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The disorders temporomandibular dysfunction and craniomandibular dysfunction are still being discussed intensely in the literature 25 year after the publication of the dissertation 'Prevalence and etiology of craniomandibular dysfunction. An epidemiological study of the Dutch adult population'. Attention is especially being devoted to occlusion and its relationship with this disorder; the conclusions reached are often contradictory. In addition to the definitions of temporomandibular and craniomandibular dysfunction and of occlusion, a possible explanation for this controversy can be found in the methodological shortcomings of the studies. On the basis of the most important results in the dissertation of 25 years ago and the scientific discussion since, 7 guidelines are formulated that are illustrated with clinical examples for an evidence-based treatment of patients with this disorder in a general dental practice.

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1: The aim was to investigate whether precision-cut rat tissue slices could be used to predict metabolic drug clearance in vivo. To obtain a complete picture, slices not only from liver, but also from lung, kidney, small intestine and colon were included. 2: The metabolic clearances of 7-ethoxycoumarin, 7-hydroxycoumarin, testosterone, methyltestosterone and warfarin were determined by measuring the disappearance of these compounds during incubation with slices prepared from liver, lung, kidney, small intestine and colon. 3: The total in vitro metabolic clearance was determined by adding the individual in vitro organ clearances from the slices. Prediction based on the in vitro clearance was within an order of magnitude to the corresponding in vivo values. Interestingly, the relative contribution of extrahepatic metabolic clearance of the studied compounds to total clearance was remarkably high, ranging from 35 to 72% of the total metabolic clearance. 4: It is concluded that the model of multi-organ precision-cut slices is a useful in vitro tool for prediction of in vivo metabolic clearance. In addition, it provides information about the relative contribution of the liver, lung, kidney, small intestine and colon to the total metabolic clearance.

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1. Organ-specific biotransformation was studied in human and rat liver, lung, kidney and small intestine slices and compared on a protein basis, using four model substances. 2. Deethylation of lidocaine was highest in liver slices from both man and rat, followed by the small intestine. 3. Metabolism of testosterone was highest in liver slices, but a different overall metabolic pattern was found between the different organs. 4. Lung, kidney and intestine slices prepared from human and rat organs showed mainly an unknown metabolite of 7-ethoxycoumarin identified as 4-ethoxy-2-hydroxyphenyl propionic acid (EPPA). 5. The maximal metabolism of 7-ethoxycoumarin in slices was equal with in vivo V(max) in the rat. 6. Phase II metabolism of 7-hydroxycoumarin in kidney and intestinal slices was about 60% of the activity in liver slices. 7. In conclusion, organs other than the liver show a surprisingly high drug-metabolizing activity. Thus, the use of precision-cut slices of a combination of drug metabolizing organs in an in vitro test system from both animal and human origin is required for a proper systematic prediction of drug metabolism in man.

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Metabolism of xenobiotics is often seen as an exclusive function of the liver, but some current findings support the notion that the lungs, kidneys and intestine may contribute considerably. After the establishment of the use of liver slices as a useful in vitro model to study metabolism and toxicity of xenobiotics, the same concept is currently being used for slices from lung, kidney and intestine. It is the aim of this review to discuss the use of organ slices in biotransformation research. The basic idea behind the use of tissue slices in biomedical research is the assumption that the cells under study will function optimally in vitro if they are cultivated in an environment that is most alike to their natural in vivo embedding, which is the case in tissue slices. Advantages in the use of organ slices are the relatively easy preparation as well as the potential standardization of both the preparation and use. Moreover, a direct interspecies comparison can be made between liver, lungs, kidneys and intestines, for example with respect to their metabolic capacity and their sensitivity for toxicants. Of major importance is that organ slices can be made with a similar procedure from organs/tissues originating from different species, including man. This latter aspect is useful in drug development in general but also for a better insight in the metabolic fate of compounds in man. Importantly the use of slices may largely contribute to a reduction in the use of experimental animals.

