Interdisciplinary Treatment Protocol Research Articles

Interdisciplinary orthodontic and prosthodontic approach for esthetic rehabilitation in an adult patient

A 38-year-old female patient reported with a chief complaint of spacing between anterior teeth, and she desire to improve her facial esthetics. The patient was diagnosed with chronic generalized periodontitis with generalized horizontal bone loss on the basis of clinical and radiographic findings. On orthodontic evaluation, she has proclined upper and lower anterior with Class I molar relationship bilaterally and a canine Class I relationship bilaterally. She was treated with an interdisciplinary therapeutic protocol that included nonsurgical periodontal therapy, endodontic treatment, orthodontic therapy, and prosthetic rehabilitation. The orthodontic therapy was performed in generalized horizontal bone loss having loss of bone support in mandibular anterior region. Space closure was done using prosthetic rehabilitation in a healthy periodontium. The interdisciplinary treatment protocol was the key factor in achieving significant improvement in facial and dental esthetics, masticatory function, and quality of life of the patient.

Protocolo de atención odontológica en niños con Epidermólisis Ampollar

La atención odontológica de los niños con Epidermólisis ampollar (EA) o bullosa (EB) son un inmenso desafío para la práctica odontológica ya que se trata de un grupo de trastornos hereditarios que manifiestan aparición de ampollas en piel y mucosas al roce o suave trauma. Presentan múltiples manifestaciones orofaciales que requieren de un protocolo de atención interdisciplinaria específico que comprenda un alto componente preventivo. Se describirán los principales ítems del mismo y las posibilidades de rehabilitación bucal integral personalizada.

Effect of alcohol on the central nervous system to develop neurological disorder: pathophysiological and lifestyle modulation can be potential therapeutic options for alcohol-induced neurotoxication.

The central nervous system (CNS) is the major target for adverse effects of alcohol and extensively promotes the development of a significant number of neurological diseases such as stroke, brain tumor, multiple sclerosis (MS), Alzheimer's disease (AD), and amyotrophic lateral sclerosis (ALS). Excessive alcohol consumption causes severe neuro-immunological changes in the internal organs including irreversible brain injury and it also reacts with the defense mechanism of the blood-brain barrier (BBB) which in turn leads to changes in the configuration of the tight junction of endothelial cells and white matter thickness of the brain. Neuronal injury associated with malnutrition and oxidative stress-related BBB dysfunction may cause neuronal degeneration and demyelination in patients with alcohol use disorder (AUD); however, the underlying mechanism still remains unknown. To address this question, studies need to be performed on the contributing mechanisms of alcohol on pathological relationships of neurodegeneration that cause permanent neuronal damage. Moreover, alcohol-induced molecular changes of white matter with conduction disturbance in neurotransmission are a likely cause of myelin defect or axonal loss which correlates with cognitive dysfunctions in AUD. To extend our current knowledge in developing a neuroprotective environment, we need to explore the pathophysiology of ethanol (EtOH) metabolism and its effect on the CNS. Recent epidemiological studies and experimental animal research have revealed the association between excessive alcohol consumption and neurodegeneration. This review supports an interdisciplinary treatment protocol to protect the nervous system and to improve the cognitive outcomes of patients who suffer from alcohol-related neurodegeneration as well as clarify the pathological involvement of alcohol in causing other major neurological disorders.

A Novel Treatment Protocol (Nocebo Hypothesis Cognitive Behavioural Therapy; NH-CBT) for Functional Neurological Symptom Disorder/Conversion Disorder: A Retrospective Consecutive Case Series.

Theories concerning the aetiology of functional neurological symptom disorder (FNSD; also known as conversion disorder) have historically inferred that psychological factors or dissociative states underlie patients' symptoms. Current psychological models of functional neurological symptoms suggest that some type of 'top-down' representations/beliefs are activated automatically (without conscious awareness), leading to symptoms. It is assumed that these representations or beliefs are similar to the idea 'I am neurologically damaged', as in our clinical experience, almost all patients have some reason to doubt the integrity of their neurological system. It was hypothesized that FNSD arises from a belief of being neurologically damaged (via a mechanism akin to a nocebo response), and an interdisciplinary treatment protocol was developed consistent with this hypothesis, transparently sharing this theory with participants. A retrospective consecutive case series design was utilized, measuring functional independence and symptom remission. Of the 13 episodes of care, 12 resulted in complete or almost complete symptom remission. Length of stay in rehabilitation was also reduced compared with previous treatment attempts. It appears as if the treatment protocol may be very effective, and further controlled study appears warranted.

