CURRENT LITERATURE

Abstracts

Cerebrovascular and Cerebral Metabolic Effects of Physo­stigmine, Midazolam, and a Benzodiazepine Antagonist.Hoffman WE, Albrecht RF, Miletich DJ, et al. AnesthAnalg 65:639, 1986

Physostigmine has been reported to reverse the seda­tion and paradoxical delirium induced by the bensodiaze­pines, diazepam and midazolam. It has been suggestedthat physostigmine may directly antagonize the effects ofbenzodiazepines at the benzodiazepine receptors. In thisstudy, the effect of physostigmine on cerebral blood flow(CBF) and cerebral oxygen consumption (CMR02) , aswell as the ability of physostigmine to reverse the effectsof midazolam and 3-carbo-t-butoxy-B-carboline (B­CCf), a benzodiazepine antagonist , was investigated in122 rats. Physostigmine alone produced a dose-depen­dent increase in blood pressure, CBF, and CMR02 , andinhibited a decrease in the same parameters produced by

.midazolam. Physostigmine potentiated the increasedCBF and CMR02 caused by B-CCT alone. The ability ofphysostigmine to antagonize the metabolic effects of mi­dazolam and to potentiate the stimulation produced byB-CCT suggests the physostigmine does not inhibit ben­zodiazepine receptor stimulation by a direct antagonisticeffect but by an indirect stimulatory effect which is addi­tive with benzodiazepines or their antagonists.-S. J.McKENNA

Reprint requests to Dr. HolTman: Anesthesiology Department,Michael Reese Hospital, Chicago, IL 60616.

Mandibular Dysfunction in Adolescents. II. Prevalence ofSigns . .Wanman A, Agerberg G. Acta Odontol Scand44:55, 1986

Signs of mandibular dysfunction are a common findingin children and adolescents. Little is known about the de­velopment of signs of mandibular dysfunction. All 28517-year-old inhabitants of a Swedish municipality werestudied for the prevalence of signs of mandibular dys­function. The most common sign was palpable tender­ness of the muscles of mastication (41%) and temporo­mandibular joint clicking (22%). Muscle tenderness mostcommonly involved the lateral pterygoid and temporalisinsertion. Girls had muscle tenderness more often thanboys. Unilateral occlusal contacts in the retruded posi­tion were recorded in 77% of those studied. Using theclinical dysfunction index derived by Helkimo, 56% ofthe subjects had signs of mandibular dysfunction; girlswere more commonly affected. The authors advocatethat routine dental examinations in this age group includea functional evaluation of the stomatognathic system.Reports on the longitudinal development of signs andsymptoms in this population will follow.-S. J.McKENNA

Reprintrequests to Dr.Wanman: Departmentof StomatognathicPhysiology, Faculty of Odontology, University of Urnea, S-90187 Umea, Sweden.

Lethal Outbreak of Hepatitis B in a Dental Practice. ShawFE Jr, Barrett CL, Hamm R, et al. lAMA 255:3260, 1986

There have been seven published reports of dentistsand oral surgeons transmitting Hepatitis B (HB) to pa-

tients. This is the eighth such report. Between April I,1984 and February 1, 1985, nine cases ofHB occurred inpatients of a dentist practicing in rural Indiana. Thiscluster of cases was more than 20 times the mean annualincidence for the geographic area in the previous decade.The dentist was asymptomatic, and his serum tested pos­itive for Hepatitis B surface antigen and Hepatitis B eantigen, and negative for Hepatitis B c IgM antibody.Two patients died of fulminant hepatitis; thus the case-fa­tality ratio was more than 10 times the U.S. mean forHepatitis B. A serosurvey was undertaken of 1133 of thedentist's patients in December 1984. Using a case defini­tion based on exposure to the dentist during a definedperiod and positivity for Hepatitis B c IgM antibody, 15asymptomatic cases were identified. Infection with Hep­atitis B was significantly associated with surgery, extrac­tions, and crown preparation. No cause was found for theexcessive lethality of the outbreak.-S. J. McKENNA

Reprint requests to Dr. Shaw: Hepatitis Branch, Division ofViral Diseases, Center for Infectious Disease, Center for Dis­ease Control, 1600 Clifton Road NE, Bldg. 6, Room 154, At­lanta, GA 30333.