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This study aimed to evaluate patients' satisfaction with resin-bonded bridges and the effect of failures on the degree of satisfaction. In two clinical trials, 358 patients completed guided questionnaires at regular recalls (n=1484). In this way, data regarding 'overall function', 'colour', 'shape', 'functional changes', 'complaints' and 'recommendation to other patients' were obtained. The scores of each criterion were evaluated for the variables 'trial', 'gender', 'time after placement' and 'failure', using 4-way ANOVA. Encountered failures were rated using a 'failure severity scale'. For all combinations of measurement periods, the changes in patient's opinions were calculated and the differences tested using the paired t-test. Overall satisfaction was correlated with 'colour', 'shape' and inversely correlated with 'complaints' (r>0.34; all P<0.005). No statistical differences were found between males and females. No significant changes were observed in patient satisfaction over time. Failures influenced the failure sensitive variables 'functional changes' and 'avoidance of load'. The z-scores were independent of the severity of the failures (r<0.13; all P>0. 10). The degree of patient satisfaction with resin-bonded bridges appeared to be high and did not seem to be influenced by the occurrence of failure.

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OBJECTIVES: To make an inventory of clinical studies on single-tooth restorations supported by implants using a systematic review procedure and to aggregate overall survival results. DATA SOURCES: Papers referring to single-tooth implants were located by a MEDLINE search 1990 to April 1998. Three hundred and twenty references were found, and they were subjected to a systematic review procedure. STUDY SELECTION: A three-step inclusion/exclusion procedure was applied to identify papers that represented: good scientific practice (GSP), reported results of all patients, implants and crowns for more than 2years, and had sufficient data to generate life-table analyses. The outcomes were 'implant failure' and 'crown completion'. Nine studies survived. These data showed an overall mean GSP of 0.37 with a predicted 4year implant survival of 97% (n=459), and an uncomplicated crown maintenance of 83% (n=240). CONCLUSION: Single-tooth implants show an acceptable short-term survival of 4years, but crown complications are common.

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The present study reports the final analysis of a randomized controlled clinical trial in which different designs of posterior resin-bonded bridges were evaluated for a period of at least 5 years. The operational hypothesis was that the bonding system and the preparation design used in posterior resin-bonded bridges have an influence on the survival and clinical functioning of these restorations. Survival in this study was defined at two levels: (1) 'primary' survival (survival without any debonding), and (2) 'functional' survival (survival including loss of retention on one occasion and successful rebonding of the original resin-bonded bridge without further debonding). Preparation of grooves in abutment teeth for posterior resin-bonded bridges appeared to be beneficial to their chance of survival. Resin-bonded bridges placed in the maxilla have a better prognosis than those made in the mandible. The bonding systems used in this study (etching/Clearfil F2, sand blasting/Panavia EX and silica-coating/Microfill Pontic C) appear to have no influence on the chance of failure with regards to the 'primary' survival. In rebonded posterior resin-bonded bridges, the bonding system silica coating/Microfill Pontic C was more retentive than the other systems tested.

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Metabolism of xenobiotics occurs mainly in the liver, but in addition, the lungs and kidneys may contribute considerably. The choice of the animal species during drug development as a predictive model for the human condition is often inadequate due to large interspecies differences. Therefore, a universal method for the preparation and incubation of human and animal liver, lung and kidney tissue is being developed for drug metabolism and toxicity testing using precision-cut organ slices. Human tissue was obtained from surgical waste material. Slices were made from rat and human liver, kidney and agar-filled (1.5%, w/v) lung tissue using a Krumdieck tissue slicer and incubated in six-well plates. The morphology and the ATP content show that viability is maintained during 3 hours of incubation. These organ slices show a variety of phase I (hydroxylation, oxidation and O- and N-deethylation) and phase II (glucuronidation and sulfation) metabolic routes using lidocaine, testosterone, 7-ethoxycoumarin and 7-hydroxycoumarin as substrates. The metabolic patterns and rates were found to be different for the various organs and species studied. The use of human tissue slices will enable us to collect more human-specific data on drug metabolism and toxicity. This may lead to a more adequate choice of animal species used during drug development and will result in a considerable reduction in the use of experimental animals.

