CURRENT LITERATURE Abstracts Cerebrovascular and Cerebral Metabolic Effects of Physo- stigmine, Midazolam, and a Benzodiazepine Antagonist. Hoffman WE, Albrecht RF, Miletich DJ, et al. Anesth Analg 65:639, 1986 Physostigmine has been reported to reverse the seda- tion and paradoxical delirium induced by the bensodiaze- pines, diazepam and midazolam. It has been suggested that physostigmine may directly antagonize the effects of benzodiazepines at the benzodiazepine receptors. In this study, the effect of physostigmine on cerebral blood flow (CBF) and cerebral oxygen consumption (CMR0 2 ), as well as the ability of physostigmine to reverse the effects of midazolam and 3-carbo-t-butoxy-B-carboline (B- CCf), a benzodiazepine antagonist, was investigated in 122 rats. Physostigmine alone produced a dose-depen- dent increase in blood pressure, CBF, and CMR0 2 , and inhibited a decrease in the same parameters produced by .midazolam. Physostigmine potentiated the increased CBF and CMR0 2 caused by B-CCT alone. The ability of physostigmine to antagonize the metabolic effects of mi- dazolam and to potentiate the stimulation produced by B-CCT suggests the physostigmine does not inhibit ben- zodiazepine receptor stimulation by a direct antagonistic effect but by an indirect stimulatory effect which is addi- tive 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 of Signs. .Wanman A, Agerberg G. Acta Odontol Scand 44:55, 1986 Signs of mandibular dysfunction are a common finding in children and adolescents. Little is known about the de- velopment of signs of mandibular dysfunction. All 285 17-year-old inhabitants of a Swedish municipality were studied for the prevalence of signs of mandibular dys- function. The most common sign was palpable tender- ness of the muscles of mastication (41%) and temporo- mandibular joint clicking (22%). Muscle tenderness most commonly involved the lateral pterygoid and temporalis insertion. Girls had muscle tenderness more often than boys. Unilateral occlusal contacts in the retruded posi- tion were recorded in 77% of those studied. Using the clinical dysfunction index derived by Helkimo, 56% of the subjects had signs of mandibular dysfunction; girls were more commonly affected. The authors advocate that routine dental examinations in this age group include a functional evaluation of the stomatognathic system. Reports on the longitudinal development of signs and symptoms in this population will follow.-S. J. McKENNA Reprint requests to Dr. Wanman: Department of Stomatognathic Physiology, Faculty of Odontology, University of Urnea, S-901 87 Umea, Sweden. Lethal Outbreak of Hepatitis B in a Dental Practice. Shaw FE Jr, Barrett CL, Hamm R, et al. lAMA 255:3260, 1986 There have been seven published reports of dentists and oral surgeons transmitting Hepatitis B (HB) to pa- tients. This is the eighth such report. Between April I, 1984and February 1, 1985, nine cases ofHB occurred in patients of a dentist practicing in rural Indiana. This cluster of cases was more than 20 times the mean annual incidence for the geographic area in the previous decade. The dentist was asymptomatic, and his serum tested pos- itive for Hepatitis B surface antigen and Hepatitis B e antigen, and negative for Hepatitis B c IgM antibody. Two patients died of fulminant hepatitis; thus the case-fa- tality ratio was more than 10 times the U.S. mean for Hepatitis B. A serosurvey was undertaken of 1133 of the dentist's patients in December 1984. Using a case defini- tion based on exposure to the dentist during a defined period and positivity for Hepatitis B c IgM antibody, 15 asymptomatic cases were identified. Infection with Hep- atitis B was significantly associated with surgery, extrac- tions, and crown preparation. No cause was found for the excessive lethality of the outbreak.-S. J. McKENNA Reprint requests to Dr. Shaw: Hepatitis Branch, Division of Viral Diseases, Center for Infectious Disease , Center for Dis- ease Control, 1600 Clifton Road NE, Bldg. 6, Room 154, At- lanta, GA 30333. Controlled Hypotension for Orthognathie Surgery. Fromme GA, MacKenzie RA, Gould AB Jr, et al. Anesth Analg 65:683, 1986 Hypotensive anesthesia has three potential benefits: 1) reduced blood loss and reduced requirement for blood products; 2) dry operative field; andS) reduced operating time. Fifty-four patients undergoing maxillary and man- dibular osteotomies were divided into three anesthetic groups with mean arterial blood pressures of 90-100 mm Hg, 75-85 mm Hg, and 55-60 mm Hg, respectively. So- dium nitroprusside was used to induce hypotension in the 55-60 mm Hg mean arterial pressure group. All patients were supine with 15° of head elevation. There were no statistically significant differences in the quality of the surgical field as assessed by the surgeon. Also, there were no statistically significant differences in the mean blood loss between the three groups. Three patients in the normotensive group had measured blood losses greater than any patient in the other groups. These three patients may represent a subset with an increased ten- dency for bleeding. In terms of blood loss, these patients may benefit from induced hypotension. The authors con- clude that their data do not support the routine use of hypotensive anesthesia in orthognathic surgery.-S. J. McKENNA Reprintrequests to Dr. Fromme:DepartmentofAnesthesiology, MayoClinicand Mayo Foundation, Rochester, MN 55905. Accuracy of Frozen-section Diagnosis in Salivary Gland Neoplasms. Rigual NR, Milley P, Lore JM, et al. Head Neck Surg 8:442, 1986 The authors carried out a retrospective study of 100 patients who had undergone surgery for salivary gland neoplasms involving frozen-section biopsy techniques. The results of the final histologic examination were com- pared to the intraoperative frozen-section diagnoses. In addition, records were reviewed to determine the impact of frozen-section diagnosis on surgical management. Of 1023
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
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.
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-
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-
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
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.
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
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.