Controlled Hypotension for Orthognathie Surgery.Fromme GA, MacKenzie RA, Gould AB Jr, et al. AnesthAnalg 65:683, 1986

Hypotensive anesthesia has three potential benefits: 1)reduced blood loss and reduced requirement for bloodproducts; 2) dry operative field; andS) reduced operatingtime. Fifty-four patients undergoing maxillary and man­dibular osteotomies were divided into three anestheticgroups with mean arterial blood pressures of 90-100 mmHg, 75-85 mm Hg, and 55-60 mm Hg, respectively. So­dium nitroprusside was used to induce hypotension in the55-60 mm Hg mean arterial pressure group. All patientswere supine with 15° of head elevation. There were nostatistically significant differences in the quality of thesurgical field as assessed by the surgeon. Also, therewere no statistically significant differences in the meanblood loss between the three groups. Three patients inthe normotensive group had measured blood lossesgreater than any patient in the other groups. These threepatients may represent a subset with an increased ten­dency for bleeding. In terms of blood loss , these patientsmay benefit from induced hypotension. The authors con­clude that their data do not support the routine use ofhypotensive anesthesia in orthognathic surgery.-S. J.McKENNA

Reprintrequests to Dr. Fromme: Departmentof Anesthesiology,MayoClinicand Mayo Foundation, Rochester, MN 55905.

Accuracy of Frozen-section Diagnosis in Salivary GlandNeoplasms. Rigual NR, Milley P, Lore JM, et al. HeadNeck Surg 8:442, 1986

The authors carried out a retrospective study of 100patients who had undergone surgery for salivary glandneoplasms involving frozen-section biopsy techniques.The results of the final histologic examination were com­pared to the intraoperative frozen-section diagnoses. Inaddition, records were reviewed to determine the impactof frozen-section diagnosis on surgical management. Of

1023

1024

the 100cases, 77% were benign lesions; 85% were in theparotid, 10% in the submandibular, and the remainderwere in minor salivary glands. The authors found thatfrozen-section diagnosis was 90% sensitive for the pres­ence of malignancy and 96% specific for the absence ofmalignancy. In 12 patients, frozen -section diagnosis re­sulted in extended, necessary surgery, and in no case wasradical surgery performed as a result of inaccuratefrozen-section diagnosis. Four clinically significant inac­curate diagnoses were made using frozen-section tech­niques . One such was the frozen-section diagnosis ofchronic sialadenitis of the submandibular gland when thefinal diagnosis was histiocytic lymphoma. The authorsconcluded that, in their institution, frozen-section diag­nosis of salivary gland neoplasms was accurate anduseful.c-Jxues R. Hure

Reprint requests to Dr. Rigual: Department of Otolaryngology,2121 Main Street, Buffalo, NY 14214.

Autotransfusion in Elective Plastic Surgical Operations.Mandel MA. Plast Reconstr Surg 77:767, 1986

The use of autologous blood products over homolo­gous products virtually eliminates the possibility of dis­ease transmission. There are other significant benefits tothe usc of autologous blood . The author compared threegroups of patients who underwent elective plastic surgeryoperations: patients who received no transfusions, pa­tients who received homologous transfusions, and thosewho received autologous transfusions. Hemoglobin, he­matocrit, and reticulocyte counts were followed at in­tervals pre- and postoperatively. Lengths of hospital stayand return to work dates were compared. The authorfound that patients who receiv ed autologous blood had ashorter hospital stay and returned to work sooner thanthe patients in the other two groups. Patients who re­ceived autologous units had higher reticulocyte counts atthe time of surgery. Patients who received homologousblood or no blood did not show increased reticulocytecounts until one week following surgery. Other addedbenefits included advanced preoperative screening of pa­tients with low red cell mass and markedly decreasedanxiety about the fear of homologous blood trans­fusion.- WILLIAM R. WHITLOW

Reprint requests to Dr. Mandel: 2080 Century Park East, Suite1009, Los Angeles, CA 90067-2066.

