 16 patients with blastomycosis two were immunosuppressed whereas all five of the pneumocystis patients were immunosuppressed. The overall survival rate was 73%; most patients with blastomycosis (67%) and pneumocystis (80%) survived to hospital discharge. The duration of ECMO support was greater for the pneumocystis group (median, 30 days; IQR, 21-43) compared with blastomycosis (median, 10 days; IQR, 8-18). Conclusions: Our findings support the use of VV-ECMO for ARDS caused by fungal pneumonias in select immunocompetent and immunocompromised patients. Although survival was high, patients with pneumocystis required longer ECMO runs.

Objective: Utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has increased significantly over the last decade. Prior studies have reported worse mortality for patients with vascular complications on VA-ECMO; however, these were limited by small sample size. The purpose of this study is to investigate predictive risk factors for vascular complications in VA-ECMO patients and their potential impact on mortality., Methods: Patients who underwent peripheral VA-ECMO from January 2011 to December 2021 were identified. Primary outcomes were lower extremity vascular complications and in-hospital mortality. Multivariate stepwise logistic regression models were used to identify predictors of vascular complications and in-hospital mortality., Results: A total of 605 VA-ECMO patients (25% female) were identified. The mean age was 56.3 ± 13 years, and 56 (10.4%) were black. In-hospital mortality was 63.8% (n = 386), and VA-ECMO ipsilateral vascular complications occurred in 72 patients (11.9%). Vascular surgical interventions (thromboembolectomy, fasciotomies, amputation, and surgical management of cannula bleeding) were required in 30 patients (41.7%). Same-side arterial and venous cannulas, cannula size, and absence of distal perfusion cannula did not increase risk of vascular complication. Multivariate analysis identified age (odds ratio, 0.948; 95% confidence interval, 0.909-0.988; P = .0116) and pre-existing peripheral arterial disease (odds ratio, 3.489; 95% confidence inteval, 1.146-10.624; P = .0278) as independent predictors of need for vascular surgery interventions. The mortality rate of patients who developed vascular complications was not significantly different compared with the mortality rate of those who did not develop vascular complications (61% vs 64%; P = .92)., Conclusions: This study represents one of the largest series to date of lower extremity vascular outcomes in patients undergoing VA-ECMO. Our results confirm the high mortality rate associated with VA-ECMO; however, vascular complications did not represent a risk factor for mortality as previously reported. Same-sided VA-ECMO cannulas, cannula size, and the presence or absence of distal perfusion cannula did not predict vascular complications. Increasing age and presence of peripheral arterial disease are independent predictors of need for vascular surgery intervention in patients on VA-ECMO., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the baseline risk of patients treated with Extracorporeal Cardiopulmonary Membrane Oxygenation (ECMO) in relation to cannulation strategy and indication for ECMO as well as the relation of cannulation strategy with survival and secondary hospitalization outcomes., Methods: Severity of illness and predicted mortality risk were assessed in 317 patients. Central cannulation was used in 52 patients unable to wean off cardiopulmonary bypass after cardiac surgery. Peripheral cannulation was used in 179 patients for extracorporeal cardiopulmonary resuscitation (eCPR) and in 86 patients who received ECMO for refractory cardiogenic shock (RCS)., Results: Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were significantly worse (P < 0.01) for peripheral ECMO eCPR (23.2) vs central ECMO (14.6) and vs peripheral ECMO for RCS (18.9). Survival After Venoarterial ECMO (SAVE) scores were significantly worse for peripheral ECMO for eCPR (-7.85) and RCS (-10.38) vs central ECMO (-3.97), and P < 0.01. Peripherally cannulated patients had significantly worse renal function. No significant difference existed for survival to discharge (peripheral ECMO for eCPR, 31%; central ECMO, 44%; peripheral ECMO for refractory cardiac shock, 39.5%; and P = 0.176), although centrally cannulated patients had significantly longer treatment durations compared with peripheral ECMO for eCPR., Conclusions: Peripherally cannulated patients with eCPR had significantly worse APACHE II and SAVE scores compared to peripherally cannulated RCS or patients with central ECMO, despite having similar mortality., (Copyright © 2020 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Objective: We sought to examine the feasibility of a home practice curriculum of vascular anastomosis in cardiovascular surgery using a low-fidelity simulation platform and to examine its effectiveness in skill acquisition in senior surgical trainees., Design: We organized a multicenter prospective randomized study of senior residents and fellows, who were oriented to a low-fidelity cardiac simulator and an 8-week curriculum of independent practice of aortic and coronary anastomosis. "Treatment" trainees received a simulator and the curriculum. Control trainees received only their usual operative experience. The groups then crossed over; all were studied for 16 weeks in total. Video skill assessments were captured at 0, 8, and 16 weeks and were scored by one blinded investigator using the Joint Council on Thoracic Surgery Education Assessment tool. A post-hoc survey was distributed to invited participants following study completion., Setting: University of Minnesota Department of Surgery, Mayo Clinic Department of Cardiovascular Surgery, and the University of Texas Health Science Center at Houston. Participants used the simulator in offices, call rooms, and their homes., Participants: Program participation in the study was solicited through the Thoracic Education Cooperative Group. Four institutions expressed interest and a total of 29 trainees were invited to the study and randomized. Of these, 12 (38%) completed the curriculum and submitted the requisite 3 sets of videos (6 treatment, 6 control). All were senior residents and fellows in general and cardiothoracic surgery., Results: No significant differences were detected in assessment scores before and after the curriculum nor before or after the control period in the overall or postgraduate year-stratified populations. Participant case numbers during the study did not have a significant effect on assessment scores. Randomized participants reported strong interest in deliberate practice of technical skills but identified competing clinical and personal obligations and significant barriers to simulation., Conclusions: Considerable variability in performance existed among participants who completed the study, but overall, the curriculum alone was insufficient to improve simulator Joint Council on Thoracic Surgery Education scores compared to those not undergoing the curriculum. Among senior residents and fellows, provision of a practice curriculum and simulator for repeated practice is feasible but clinical and personal responsibilities were barriers to repetitive practice., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Deep Vein Thrombosis (DVT) is a common complication in trauma patients. Venous duplex surveillance is used widely for the diagnosis of DVT, however, there is controversy concerning its appropriate use. The Wells criterion is a clinically validated scoring system in an outpatient setting, but its use in trauma patients has not been studied. This study evaluated the application of the Wells scoring system in trauma population., Methods: Wells scores were calculated retrospectively for all patients who were admitted to the trauma service and underwent Venous Duplex Scanning (VDS) at the author's institution between 2012 and 2013. Correlation of Wells score with DVT and its efficacy in risk stratifying the patients after trauma was analyzed using linear correlation and receiver operating characteristic (ROC) curve. Sensitivity and specificity of Wells score in ruling out or ruling in DVT were calculated in various risk groups., Results: Of 298 patients evaluated, 18 (6 %) patients were positive for DVT. A linear correlation was present between Wells score and DVT with R (2)  = 0.88 (p = 0.0016). Median Wells score of patients without DVT was 1 (1-3) compared to a median score of 2 (1-5) in those with DVT (p < 0.0001). In low risk patients (scores <1), Wells scoring was able to rule out the possibility of DVT with a sensitivity of 100 % and NPV of 100 %, while in moderate-high risk patients (scores ≥2), it was able to predict DVT with a specificity of 90 %. Area under ROC curve was 0.859 (p < 0.0001) demonstrating the accuracy of Wells scoring system for DVT risk stratification in post trauma patients., Conclusions: A Wells score of <1 can reliably rule out the possibility of DVT in the trauma patients. Risk of developing DVT correlates linearly with Wells score, establishing it as a valid pretest tool for risk stratification.