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The replacement of amalgam restorations by adhesive inlays requires an adjustment to the cavity form. This often necessitates the removal of sound tooth substance. Undercuts may be blocked out by a base, but an extensive use of glass ionomer for this purpose is not recommended due to the weak mechanical properties of this material. The present study estimated the amount of sound tissue removed when a given amalgam preparation was reshaped for an adhesive inlay without the use of a base. An MOD amalgam preparation was created in an acrylic tooth. Twenty copies were distributed among 20 operators, who were requested to transform the preparation into an adhesive inlay preparation, removing as little material as possible. One control preparation with parallel walls was produced. All teeth were weighed before and after the alteration. The preparations' volumes were calculated: original amalgam preparation 0.130 ml, parallel preparation 0.136 ml. The minimum removal necessary was therefore 0.006 ml. The amount removed by the operators varied, with a mean volume of 0.0138 +/- 0.004 ml. Statistical analysis showed that for the given preparation, significantly more material was removed than necessary for undercut elimination. On average, more than twice the minimal volume of material was lost. This loss can be minimized by developing alternative techniques for undercut elimination.

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OBJECTIVES: A randomized controlled clinical trial was undertaken, to study the influence of some patient- and operator-dependent variables on the survival of posterior resin-bonded bridges (PRBBs) and to assess the survival of replacement' PRBBs. This report contains some of the results of the 5-year analysis. METHODS: Survival was defined at three levels: (1) complete survival (without any debonding), (2) functional survival (i.e. survival after one loss of retention) and (3) replacement survival (survival of 'replacement' PRBBs, inserted after rebonded bridges suffered a second dislodgement). Potential risk factors were analysed with Cox's proportional hazards model and differences were tested for significance with the Breslow test. Observed effects are expressed as conditional-relative-risk (CRR). Survival of 'replacement' PRBBs was assessed with the Kaplan-Meier method. RESULTS: Factors showing significant influences on complete survival were: 'location' (highest risk for mandibular PRBBs: CRR = 2.2), 'aetiology' (higher risk in treatment of aplasia: CRR = 2.9), and 'time of existence' (open spaces existing less than 2 years before insertion of PRBB: CRR: 2.0). The factor 'large open spaces in the mandible' was a risk for both complete and functional survival (CCR values 3.1 and 3.5, respectively). The survival of mandibular and maxillary 'replacement' PRBBs after 5 years was 19 +/- 7% and 31 +/- 18%, respectively. CONCLUSIONS: Risk factors for PRBBs were: 'location', 'aetiology', 'time of existence', 'isolation method' and 'large open spaces in the mandible'. Mandibular 'replacement' PRBBs showed such an unacceptably low survival rate that fabrication is not recommended.

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OBJECTIVE: This study aimed to investigate the milling behaviour of natural inlays (NI) dental restorations constructed from sound extracted teeth. This was done by comparing the milling accuracy and fit of NI to those of industrial porcelain inlays (PI), milled in the same way. METHODS: A calibration pro-inlay was used to mill three NI and three PI. These were cemented in six acrylic cavities reproduced from the calibration mould, using composite luting cement. No etching and bonding were done. After storage for 24 h in water at room temperature the specimens were sliced buccolingually in a standardised way. For each specimen, two sections were photographed under a light-microscope, resulting in enlarged pictures of the sections. An acetate matrix with the measurement points was placed over each picture in a standardised way. The interfaces between inlays and moulds were measured at 13 fixed points per section using computerised image analysis software. The mean vertical- and floor-interfaces were calculated for each picture, and the overall means were found for each group. Confidence intervals were used for comparison of the differences. The profiles of the milled materials were examined using scanning electron microscopy. RESULTS: There were no differences between NI and PI in the mean interfaces (NI, 102 +/- 8 micrometers; PI, 107 +/- 8 micrometers). Electron microscopy revealed no apparent differences in the profiles of the milled surfaces. CONCLUSION: These findings indicate that the milling accuracy and the fit of natural inlays and milled porcelain inlays are comparable.

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1. Precision-cut liver slices represent a suitable and convenient in vitro preparation for studying metabolism and toxicity mechanisms of drugs and toxic chemicals. Particularly in the case of human liver slices, cryopreservation would enable more efficient utilization of this scarce and irregularly available tissue. 2. Liver slices from consecutive human livers were cryopreserved using a method previously developed for rat and monkey liver slices. This procedure involves incubation in 12% dimethyl sulphoxide for 30 min on ice and direct immersion into liquid nitrogen. 3. Functional integrity of cryopreserved human liver slices, as compared with that of fresh liver slices, was maintained at 66 +/- 8% (alanine aminotransferase activity retained in the slices), 78 +/- 7% (urea synthesis), 88 +/- 14% (testosterone hydroxylation), 84 +/- 7% (N-deethylation of lidocaine) and 88 +/- 10% (total O-deethylation of 7-ethoxycoumarin). The ratios of testosterone metabolites did not change on cryopreservation. 4. These results show that the cryopreserved human liver slices retained the measured drug metabolism activities. Therefore, this cryopreservation method is suitable for storing liver slices to be used for comparing drug metabolism patterns, at least qualitatively, between species.