Surgical treatment of Early-stage Carcinoma of the OralTongue-Would Adjuvant Treatment be Beneficial?O'Brien CJ, Lahr CJ, Soong SJ, et al, Head Neck Surg8:401, 1986

Ninety-seven patients with .clinical Stage I (67) andStage II (30) squamous carcinoma of the oral tongue weretreated by partial glossectomy alone . The preoperativeclinical picture was then compared to the presence andsite of any recurrences, with follow-up ranging from twoto 20 years (median 10 years). The incidence of recur­rence for Tl tumors (25%) and 1'2 tumors (37%) was notsignificantly different. The most common site of initialrecurrence was the ipsilateral neck. Local recurrence af­fected 6% of Tl tumor patients and 17% of T2 tumor pa­tients; this difference was not statistically significant. Re­currence did not correlate significantly with patient age,sex, or tumor size. The only histologic correlation be-

CURRENT LITERATURE

tween the tumors and the recurrence rate was the findingof perineural spread; four of five patients with this findinghad local recurrence. The authors conclude that partialglossectomy alone is adequate treatment for the majorityof patients with Stage I or II squamous carcinoma of theoral tongue. Those patients with perineural invasionshould receive postoperative radiation therapy to the pri­mary site and the ipsilateral neck. Close follow-up of allpatients is important for the early detection of recur­rence .-JAMES R. Hupp

Reprint reque sts to Dr. Maddox : Section of Surgical Oncology,Department of Surgery, University Station, Birmingham, AL35294.

Collagen Tube Containers: an Effective Means of Control­ling Particulate Hydroxyapatite Implants. Shen K, Gong­loff RK . J Prosthet Dent 56: I, 1986

Several different forms of hydroxyapatite (HA) havebeen used successfully for alveolar ridge augmentation.The usc of particulate HA to restore alveolar ridge heighthas been hampered by the difficulty in confining the ma­terial to the area of the desired augmentation. In thisstudy the authors evaluated the use of HA encased in acollagen film. Eighteen Sprague-Dawley rats were used.In 15 rats 5 to 7 mm oval defects cut into the mandibularangle were treated: received HA encased in collagen filmone side of the mandible, and the other side of the man­dible received HA only. In three rats acting as controls,collagen alone was placed on one side of the mandibleand nothing on the other side. Graft sites were evaluatedgrossly, microscopically, and radiographically. Six ratswere lost to the study; three to anesthetic complicationsand three to gross infections in the immediate postopera­tive period. In the control group no bony fill occurred inthe collagen-grafted or untreated defects. In the lO re­maining experimental animals, gross, microscopic, andradiographic evaluation revealed that the collagen filmhelped to contain the particulate HA within the surgicaldefects . The tissue response to HA was unchanged by thepresence of the collagen film. The authors feel that thecollagen film was an effective means to shape and containthe particulate HA implants.-JAMEs B. MURPHY

Reprint requests to Dr. Gongloff: Dental Service (160), VeteransAdministration Medical Center, 4150 Clement Street, San Fran­cisco, CA 94121.