Background: No guidelines exist for credentialing extracorporeal membrane oxygenation (ECMO) physicians despite variable training backgrounds. We aim to identify national patterns of institutional credentialing for ECMO physicians., Methods: Program directors from 173 US ECMO centers were surveyed regarding credentialing, recertification, training elements, and barriers., Results: Response rate was 42% (73/173). ECMO credentialing for physicians was required in 66% of responding ECMO centers. Only 57% reported an established institutional ECMO credentialing program. Yearly recertification was required in 16%. Common elements included didactic courses (90%), simulation (73%), and proctored cases (68%). Lack of standardization for credentialing (36%) and too little time (36%) were major barriers to program establishment. No differences were found between small- and large-volume centers with respect to credentialing or recertification., Conclusions: Not all physicians managing ECMO are credentialed and only about half of US centers have established credentialing programs. Standardization of ECMO credentialing may increase training rates and improve variability in credentialing practices across the United States., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: An operative anatomy course was developed within the construct of a surgical internship preparatory curriculum. This course provided fourth-year medical students matching into a surgical residency the opportunity to perform intern-level procedures on cadavers under the guidance of surgical faculty members., Methods: Senior medical students performed intern-level procedures on cadavers with the assistance of faculty surgeons. Students' confidence, anxiety, and procedural knowledge were evaluated both preoperatively and postoperatively. Preoperative and postoperative data were compared both collectively and based on individual procedures., Results: Student confidence and procedural knowledge significantly increased and anxiety significantly decreased when preoperative and postoperative data were compared (P < .05). Students reported moderate to significant improvement in their ability to perform a variety of surgical tasks., Conclusions: The consistent improvement in confidence, knowledge, and anxiety justifies further development of an operative anatomy course, with future assessment of the impact on performance in surgical residency., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Excessive obesity poses a significant limitation to radiographic magnetic resonance imaging (MRI), particularly related to aperture or bore diameter due to the patient's girth. Determination of whether a patient will fit into the bore of the MRI scanner is currently accomplished using patient height, weight, and MRI technician experience. These simple methods have proven unreliable. We sought to develop a device and method which could accurately determine whether a patient would fit into the MRI scanner. We developed an MRI template prototype which was tested against the standard radiology methods in a pilot study (n = 6). We then performed a prospective validation study in adult human volunteers (n = 100) to assess the accuracy of the MRI template. We collected height, weight, shoulder and pelvis girth/diameter for each study participant to evaluate the body dimension measurements that would assist in determination of whether a patient would fit into the MRI scanner. Using the MRI template, we determined that 11 of the 100 study participants would not fit in the MRI scanner and 10 were confirmed to not fit into the MRI aperture [positive predictive value (PPV) 0.91 (0.58-0.99); negative predictive value (NPV) 1.00 (0.95-1.00), sensitivity 1.00 (0.69-1.00), specificity 0.99 (0.93-0.99), likelihood ratio positive test 90 (12.81-632), likelihood ratio negative test 0, accuracy 99%]. In comparison, the body measurement method did not perform as well [PPV 0.66 (0.34-0.90), NPV 0.97 (0.92-0.99), sensitivity 0.80 (0.44-0.97), specificity 0.95 (0.89-0.98), likelihood ratio positive test 17.97 (6.56-49.2), likelihood ratio negative test 0.209 (0.06-0.72), accuracy 94%]. This study confirmed that the use of an MRI template is an accurate tool in determining whether an obese patient can fit through the MRI bore and be accommodated in the MRI scanner.