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OBJECTIVES: Bases are used in restorative dentistry for several reasons (i.e. isolation, elimination of undercuts, etc). Glass ionomers are the standard materials used as bases for porcelain inlays, despite the disadvantages of their mechanical properties. An alternative basing material is composite: a generous layer of posterior composite is cured and shaped in the cavity before an impression is taken. The composite basing technique has several clinical advantages. The aim of this study was to investigate the effect of the thickness of a composite base on the bulk fracture resistance of industrial porcelain, and to describe the procedure. METHODS: Fifteen porcelain (P) and 15 composite (C) bars, 1-, 2-, and 3-mm thick were joined to form 15 C/P bars, all 4-mm thick. Three groups were created: C 1 mm/P 3 mm (group 1), C 2 mm/P 2 mm (group 2), and C 3 mm/P 1 mm (group 3). The pairs were joined using Twinlook cement, subjected to a three-point bending test and loaded to fracture. The beam theory was used to support and explain the results. RESULTS: The fracture load means were: group 1, 197.7 +/- 18.7 N; group 2, 234.3 +/- 63.3 N, group 3, 336.3 +/- 31.3 N. Group 3 was significantly stronger than group 1 (P = 0.01) and group 2 (P = 0.03). Groups 1 and 2 were not statistically different. CONCLUSION: Composite basing is a tissue conserving method which may significantly increase the resistance to bulk fracture of adhesive porcelain inlays.

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Previous clinical observations have revealed that resin-bonded bridges for posterior tooth replacements are less retentive than anterior resin-bonded bridges. Improved bonding procedures and preparation designs, however, may have a positive effect on the functional durability of these restorations. The present study reports the final analysis of a randomized controlled clinical trial in which different designs of posterior resin-bonded bridges were evaluated for a period of at least 5 years. The operational hypothesis was that the bonding system and the preparation design used in posterior resin-bonded bridges have an influence on the survival and clinical functioning of these restorations. Survival in this study was defined at two levels: (1) 'complete' survival (survival without any debonding), and (2) 'functional' survival (survival including loss of retention on one occasion and successful rebonding of the original RBB without further debonding). With regard to 'complete' survival, no significant differences were found between the bonding systems used for adherence of the restorations to abutment teeth (etching/Clearfil F2, sandblasting/Panavia EX, and silica-coating/Microfill Pontic C). The variable 'preparation form' (conventional preparation form vs. modified preparation form) for complete survival was statistically in favor of the modified preparation form (62% vs. 46%), but did not influence the functional survival. With regard to 'functional' survival, the combination of silica coating and Microfill Pontic C was more retentive than the other bonding systems (90% survival vs. 72% and 75%, p < 0.01). Factor location was found to be highly significant for both survival levels [Cox's PH model, p = 0.0002 (Cox, 1972)]: The five-year 'complete' survival rates were 65% for maxillary restorations and 40% for mandibular restorations, while the five-year 'functional' survival rates were 89% and 68%, respectively. It is concluded that preparation of grooves in abutment teeth for posterior resin-bonded bridges is beneficial to their chance of survival. Resin-bonded bridges placed in the maxilla have a better prognosis than those made in the mandible. The bonding systems used in this study appear to have no influence on the chance of failure. In rebonded posterior resin-bonded bridges, the bonding system silica-coating/Microfill Pontic C was more retentive than the other systems tested.