Combined Periodontal, Orthodontic, and Prosthetic Treatment in an Adult Patient.

A 41-year-old man had a significant loss of bone and supporting tissues with pathologic migration of several teeth and several missing teeth. He was treated with an interdisciplinary therapeutic protocol that included nonsurgical periodontal therapy based on strict control of supragingival plaque, subgingival periodontal therapy, orthodontic and endodontic treatment, and replacement of restorations. The orthodontic therapy was performed in a severely reduced bone support and the presence of pathological tooth migration after periodontal disease control. The interdisciplinary treatment protocol was the key to achieve a significant improvement in his facial and dental esthetics, masticatory function, and quality of life.

Restoring esthetics using adjunctive orthodontics – Case reports

Pre-restorative orthodontic alignment has definite advantages especially in patients with mal-aligned dentition seeking prosthetic rehabilitation. As adult orthodontics has gained popularity, orthodontic practices have seen a change in the patient population they encounter on a day-to-day basis. From completely dentulous adolescents, this population has widened to encompass adult dentitions with worn or abraded teeth, peg-shaped lateral incisors, fractured teeth, gummy smiles, multiple edentulous spaces, or other restorative needs that often require tooth positioning that is slightly different from non restored, nonabraded, adolescent teeth. In such instances, an interdisciplinary approach is necessary to evaluate, diagnose, and resolve esthetic problems using a combination of orthodontic, periodontic, endodontic and prosthodontic treatments. The aim of the article is to emphasize the importance of adjunctive orthodontics in such interdisciplinary treatment protocols, through two case reports.

Pierre Robin Sequenz: Pränatale Diagnostik und interdisziplinäre Therapie

Pierre Robin Sequence (PRS) is characterised by mandibular micrognathia and/or retrognathia, glossoptosis and upper airway obstruction (UAO). In severe cases, UAO and cyanosis occur immediately after birth and endoscopic intubation may become necessary. Therefore, prenatal diagnosis with referral to a specialized department is important. A non-invasive interdisciplinary treatment protocol is presented. The postnatal adjustment of the preepiglottic baton plate (PEBP) as early as possible is essential in this concept. In a randomised cross-over trial with 11 patients with isolated PRS, the PEBP was found to reduce the apnoea index significantly and to be superior to a conventional palatal plate. An uncontrolled longitudinal study indicated that the UAO had normalised 3 months after discharge; all infants showed adequate weight gain with bottle feeding. In a comparative study with 34 healthy children and 34 children with isolated PRS, no significant differences in cognitive outcome was found. Interdisciplinary co-operation between prenatal care, neonatology and orthodontics is a pre-requisite for optimal postnatal therapy. Complications of UAO can be avoided by early and adequate treatment, resulting in good results for feeding, speech and facial profile. Invasive surgical treatment options like tongue-lip-adhesion, mandibular extension or distraction should be obsolete.

Severe hypodontia: identifying patterns of human tooth agenesis

Tooth agenesis is the most common dental anomaly. The aim of this retrospective study was to identify common patterns of tooth agenesis in a sample of 92 patients (55 females and 37 males; mean age 27.7 years) with non-syndromic severe hypodontia. The Tooth Agenesis Code (TAC) procedure was used for that purpose. The patients in this study were missing between 6 and 22 permanent teeth (mean 11.6; median 10.0; SD 4.35). In the maxilla, 47.9 (left side) and 50.0 (right side) per cent can be described using only five different patterns. The most common patterns involved agenesis of the maxillary lateral incisor and both premolars. In the mandible, 35.8 (lower left) or 43.5 (lower right) per cent can be described by five patterns, the most common of which was agenesis of all mandibular premolars. When comparing patients with and without symmetric agenesis patterns (symmetry in the upper or lower arch versus no symmetry), a Student's t-test revealed no difference in the total number of missing teeth. Common patterns of tooth agenesis were successfully identified in patients with non-syndromic severe hypodontia. The present findings may be used to develop interdisciplinary treatment protocols for the most common patterns to increase the quality of interdisciplinary treatment for patients with severe hypodontia.