Background: Improvements in prehospital care and resuscitation have led to increases in the number of severely injured patients who are salvageable. Massive transfusion has been increasingly used. Patients often present with markedly abnormal physiologic and biochemical data. The purpose of this study was to identify objective data that can be used to identify clinical futility in massively transfused trauma patients to allow for early termination of resuscitative efforts., Methods: A multicenter database was used. Initial physiologic and biochemical data were obtained, and mortality was determined for patients in the 5th and 10th percentiles for each variable. Raw data from the extreme outliers for each variable were also examined to determine whether a point of excessive mortality could be identified. Injury scoring data were also analyzed. A classification tree model was used to look for variable combinations that predict clinical futility., Results: The cohort included 704 patients. Overall mortality was 40.2%. The highest mortality rates were seen in patients in the 10th percentile for lactate (77%) and pH (72%). Survivors at the extreme ends of the distribution curves for each variable were not uncommon. The classification tree analysis failed to identify any biochemical and physiologic variable combination predictive of >90% mortality. Patients older than 65 years with severe head injuries had 100% mortality., Conclusion: Consideration should be given to withholding massive transfusion for patients older than 65 years with severe head injuries. Otherwise we did not identify any objective variables that reliably predict clinical futility in individual cases. Significant survival rates can be expected even in patients with profoundly abnormal physiologic and biochemical data.

Background: Significant differences in outcomes have been demonstrated between Level I trauma centers. Usually these differences are ascribed to regional or administrative differences, although the influence of variation in clinical practice is rarely considered. This study was undertaken to determine whether differences in early mortality of patients receiving a massive transfusion (MT, ≥ 10 units pf RBCs within 24 hours of admission) persist after adjustment for patient and transfusion practice differences. We hypothesized differences among centers in 24-hour mortality could predominantly be accounted for by differences in transfusion practices as well as patient characteristics., Methods: Data were retrospectively collected over a 1-year period from 15 Level I centers on patients receiving an MT. A purposeful variable selection strategy was used to build the final multivariable logistic model to assess differences between centers in 24-hour mortality. Adjusted odds ratios for each center were calculated., Results: : There were 550 patients evaluated, but only 443 patients had complete data for the set of variables included in the final model. Unadjusted mortality varied considerably across centers, ranging from 10% to 75%. Multivariable logistic regression identified injury severity score (ISS), abbreviated injury scale (AIS) of the chest, admission base deficit, admission heart rate, and total units of RBC transfused, as well as ratios of plasma:RBC and platelet:RBC to be associated with 24-hour mortality. After adjusting for severity of injury and transfusion, treatment variables between center differences were no longer significant., Conclusions: In the defined population of patients receiving an MT, between-center differences in 24-hour mortality may be accounted for by severity of injury as well as transfusion practices.

Background: Improvements in trauma systems and resuscitation have increased survival in severely injured patients. Massive transfusion has been increasingly used in the civilian setting. Objective predictors of mortality have not been well described. This study examined data available in the early postinjury period to identify variables that are predictive of 24-hour- and 30-day mortality in massively transfused trauma patients., Methods: Massively transfused trauma patients from 23 Level I centers were studied. Variables available on patient arrival that were predictive of mortality at 24 hours were entered into a logistic regression model. A second model was created adding data available 6 hours after injury. A third model evaluated mortality at 30 days. Receiver operating characteristic curves and the Hosmer-Lemeshow test were used to assess model quality., Results: Seven hundred four massively transfused patients were analyzed. The model best able to predict 24-hour mortality included pH, Glasgow Coma Scale score, and heart rate, with an area under the receiver operating characteristic curve (AUROC) of 0.747. Addition of the 6-hour red blood cell requirement increased the AUROC to 0.769. The model best able to predict 30-day mortality included the above variables plus age and Injury Severity Score with an AUROC of 0.828., Conclusion: Glasgow Coma Scale score, pH, heart rate, age, Injury Severity Score, and 6-hour red blood cell transfusion requirement independently predict mortality in massively transfused trauma patients. Models incorporating these data have only a modest ability to predict mortality and should not be used to justify withholding massive transfusion in individual cases.