Osscointegration in Maxillofacial Prosthetics. Part I: In­traoral Applications. Parel S, Branemark P, Jansson T. JProsthet Dent 55:4, 1986

This paper is intended for the practitioner already fa­miliar with the basic biologic concepts of osseointegra­tion and its use in supplementing prosthetic rehabilitationfor conventional oral prosthetic problems. The authorsstate that the predictably successful results of the os­seointegration system led to the application of these prin­ciples for the maxillofaciaHy handicapped patient. Theauthors suggest that the same osseointegrated implantsused in their conventional technique can be used to an­chor prostheses in congenital or acquired defects of themaxilla or mandible. The osseointcgrated implant can beused to prevent the cantilevered forces placed on the re­maining dentition by conventional maxillofacialprostheses. They can also be used to replace key sup-

CURRENT LITERATURE

porting teeth lost or rendered non-retentive by the de­structive processes secondary to long-time use of me­chanically unfavorable prostheses. A technique is alsoshown where osseointegrated fixtures were placed in theiliac crest and later removed in situ with the crest andused with the bone graft for discontinuity defects of themandible. The authors state the fixtures may be used inthese compromised patients equally well for maxillary ormandibular defects.-JAMEs B. MURPHY

Reprint requests to Dr. Parel: University of Texas, HealthScience Center, Dental School, San Antonio, TX 78274.

Inferior Joint Space Arthrography of Normal Temporo­mandibular Joints: Reassessment of Diagnostic Criteria.Kaplan PA, Lydiatt DD, Laney TJ. Radiology 159:585,1986

Inferior joint space arthrograms were performed on thetemporomandibular joints of 31· healthy volunteers withnormal, asymptomatic TMJs to establish diagnostic cri­teria. Previous diagnostic criteria were established usingarthrograms of the asymptomatic joints of cadavers orpatients with TMJ dysfunction. Sixteen women and 15men ranging in age from 20 to 49 years (mean 28 years)were selected for the study. Bilateral inferior joint spacearthrographs were performed utilizing a technique similarto that described by Bell and Walters. The study evalu­ated the following parameters: size and configuration ofthe anterior and posterior recesses with the mouthclosed, changes in size and configuration of the anteriorand posterior recesses with the mouth open, extent ofanterior translation of the condyle, symmetry of arthro­graphic findings from one side to the other, and dynamicanatomy of the joint as shown on videotape studies. Onthe basis of this study it was concluded that the superiormargin of the anterior recess with the mouth closed wassmooth and flat in 68% of the joints and concave in 32%.The concavity was the result of impingement of the ante­rior ridge of the disc on the contrast medium which waseasily distinguished from an anteriorly placed disc withvideotape studies. With the mouth at maximal opening,the anterior recess decreased to a small crescent shape inapproximately 84% of the joints and remained large in16% of the joints. The configuration of the posterior re­cess with the mouth closed was as previously described;however, it was larger than the anterior recess, whichwas contrary to most previous reports.-JAMEs T.MULLER

Reprint requests to Dr. Kaplan: Department of Radiology, Uni­versity of Nebraska, Medical Center, 42 and Dewey Avenue,Omaha, NE 68105.

Anaphylactic Reaction to Lidocaine. Kennedy KS, CaveRH. Arch Otolaryngol Head Neck Surg 112:671, 1986

Lidocaine hydrochloride as a local anesthetic is uti­lized for a variety of surgical procedures. Reported anddocumented anaphylactic reactions to lidocaine are ex­tremely rare. Presented is a case report of documentedlidocaine sensitivity in a 43-year-old woman with ahistory of an anaphylactic reaction to lidocaine. Sensi­tivity testing included the subcutaneous injection of lido­caine hydrochloride with and without methylparabenpreservative, chloroprocaine hydrochloride, mepivacaine