Interdisciplinary Management for Total Knee Replacement in Patients with Hemophilia and Severe Arthropathy.

Severe hemophilia is complicated by spontaneous joint bleedings, leading to severe secondary arthrosis. Hemophilic arthropathy with symptoms of incapacitating knee pain, not responding to medical treatment, associated with an impaired function is a clear indication for total knee replacement (TKR). Primary goals of total knee arthroplasty (TKA) are pain relief and satisfactory function which depends on adequate joint stability and motion. A well-balanced hemostasis is a basic requirement for successful interventions in hemophilic patients. Furthermore, the postoperative range of motion (ROM) depends on many factors, including surgical technique, preoperative motion, and appropriate rehabilitation.We report on our experience with 7 arthroplasties of knee joint arthropathies in 7 patients with severe hemophilia A (n = 4) and severe hemophilia B (n = 3). Indication for total knee replacement was arthropathy in stage III–V, progressive joint destruction, flexion contracture, axial malalignment, and pain refractory to conservative treatment. The average age of the patients at the time of arthroplasty was 35 years (range 18–42 years). Three patients were seropositive for HIV and HCV, 1 patient for HIV, 1 patient for HCV, and 2 patients had no viral infections. Mean hospitalization was 16.7 days (range 14 – 21 days). Six of 7 patients received a non-constrained bicondylar TKA (LCS complete n=5, Rotaglide n=1) and one patient a constrained bicondylar TKA (custom-made prostheses). The TKAs were inserted using bone cement containing gentamycin. Implantation was performed after arterial closure via medial dissection. Surgery was covered by appropriate factor VIII or IX replacement therapy with episodic bolus injections (factor VIII activity aimed at 100%). Median consumption of coagulation factor was 113.742 units (range 55.000 – 157.000 units). The postoperative blood loss was approximately 831 ml blood (range 250–1200 ml) in the low-vacuum drainage systems, the mean range of preoperative and postoperative haemoglobin (13.8 g/dl vs. 9.3 g/dl) was 4.5 g/dl. Transfusion of red blood cells was not required in any of the 7 individuals. Postoperative thromboembolic prophylaxis with low molecular weight heparin (4000 IE/day) was performed in all patients. The short-term results after a mean follow-up interval of 22 month (range 2–59 months) revealed no peri- and postoperative thromboembolic or bleeding complications and no infections. In 6 of 7 patients the knee extension improved with an average from 29.3° preoperatively to 5° postoperatively. One patient with reduced compliance (left hospital contrary to medical advice, rejected rehabilitation) suffered from postoperative articular fibrosis which made an open arthrolysis 3 and 8 month postoperative necessary and brought benefit in ROM from flexion/extension pre-operative 100/30/0 to 80/0/0 postoperative. In summary, our interdisciplinary treatment protocol demonstrates that total knee arthroplasty can be performed in high- risk hemophilic patients with a low rate of complications and in improvement in quality of life because of pain-relief and increase of motility and function in all patients. The high-dose replacement therapy is justified by the clinical outcome and benefit to the patients.