Background: Recent data suggest that patients undergoing massive transfusion have lower mortality rates when ratios of plasma and platelets to red blood cells (RBCs) of ≥ 1:2 are used. This has not been examined independently in women and men. A gender dichotomy in outcome after severe injury is known to exist. This study examined gender-related differences in mortality after high product ratio massive transfusion., Methods: A retrospective study was conducted using a database containing massively transfused trauma patients from 23 Level I trauma centers. Baseline demographic, physiologic, and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) or low (<1:2) ratios of plasma or platelets to RBCs was compared in women and men independently., Results: Seven hundred four patients were analyzed. In males, mortality was lower for patients receiving a high plasma:RBC ratio at 24 hours (20.6% vs. 33.0% for low ratio, p = 0.005) and at 30 days (34.9% vs. 42.8%, p = 0.032). Males receiving a high platelet:RBC ratio also had lower 24-hour mortality (17.6% vs. 31.5%, p = 0.004) and 30-day mortality (32.1% vs. 42.2%, p = 0.045). Females receiving high ratios of plasma or platelets to RBCs had no improvement in 24-hour mortality (p = 0.119 and 0.329, respectively) or 30-day mortality (p = 0.199 and 0.911, respectively). Use of high product ratio transfusions did not affect 24-hour RBC requirements in males or females., Conclusion: Use of high plasma:RBC or platelet:RBC ratios in massive transfusion may benefit men more than women. This may be due to gender-related differences in coagulability. Further study is needed to determine whether separate protocols for women and men should be established.

Background: Coagulopathy is present in 25% to 38% of trauma patients on arrival to the hospital, and these patients are four times more likely to die than trauma patients without coagulopathy. Recently, a high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBCs) has been shown to decrease mortality in massively transfused trauma patients. Therefore, we hypothesized that patients with elevated International Normalized Ratio (INR) on arrival to the hospital may benefit more from transfusion with a high ratio of FFP:PRBC than those with a lower INR., Methods: Retrospective multicenter cohort study of 437 massively transfused trauma patients was conducted to determine whether the effect of the ratio of FFP:PRBC on death at 24 hours is modified by a patient's admission INR on arrival to the hospital. Contingency tables and logistic regression were used., Results: Trauma patients who arrived to the hospital with an elevated INR had a greater risk of death than those with a lower INR. However, as the ratio of FFP:PRBC transfused increased, mortality decreased similarly between the INR quartiles., Conclusions: The mortality benefit from a high FFP:PRBC ratio is similar for all massively transfused trauma patients. This is contrary to the current belief that only coagulopathic trauma patients benefit from a high FFP:PRBC ratio. Furthermore, it is unnecessary to determine whether INR is elevated before transfusing a high FFP:PRBC ratio. Future studies are needed to determine the mechanism by which a high FFP:PRBC ratio decreases mortality in all massively transfused trauma patients.

Background: Platelets play a central role in hemostasis after trauma. However, the platelet count of most trauma patients does not fall below the normal range (100-450 × 10(9)/L), and as a result, admission platelet count has not been adequately investigated as a predictor of outcome. The purpose of this study was to examine the relationship between admission platelet count and outcomes after trauma., Methods: A retrospective cohort study of 389 massively transfused trauma patients. Regression methods and the Kruskal-Wallis test were used to test the association between admission platelet count and 24-hour mortality and units of packed red blood cells (PRBCs) transfused., Results: For every 50 × 10(9)/L increase in admission platelet count, the odds of death decreased 17% at 6 hours (p = 0.03; 95% confidence interval [CI], 0.70-0.99) and 14% at 24 hours (p = 0.02; 95% CI, 0.75-0.98). The probability of death at 24 hours decreased with increasing platelet count. For every 50 × 10(9)/L increase in platelet count, patients received 0.7 fewer units of blood within the first 6 hours (p = 0.01; 95% CI, -1.3 to -0.14) and one less unit of blood within the first 24 hours (p = 0.002; 95% CI, -1.6 to -0.36). The mean number of units of PRBCs transfused within the first 6 hours and 24 hours decreased with increasing platelet count., Conclusions: Admission platelet count was inversely correlated with 24-hour mortality and transfusion of PRBCs. A normal platelet count may be insufficient after severe trauma, and as a result, these patients may benefit from a lower platelet transfusion threshold. Future studies of platelet number and function after injury are needed.

Background: The Injury Severity Score (ISS) is widely used as a method for rating severity of injury. The ISS is the sum of the squares of the three worst Abbreviated Injury Scale (AIS) values from three body regions. Patients with penetrating injuries tend to have higher mortality rates for a given ISS than patients with blunt injuries. This is thought to be secondary to the increased prevalence of multiple severe injuries in the same body region in patients with penetrating injuries, which the ISS does not account for. We hypothesized that the mechanism-based difference in mortality could be attributed to certain ISS ranges and specific AIS values by body region., Methods: Outcome and injury scoring data were obtained from transfused patients admitted to 23 Level I trauma centers. ISS values were grouped into categories, and a logistic regression model was created. Mortality for each ISS category was determined and compared with the ISS 1 to 15 group. An interaction term was added to evaluate the effect of mechanism. Additional logistic regression models were created to examine each AIS category individually., Results: There were 2,292 patients in the cohort. An overall interaction between ISS and mechanism was observed (p = 0.049). Mortality rates between blunt and penetrating patients with an ISS between 25 and 40 were significantly different (23.6 vs. 36.1%; p = 0.022). Within this range, the magnitude of the difference in mortality was far higher for penetrating patients with head injuries (75% vs. 37% for blunt) than truncal injuries (26% vs. 17% for blunt). Penetrating trauma patients with an AIS head of 4 or 5, AIS abdomen of 3, or AIS extremity of 3 all had adjusted mortality rates higher than blunt trauma patients with those values., Conclusion: Significant differences in mortality between blunt and penetrating trauma patients exist at certain ISS and AIS category values. The mortality difference is greatest for head injured patients.