1025

hydrochloride and bupivacainc hydrochlordie. Controlsof sterile water and 0.9% saline solution were also in­jected subcutaneously, Reactions to the medicationswere graded from 0 to 4 + on the basis of size andseverity of the wheal and flare reactions at one hour.Lidocaine, mepivacaine and sterile water reactions wereI +. Chloroprocaine reaction was 2 +. Normal saline andbupivacaine showed no reaction. Following skin testing,the patient was challenged with 10 mg of lidocaine hydro­chloride IV, which resulted in prompt onset of coughing,wheezing, and chest tightness lasting approximately fiveminutes. After 30 minutes, the patient was informed lido­caine was again being injected; however, normal salinewas injected without symptoms. After another 30 minuteinterval, the patient was informed normal saline wasbeing injected; however, 5 mg of lidocaine hydrochloridewas injected. Following the second injection of lidocaine,the patient became short of breath, began coughing, hadaudible and auscultable wheezing and systolic BP of 96.The patient required treatment with 0.2 ml of 1:1000 epi­nephrine subcutaneously, 25% face mask O2 and a 500 ccbolus of lactated Ringer's solution for stabilization. Thepatient's symptoms subsided over a 3D-minute period.Based on this case report, it was concluded that althoughrare, allergic reactions and anaphylactic reaction to lido­caine can occur. Skin testing as well as incremental chal­lenges are highly recommended prior to use of a localanesthetic on patients with a stated drug allergy to avoiddisastrous adverse reaction.-JAMEs T. MULLER

Reprint requests to Dr. Kennedy: Department of Otolaryn­gology, Head and Neck Surgery, Navel Hospital, Oakland, CA94627-5000.

Pterygoid Plate Fractures Caused by the LeFort I Oste­otomy. Robinson PP, Hendy CWo Br J Oral MaxillofacSurg 24: 198, 1986

The standard Le Fort I osteotomy technique requiresseparation of the pterygoid plates from the maxillary tu­berosities by the use of a curved osteotome. An earlierstudy carried out on cadavers on hemisectcd heads aftercheek tissue had been divided for access, suggested pter­ygoid plate fractures occur. This investigation, however,was performed on intact, unfixed cavaders to determinewhether the pterygoid plates remain intact and attachedto the skull. The standard Le Fort I osteotomy approachwas employed on eight cadaver heads and a mallet wasused to strike the curved osteotome. The maxilla wasdownfractured using finger pressure, soft tissue re­moved, and the pterygoid plates studied. The pterygoidplates were completely separated in 14 of 16 sides, andwere completely intact and attached to the skull in four of16 sides. Fractures into two or more segments occurredin 12 of 16 sides; seven fractures were at the level of theosteotomy cut and five occurred near the base of theskull. Four specimens also had fractures on the posteriorwall of the maxillary sinus. Pterygoid plate fragments andmuscle attachments drawn forward with an anterior re­positioned maxilla may contribute to relapse. The place­ment of an interpositional bone graft between the tuber­osity and the pterygoid plates may be unnecessary if thepterygoid plates are free.-R. B. YOUNG

Reprint requests to Dr. Robinson: Department of Oral Surgery,John Radcliff Hospital, Oxford, England.

1026

Statistical and Pathological Analysis of Oral Tumors in theHong Kong Chinese. Wu PC, Pang SW, Chan KW, et al.Oral Pathol 15:98, 1986

From 1964-1982, a total of 805 intraoral neoplasms and172 tumor-like growths were diagnosed in Chinese pa­tients at the University Department Hospital, HongKong. Fifty-five per cent of all lesions was squamous cellcarcinoma (SCC), thereby constituting 86% of all malig­nancies. The other malignancies included salivary glandtumors, lymphomas, and sarcomas. Most of the SCCs(82%) were well-differentiated, although palatal SCC infemales showed relatively poor differentiation. The oc­currence of SCC predominated in males, with an overallproportion of73%. The mean age was 59.4 years. Almosthalf of oral SCCs originated from the tongue (46%), fol­lowed by palate (16%), gingiva and cheek (each 12%),and floor of mouth (10%). Despite a notable decline inoral cancer in the Western countries, this study found arise in incidence in both Chinese men and women inHong Kong over the past decade. It is speculated that, inthe absence of improved oral hygiene and dental care,changes in the smoking and drinking habits in the localChinese are of causal importance.-JEFF KENNEY

Reprint requests to Dr. Wu: Department of Pathology, Univer­sity of Hong Kong, Prince Philip Dental Hospital, Hong Kong.