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Precision-cut liver slices are presently used for various research objects, e.g. to study metabolism, transport, and toxicity of xenobiotics. Various incubation systems are presently employed, but a systematic comparison between these incubation systems with respect to preservation of slice function has not been performed yet. Therefore, we started a comparative study to evaluate five of these systems: the shaken flask (an Erlenmeyer in a shaking water bath), the stirred-well (24-well culture plate equipped with grids and magnetic stirrers), rocker platform (6-well culture plate with Netwell insert rocked on a platform), the roller system (dynamic organ culture rolled on an insert in a glass vial), and the 6-well shaker (6-well culture plate in a shaking water bath). The liver slices were incubated in these incubation systems for 0.5, 1.5, and 24.5 h and subsequently subjected to viability and metabolic function tests. The viability of the incubated liver slices was evaluated by: potassium content, MTT assay, energy charge, histomorphology, and LDH leakage. Their metabolic functions were studied by determination of the metabolism of lidocaine, testosterone, and antipyrine. Up to 1.5 h of incubation all five incubation systems gave similar results with respect to viability and metabolic function of the liver slices. However, after 24 h, the shaken flask, the rocker platform, and the 6-well shaker incubation systems appeared to be superior to the stirred well and the roller incubation systems.

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OBJECTIVES: A clinical trial, involving 203 resin-bonded bridges (RBBs) was undertaken to investigate the influence of retainer-type and luting material on the survival of these restorations. METHODS: For this evaluation, 157 patients were available (14% of the original sample was lost to follow-up or excluded from the study following the stopping criteria). Fifty per cent of the patients were questioned concerning the fate of the RBBs and 59% of questioned patients were examined clinically. The patients that were seen for examination were representatives of the experimental groups. The findings from the clinical examination were compared with the data obtained from the questionnaire. Missing data were censored at the date of the last available information. Kaplan-Meier estimates were calculated to assess the survivals at the endpoints and compared using Cox's proportional hazards procedure. RESULTS: A significant difference was found between perforated (P-type) and etched (E-type) RBBs (P = 0.05) for original bonded restorations but not when rebonded RBBs were taken into account. The results of the survival analysis were: anterior P-type, 49 +/- 7% after 10.5 years: anterior E-type, 57 +/- 7% after 10.5 years; posterior P-type, 18 +/- 11% after 6.8 years; posterior E-type, 37 +/- 13% after 10.2 years. Survivals of RBBs that were rebonded once during the evaluation period were 62 +/- 9% (11.0 years) for anterior RBBs and 51 +/- 11% (10.2 years) for posterior RBBs. CONCLUSIONS: The factor location (anterior versus posterior) was as in previous analyses, highly significant. Differences in survival between cementation materials were not significant.

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Patients suffering with various orofacial pain conditions are likely to seek advice and treatment from a family physician. Temporomandibular disorders (TMD) are common in the general population, and the clinician should be aware of the common associated signs and symptoms so that proper therapy can be provided. The family physician can often provide initial therapies that are effective in reducing TMD symptoms. In some instances, it is appropriate for the family physician to refer the patient to a dentist for a more comprehensive evaluation of the masticatory system. This article describes the common patient complaints associated with TM disorders. A few simple therapies are discussed along with suggestions regarding the appropriate time for referral to a dentist for a thorough dental evaluation.

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A nationwide survey of oral conditions, treatment needs, and attitudes toward dental health care in Dutch adults was carried out in 1986. One of the aims of the study was to assess the prevalence of signs and symptoms of temporomandibular disorder (TMD). A sample of 6577 persons (from 15 to 74 yr of age), stratified for gender, age, region, and socio-economic status, was contacted. Of this sample, 4496 persons participated in the behavioral part of the study, of whom 3526 were examined clinically. The TMD prevalence was based on (1) perceived signs and symptoms of TMD and (2) clinical examination of joint sounds, deviation, and pain on mandibular movements. A total of 21.5% of the Dutch adult population perceived some dysfunction, and 44.4% showed clinically assessed signs and symptoms of TMD. In nearly all age groups, the signs and symptoms of TMD appeared more in women than in men. Agreement between the results of the clinical examination and the anamnestic dysfunction index was significant (p < 0.0001); however, the Pearson's correlation coefficient was low (r = 0.29). The odds-value (risk-ratio) that subjects who perceived signs and symptoms of TMD would present with clinically assessed signs and symptoms of TMD was 2.3. The results of the survey were compared with results of a meta-analysis performed on 51 TMD prevalence studies. The analysis revealed (1) a perceived dysfunction rate of 30% and (2) a clinically assessed dysfunction of 44%, both based on compound samples of, respectively, over 15,000 (23 studies) and over 16,000 (22 studies) randomly selected subjects.

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