Background: Administration of high transfusion ratios in patients not requiring massive transfusion might be harmful. We aimed to determine the effect of high ratios of fresh frozen plasma (FFP) and platelets (PLT) to packed red blood cells (PRBC) in nonmassively transfused patients., Methods: Records of 1,788 transfused trauma patients who received <10 units of PRBC in 24 hours at 23 United States Level I trauma centers were reviewed. The relationship between ratio category (low and high) and in-hospital mortality was assessed with propensity-adjusted multivariate proportional hazards models., Results: At baseline, patients transfused with a high FFP:PRBC ratio were younger, had a lower Glasgow Coma Scale score, and a higher Injury Severity Score. Those receiving a high PLT:PRBC ratio were older. The risk of in-hospital mortality did not vary significantly with FFP:PRBC ratio category. Intensive care unit (ICU)-free days, hospital-free days, and ventilator-free days did not vary significantly with FFP:PRBC ratio category. ICU-free days and ventilator-free days were significantly decreased among patients in the high (≥1:1) PLT:PRBC category, and hospital-free days did not vary significantly with PLT:PRBC ratio category. The analysis was repeated using 1:2 as the cutoff for high and low ratios. Using this cutoff, there was still no difference in mortality with either FFP:PRBC ratios or platelet:PRBC ratios. However, patients receiving a >1:2 ratio of FFP:PRBCs or a >1:2 ratio PLT:PRBCs had significantly decreased ICU-free days and ventilator-free days., Conclusions: FFP:PRBC and PLT:PRBC ratios were not associated with in-hospital mortality. Depending on the threshold analyzed, a high ratio of FFP:PRBC and PLT:PRBC transfusion was associated with fewer ICU-free days and fewer ventilator-free days, suggesting that the damage control infusion of FFP and PLT may cause increased morbidity in nonmassively transfused patients and should be rapidly terminated when it becomes clear that a massive transfusion will not be required.

Background: Current trauma resuscitation guidelines recommend giving an initial crystalloid bolus as first line for resuscitation. Recent studies have shown a survival benefit for trauma patients resuscitated with high ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC). Our aim was to determine whether the volume of crystalloid given during resuscitation correlated with differences in morbidity or mortality based on the ratio of FFP:PRBC given., Methods: This was a retrospective review of 2,473 transfused trauma patients at 23 Level I trauma centers from July 2005 to October 2007. Patients were separated based on the ratios of FFP:PRBC they received (<1:4, 1:4-1:1, and >1:1) and then analyzed for morbidity and mortality based on whether or not they received at least 1 L crystalloid for each unit of PRBC. Outcomes analyzed were 6-hour, 24-hour, and 30-day survival as well as intensive care unit (ICU)-free days, ventilator-free days, and hospital-free days., Results: Massive transfusion patients who received <1:4 ratios of FFP:PRBC had significantly improved 6-hour, 24-hour, and 30-day mortality and significantly more ventilator-free days if they received at least 1 L of crystalloid for each unit of PRBC. Nonmassive transfusion patients who received <1:4 ratios of FFP:PRBC had significantly improved 6-hour, 24-hour, and 30-day mortality and significantly more ICU-free days, ventilator-free days, and hospital-free days if they received at least 1 L crystalloid for each unit of PRBC. In both massive and nonmassive transfusion groups, the survival benefit and morbidity benefit was progressively less for the 1:4 to 1:1 FFP:PRBC groups and >1:1 FFP:PRBC groups., Conclusions: If high ratios of FFP:PRBC are unable to be given to trauma patients, resuscitation with at least 1 L of crystalloid per unit of PRBC is associated with improved overall mortality.

Background: Recent data suggest that massively transfused patients have lower mortality rates when high ratios (>1:2) of plasma or platelets to red blood cells (RBCs) are used. Blunt and penetrating trauma patients have different injury patterns and may respond differently to resuscitation. This study was performed to determine whether mortality after high product ratio massive transfusion is different in blunt and penetrating trauma patients., Methods: Patients receiving 10 or more units of RBCs in the first 24 hours after admission to one of 23 Level I trauma centers were analyzed. Baseline physiologic and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) and low (<1:2) ratios of plasma or platelets to RBCs was calculated for blunt and penetrating trauma patients., Results: The cohort contained 703 patients. Blunt injury patients receiving a high ratio of plasma or platelets to RBCs had lower 24-hour mortality (22% vs. 31% for plasma, p = 0.007; 20% vs. 30% for platelets, p = 0.032), but there was no difference in 30-day mortality (40% vs. 44% for plasma, p = 0.085; 37% vs. 44% for platelets, p = 0.063). Patients with penetrating injuries receiving a high plasma:RBC ratio had lower 24-hour mortality (21% vs. 37%, p = 0.005) and 30-day mortality (29% vs. 45%, p = 0.005). High platelet:RBC ratios did not affect mortality in penetrating patients., Conclusion: Use of high plasma:RBC ratios during massive transfusion may benefit penetrating trauma patients to a greater degree than blunt trauma patients. High platelet:RBC ratios did not benefit either group.