Ewing Sarcoma of the Mandible in a Child: Interdisciplinary Treatment Concepts and Surgical Reconstruction

Ewing's sarcoma is the second most common primary bone malignancy in childhood and adolescence. We present a standardized interdisciplinary treatment protocol according to the EURO-E.W.I.N.G. 99 study, applied in the treatment of a 7-year-old patient with localized Ewing's sarcoma of the left mandible. After six blocks of VIDE (vincristine/ifosfamide/doxorubicin/etoposide) chemotherapy and stem cells rescue, intensity modulated external radiation with 48.6 Gy and subsequent high dose therapy with busulphan-melphalan were administered. Tumor resection and immediate bony reconstruction was performed using a microvascular fibula graft 10 weeks after radiation. Because of the effective neoadjuvant treatment, no extensive soft tissue resection was necessary. Healing of the osteosynthesis was uneventful. No local or systemic recurrence and no signs of significant facial deformity were found after 12 month follow-up. The presented case underlines the requirement for multidisciplinary protocols involving radiologists, pathologists, oncologists, radiation oncologists, and surgeons for accurate diagnosis and appropriate therapy. To preserve cosmetics and function within the craniofacial area after tumor resection in children, microvascular reconstructive procedures can be successfully performed with a vascularized fibular graft.

A radiation-shielding device for craniofacial implant placement

The use of radiation shields in the head and neck cancer patient receiving adjuvant radiation therapy is a treatment alternative for protecting anticipated prosthetic implant sites. Shields can be fabricated easily as part of an interdisciplinary treatment protocol. In this article, the methods used to fabricate an extraoral radiation shield are described, and a patient treatment that illustrates possible uses of the shield for both extraoral and intraoral sites is presented. (J Prosthet Dent 2001;86:348-51.)

The neurodevelopmental price of survival in children with malignant brain tumours.

Increasing survival rates in malignant brain tumors treatment have directed attention to the side effects of long-term disease control. Nevertheless, although the treatment protocols are continuously remodelled, the quality of life of children surviving for a long time is still poor. The most severe sequelae are neurocognitive disorders, which are associated with neurobehavioural alterations. The last are partly derived directly from the lesion localisation and treatments, but are often reinforced by academic and social failure. The deleterious effect of radiotherapy (CRT) is very well documented and confirmed in all the studies. The radiation dose delivered according to the age has reduced, but not fully eliminated, the negative influence on mental functioning. Also the CRT hyperfractionation has reduced, but not cancelled, this cognitive negative impact. Intrathecal methotrexate per se is responsible for a severe cognitive impairment, which can be even more severe in association to CRT. Some surgical approaches have been responsible for postoperative behavioural disturbances. Serial neuropsychological and behavioural evaluations, which should also include the survivors' own perception of their quality of life, are badly needed. The results of these evaluations should be covariate with several factors (age, type of surgery, lesion site, hydrocephalus, complementary therapies) in an attempt to define interdisciplinary treatment protocols to maximise survival while minimising cognitive/behavioural deficits.

Relaxation Training for Nursing Home Patients

Thirteen nursing home patients, randomly assigned to a treatment or wait-list control group, completed a course in relaxation training. The goals of the study were to develop a well defined interdisciplinary treatment protocol; to evaluate treatment effectiveness; and to use these results to refine the original treatment protocol for future clinical application. Modest reductions in subjective pain and increments in morale were found in the treatment group as compared to the control group. Individual differences in ability to benefit from the group related to medical and psychiatric diagnoses, but not age. Relaxation training is a useful intervention for nursing home elderly, but treatments need to be simplified and structured for the nursing home population, and tailored to patients cognitive and psychiatric level.

An interdisciplinary nutrition assessment and intervention protocol for children with disabilities

Because of the multifactorial nature of the nutrition problems associated with developmental disabilities, a well-organized, interdisciplinary effort is necessary to deal with such problems. A team composed of professional and support staff, the client, and the family needs to be involved in an integrated approach to service. The team members share their knowledge and expertise in developing an individual program plan to meet identified needs. This article describes the development and implementation of a prototype for interdisciplinary nutritional evaluation and intervention in an outpatient setting. In 1987, a Regional Nutrition and Feeding Diagnosis and Evaluation Clinic was established through a contractual agreement between the University of Georgia University Affiliated Program and St. Mary's Hospital in Athens, GA. The purposes of the clinic are twofold: to offer direct services to developmentally disabled infants and children who require outpatient services and to provide a unique community-based interdisciplinary training experience for graduate students in nutrition and other health disciplines. The interdisciplinary treatment protocol is based on current knowledge in the treatment of developmental disabilities.