Mandibular Reconstruction: New Concepts. Gullane TJ,Holmes H. Arch Otolaryngol 112:714, 1986

Restoration of mandibular defects after surgical resec­tion in irradiated patients has been successful when amyocutaneous flap is used in combination with a three­dimensional flexible reconstruction plate. Twenty-eightpatients were divided into two groups: group one (II =23) required a myocutaneous flap to close a soft tissuedefect, while group two (II = 5) was treated by primaryclosure. Seventy-three per cent of group one and 60% ofgroup two patients had presurgical irradiation but nonefollowing surgery. Sixty-four per cent have retained theirflexible plates for longer than one year; of these, halfhave had their plates for longer than two years. Twenty­one per cent have had their plates for longer than sixmonths; 14% less than six months. One plate was lostwhen the patient was treated by primary closure. A briefdiscussion of four reconstruction methods is presented.-R. B. YOUNG

Reprint requests to Dr. Gullane: Department of Otolaryngology,Toronto General Hospital, 200 Elizabeth Street, Eaton NorthWing 7-242, Toronto, Ontario M5G IL7, Canada.

Esophageal Intubation: A Review of Detection Techniques.Birmingham PK, Cheney FW, Ward RJ. Anesth Analg65:886, 1986

Endotracheal intubation is a routinely performed pro­cedure and the ability to accurately evaluate proper tube

CURRENT LITERATURE

position is crucial. Unrecognized esophageal intubationremains a problem even among anesthesiology per­sonnel. Between 1970 and 1978 in the United Kingdom,nearly half the reported anesthetic accidents resulting indeath or cerebral damage were due to faulty technique.The most commonly identified technical mishap was in­advertent esophageal placement of the endotrachealtube. The authors reviewed the reliability of commonlyprescribed methods of assessing tube position after at­tempted endotracheal intubation. Direct visualization ofthe endotracheal tube as it passes through the vocal cordsis considered the "gold standard" of correct tube place­ment by many workers. Unfortunately, direct visualiza­tion is not always achieved. Documented cases of unrec­ognized esophageal intubation exist for several methodsof assessing endotracheal tube position including chestmovement, breath sounds, epigastric auscultation, tubecondensation, and chest radiography. Capnometry, themeasurement of carbon dioxide concentration during therespiratory cycle, is perhaps the most reliable means ofdetermining proper endotracheal tube placement. Withesophageal intubation, end-tidal CO2 is low and CO 2levels rapidly diminish with repeated ventilation. Easilyidentifiable CO 2 curves are obtained with ventilationthrough the trachea. The authors recommend that end­tidal CO2 monitoring should be employed routinely wher­ever possible.-S. J. McKENNA

Reprint requests to Dr. Cheney: Department of Anesthesiology,University of Washington School of Medicine RN-IO, Seattle,WA98195.

The Long Term Efficacy of Currently Used Dental, Im­plants: A Review and Proposed Criteria of Success. AI­berktsson T, Zarb G, Worthington P, et al. Int J OralMaxillofac Implants I: II, 1986

The success criteria for dental implants, as proposedby the authors, are compared to the National Institute ofHealth criteria of 1979. These new criteria are then ap­plied in the evaluation of long-term success of the fol­lowing dental implant systems: subperiosteal implant,vitreous carbon implant, blade vent implant, singlecrystal sapphire implant, tuebingen implant, TCP-im­plant, TPS-screw, ITI hollow cylinder implant, IMZdental implant, Core-Vent titanium alloy implant, trans­osteal mandibular staple bone plate, and the Branernarkosseointegrated titanium implant. The discussion foreach system includes the implant material, researchbackground, indications for use, insertion technique andloading time, complications, and clinical results.-R. B.YOUNG

Reprint requests to Dr. Alberktsson: Institute for Applied Bio­technology, Laboratory and Experimental Biology, Departmentof Anatomy and Handicap Research, P.O. Box 33031 5-40033,Gothenburg, Sweden.