Background: The effect of blood component ratios on the survival of patients with traumatic brain injury (TBI) has not been studied., Methods: A database of patients transfused in the first 24 hours after admission for injury from 22 Level I trauma centers over an 18-month period was queried to find patients who (1) met different definitions of massive transfusion (5 units red blood cell [RBC] in 6 hours vs. 10 units RBC in 24 hours), (2) received high or low ratios of platelets or plasma to RBC units (<1:2 vs. ≥ 1:2), and (3) had severe TBI (head abbreviated injury score ≥ 3) (TBI+)., Results: Of 2,312 total patients, 850 patients were transfused with ≥ 5 RBC units in 6 hours and 807 could be classified into TBI+ (n = 281) or TBI- (n = 526). Six hundred forty-three patients were transfused with ≥ 10 RBC units in 24 hours with 622 classified into TBI+ (n = 220) and TBI- (n = 402). For both high-risk populations, a high ratio of platelets:RBCs (not plasma) was independently associated with improved 30-day survival for patients with TBI+ and a high ratio of plasma:RBCs (not platelets) was independently associated with improved 30-day survival in TBI- patients., Conclusions: High platelet ratio was associated with improved survival in TBI+ patients while a high plasma ratio was associated with improved survival in TBI- patients. Prospective studies of blood product ratios should include TBI in the analysis for determination of optimal use of ratios on outcome in injured patients.

Background: Several recent military and civilian trauma studies demonstrate that improved outcomes are associated with early and increased use of plasma-based resuscitation strategies. However, outcomes associated with platelet transfusions are poorly characterized. We hypothesized that increased platelet:red blood cells (RBC) ratios would decrease hemorrhagic death and improve survival after massive transfusion (MT)., Methods: A transfusion database of patients transported from the scene to 22 Level I Trauma Centers over 12 months in 2005 to 2006 was reviewed. MT was defined as receiving ≥ 10 RBC units within 24 hours of admission. To mitigate survival bias, 25 patients who died within 60 minutes of arrival were excluded from analysis. Six random donor platelet units were considered equal to a single apheresis platelet unit. Admission and outcome data associated with the low (>1:20), medium (1:2), and high (1:1) platelet:RBC ratios were examined. These groups were based on the median value of the tertiles for the ratio of platelets:RBC units., Results: Two thousand three hundred twelve patients received at least one unit of blood and 643 received an MT. Admission vital signs, INR, temperature, pH, Glasgow Coma Scale, Injury Severity Score, and age were similar between platelet ratio groups. The average admission platelet counts were lower in the patients who received the high platelet:RBC ratio versus the low ratio (192 vs. 216, p = 0.03). Patients who received MT were severely injured, with a mean (± standard deviation) Injury Severity Score of 33 ± 16 and received 22 ± 15 RBCs and 11 ± 14 platelets within 24 hours of injury. Increased platelet ratios were associated with improved survival at 24 hours and 30 days (p < 0.001 for both). Truncal hemorrhage as a cause of death was decreased (low: 67%, medium: 60%, high: 47%, p = 0.04). Multiple organ failure mortality was increased (low: 7%, medium: 16%, high: 27%, p = 0.003), but overall 30-day survival was improved (low: 52%, medium: 57%, high: 70%) in the high ratio group (medium vs. high: p = 0.008; low vs. high: p = 0.007)., Conclusion: Similar to recently published military data, transfusion of platelet:RBC ratios of 1:1 was associated with improved early and late survival, decreased hemorrhagic death and a concomitant increase in multiple organ failure-related mortality. Based on this large retrospective study, increased and early use of platelets may be justified, pending the results of prospective randomized transfusion data.

The purpose of this study was to compare Bio-Oss (BO), an anorganic bovine bone xenograft, in combination with Bio-Gide (BG), a bioabsorbable collagen barrier, to open-flap debridement (OFD) surgery in human mandibular Class II furcation defects. A total of 31 furcations (18 treatment, 13 control) in 21 patients were treated. There was a statistically significant improvement in most clinical indices for the BO/BG group, with minimal improvement noted for the OFD group. Vertical probing depth reduction of 2.0 mm and horizontal probing depth reduction of 2.2 mm were noted for the BO/BG group, with 0.3 mm and 0.2 mm reductions, respectively, noted for OFD. Hard tissue measurements showed 2.0 mm of vertical furcation bone fill for BO/BG and 0.5 mm for OFD. The BO/BG group had 3.0 mm of horizontal furcation bone fill, and the OFD group had 0.9 mm. The BO/BG group had a defect resolution of 82.7%; 42.5% was noted for the OFD group. There was a statistically significant difference between BO/BG and OFD in all soft and hard tissue measurements with the exception of attachment level, recession, and alveolar crest resorption.

Background: Multiple exposures to enamel matrix protein derivative (EMD) during periodontal therapy have been shown to be safe for the patient. The purpose of this study was to clinically determine if an altered course of wound healing would occur after multiple exposures to EMD in the treatment of intrabony defects. A secondary aim was to assess the efficacy of EMD in probing depth reduction and clinical attachment level gain., Methods: Thirty-two systemically healthy patients (18 females, 14 males, 33 to 69 years old) who were being treated for moderate to advanced periodontal disease were selected for the study. Surgical procedures involving 2 sites were separated by at least 8 weeks, and wound healing comparisons were made between the first and second procedure. Patients were given a diary card the day of surgery, which consisted of questions concerning the presence and severity of headaches, root hypersensitivity, tooth pain, swelling, and itching. Patients were also examined at postoperative visits to clinically assess wound healing and discuss responses to the questionnaire. Soft tissue measurements were taken the day of surgery and 6 months postoperatively to ascertain probing depth reduction (PD) and gains in clinical attachment levels (CAL)., Results: The results revealed no clinically detectable reaction that could not be attributed to normal postoperative sequelae. There were no differences in reported symptoms between patient gender, first and second procedures, or intrabony and non-intrabony defects. Smokers were found to have a statistically significantly higher incidence of severe symptoms in root hypersensitivity, tooth pain, and swelling compared to non-smokers (n = 21). The mean probing depth reduction was 3.8 +/- 1.5 mm (2 to 9 mm), while the mean clinical attachment level gain was 2.8 +/- 1.7 mm (0 to 8 mm)., Conclusions: The findings of this study demonstrate that EMD is a clinically safe product to use in the treatment of periodontal defects and that multiple uses do not have a negative impact on periodontal wound healing. In addition, a statistically significant gain in clinical attachment and reduction in probing depth were demonstrated.

Background: There is limited clinical evidence that pathologically migrated teeth may reposition themselves after conventional periodontal treatment. The current research was carried out to determine the frequency of spontaneous repositioning of pathologically migrated teeth after routine periodontal therapy, and to study the relation between the severity of migration and the degree of repositioning following treatment., Methods: Sixteen patients with moderate to severe periodontal disease and presenting 33 diastema sites secondary to pathologic migration participated in this study. After conventional periodontal treatment had been performed, reactive repositioning was assessed by measuring the space between pathologically migrated teeth and adjacent teeth on study models obtained at baseline, re-evaluation at 6 weeks after scaling and root planing, and 4 months after surgery., Results: After scaling and root planing only, 48.5% of all sites exhibited some degree of repositioning with 36.4% of all sites closing completely. After surgery (6 months after baseline observations), 69.7% of all sites exhibited some degree of repositioning with 51.5% of all sites closing completely. When only small to moderate diastemata were considered (<1 mm), 77.8% of sites closed completely., Conclusions: The findings of this study support the hypothesis that spontaneous repositioning after conventional periodontal treatment is likely, particularly when only light to moderate degrees of pathologic migration are considered. We hypothesize that this spontaneous movement is due to wound contraction during healing.

Background: Hardly any data are available concerning the chief complaints, or CCs, of patients with periodontitis. The authors conducted a study to determine the most common CCs among a group of subjects with periodontitis., Methods: The authors examined the dental records of 191 patients with periodontitis to determine what CCs they orally reported having at an initial examination. Patients were referred mainly by other members of the dental health team. Eighty percent of the patients were diagnosed with moderate or moderate-to-severe periodontitis. The authors recorded the frequency of different CCs to determine the most common complaints., Results: The authors recorded 336 CCs from the records of 191 subjects with periodontitis. There were 21 different CCs. The most common CC reported was, "I was told I have gum disease." The second most common CC reported was, "I would like to save my teeth." Neither of these CCs are true periodontitis symptoms. Bleeding gums--a true periodontitis symptom--was the third most common CC. Only 6.2 percent of the subjects reported having painful gingiva, and only 29.3 percent of the subjects reported having dental-emergency-related CCs., Conclusions: The authors found that the motivation to seek periodontal treatment was most commonly based on information given to the subjects by a member of the dental health team, rather than a periodontitis symptom., Clinical Implications: Renewed efforts and increased responsibility of the dental health team members to inform patients about the presence of periodontitis are needed, as well as emphasizing to the public the risk of losing teeth as a result of periodontitis.

The purpose of this study was to determine the prevalence of pathologic migration of anterior teeth in patients with moderate to severe periodontitis. The correlation between pathologic migration of anterior teeth and attachment loss (AL) was investigated, and an attempt was made to identify the most common early form of pathologic migration. Prevalence of tooth migration was studied in a group of 343 patients with moderate to severe periodontitis before treatment. The presence of pathologic migration was determined from the chief complaint and patient awareness o tooth movement in the last 5 years. Forty-four patients (age range 18 to 69; mean = 48.75) with 75 pairs of migrated and non-migrated teeth were studied further to determine if there is a correlation between severity of periodontal AL and pathologic migration. Migrated teeth were compared to control contralateral teeth that did not have migration. In addition, tooth mobility of the anterior teeth on 36 of the 44 patients was measured using the mobility meter. It was anticipated that tooth mobility would follow the same pattern as AL in relation to pathologic migration. The type and severity of displacement was recorded for each tooth affected by migration. The types of pathologic migration recorded were diastema, extrusion, rotation, facial flaring, and drifting into edentulous spaces. Pathologic migration prevalence was 30.03% +/- 2.5 (103/343 subjects). The mean AL of migrated teeth (4.79 +/- 0.28 mm) was significantly greater (P < 0.0001) than control teeth (3.21 +/- 0.18 mm). The numeric values (called PTV) of migrated teeth (17.6 +/- 1.5) were significantly greater (P < 0.0001) than control teeth (9.4 +/- 1.1). It was difficult to identify a primary form of displacement, as most patients demonstrated a combination of movements. The percentage of the 44 patients who presented with a specific type of movement was: facial flaring (90.9 +/- 4.4%), diastema (88.6 +/- 4.8%), rotation (72.7 +/- 6.8%), extrusion (68.2 +/- 7.1%), and tipping (13.6 +/- 5.2%). The results of this study confirms clinical impressions that periodontal disease destruction of the attachment apparatus plays a major role in the etiology of pathologic migration.

This study evaluated a bioresorbable barrier with and without decalcified freeze-dried bone allograft (DFDBA) in the treatment of human molar furcations. 14 subjects with paired class II mandibular molar furcation defects participated in the study (8 male and 6 female). The class-II furcation defects were randomly treated with either the resorbable barrier alone or resorbable barrier in combination with decalcified freeze-dried bone allograft (DFDBA). Gingival recession, probing depth, clinical attachment, and bone fill were measured 6 months post-treatment measurements were repeated and each site was surgically re-entered. When the resorbable barrier alone was compared to resorbable barrier in combination with DFDBA, probing depth reduction was significantly (p < 0.01) in favor of the combination therapy. Vertical bone gain was significant with the combination treatment demonstrating more bone fill (p < 0.02). Smoking was also a variable examined in this study. When compared to smokers, non-smokers for both treatment groups revealed greater probing depth reduction, vertical bone gain, and horizontal bone gain. Within the non-smoking group, probing depth reduction was also significantly higher for the resorbable barrier and DFDBA group than the resorbable alone group (p < 0.02). These results illustrate that the probing depth reduction is better in the non-smoker and the best in the non-smoker with the combination therapy of resorbable barrier and DFDBA than with resorbable barrier alone.

Two case reports illustrate spontaneous correction of pathologic migration following periodontal therapy. In one case, the displaced teeth were repositioned without orthodontic appliances after nonsurgical and surgical periodontal treatment. In the other case, closure of a diastema occurred following only nonsurgical therapy. The predictability of these findings needs further investigation. A discussion of possible reasons for this type of tooth movement is included.

This cross-sectional study examined the strength of association between systemic osteoporosis and periodontal status in postmenopausal non-Hispanic white women. Twenty subjects with low bone density and a spine bone density of 0.753 +/- 0.039 dual-energy x-ray absorptiometry units (g/cm2) and 22 subjects with high bone density and a spine bone density of 1.032 +/- 0.028 dual-energy x-ray absorptiometry units (g/cm2) were randomly selected from a cohort of 565 women. Periodontal assessment included Plaque Index, Gingival Index, pocket depth, gingival recession, and periodontal attachment level. There were no significant differences in Plaque Index, Gingival Index, and probing depth in both groups; however, there were significant differences in gingival recession components of periodontal attachment level in both groups. This study suggests that systemic osteoporosis may contribute to periodontal attachment loss in the form of gingival recession.

The purpose was to evaluate the use of demineralized freeze-dried bone allograft reconstituted with 50 mg/ml tetracycline hydrochloride in the treatment of intrabony periodontal defects. Fifteen systemically healthy patients (12 females, 3 males; aged 35 to 61) with moderate-advanced periodontitis were treated. Patients had 3 osseous defects with probing depths (PD) > 5 mm after initial therapy. Each site in each subject was randomly assigned to one of the following groups: 1) demineralized freeze-dried bone allograft reconstituted with 50 mg/ml tetracycline (DFDBA + TCN); 2) demineralized freeze-dried bone allograft alone (DFDBA); or 3) debridement only (D). Clinical measurements were taken the day of surgery, 6 months, and 1 year. Standardized radiographs were taken at baseline and 1 year and were evaluated by computer assisted densitometric image analysis (CADIA). Clinical measurements included gingival recession, PD, clinical attachment level, and mobility. Osseous defect measurements were taken at baseline and at the 1 year reentry. No adverse healing responses occurred. The results showed that all patients had a statistically significant improvement in probing depth and attachment level at 1 year. Osseous measurements showed bone fill of 2.27 mm (51.6%) for the DFDBA + TCN group, 2.20 mm (52.4%) for the DFDBA group, and 1.27 mm (32.8%) for the D group. Defect resolution was 77.3% for the DFDBA + TCN group, 77.9% for the DFDBA group, and 63.8% for the D group. The mean CADIA values were 5.04 for the DFDBA + TCN group, 6.79 for the DFDBA group and 2.78 for the D group. The CADIA values did not correlate with the clinical parameters. Although the grafted groups showed greater bone fill and defect resolution, there was no statistically significant difference in any of the clinical parameters between the treatment groups. This study suggests that there is no significant benefit from reconstituting the allograft with 50 mg/ml of tetracycline hydrochloride.

Mandibular tori are sometimes removed to enhance periodontal and prosthodontic treatment. The exact cause of these benign bony overgrowths is not well understood, and therefore, their potential to recur after removal is also uncertain. Two case reports are presented in this article that provide evidence that at least some mandibular tori recur after surgical removal. One patient was followed-up for 11 years, and the other patient was followed-up for 14 years.

A review of the literature on the relationship between osteoporosis and periodontal disease is presented. Osteoporosis, a metabolic disease, and periodontal disease, which is infectious, are both major health problems with multifactorial etiologies. There is histologic and radiographic evidence from animals and humans that osteoporosis does affect alveolar bone by decreasing bone mass and trabeculation. The literature reviewed in this paper suggests, but does not yet provide conclusive evidence for, a direct relationship between osteoporosis and periodontal disease.