The healing of dental extraction sockets in insulin-dependent diabetic patients: a prospective controlled observational study.

BACKGROUND: The aim of this study was to determine whether there was a difference in delayed healing following dental extractions for insulin-dependent diabetics as compared to non-diabetic patients. METHODS: Prospective patients referred to the Adelaide Dental Hospital exodontia clinic for dental extractions were recruited into two groups: Known insulin-dependent diabetics and healthy non-diabetics. All had a random blood glucose level (BGL). Delayed healing cases were identified, and statistical evaluation was performed. RESULTS: There were 56 insulin-dependent diabetic patients (BGL 10.03, range 4.9-26) and 49 non-diabetic, age- and sex-matched patients. Seven patients (12.5%) in the study group showed delayed healing following extraction, while only four patients (8.2%) in the control group suffered delayed healing. This difference was not statistically significant. Two of the study group developed postextraction infections, requiring incision, drainage and antibiotics. CONCLUSION: The study shows that Type 1 and insulin-dependent Type 2 diabetic patients, if well controlled, tend to heal up well following dental extractions but with a small but not statistically different rate of postextraction complications including infection. This is contrary to what is usually taught. Clinicians should take great care with management of insulin-dependent diabetic patients, as compared to non-insulin dependent diabetics or non-diabetic patients.

Contemporary exodontia.

Exodontia is a cardinal skill of all dentists. Patients expect extractions to be skillfully and painlessly accomplished every time. It's not necessarily so simple and can be challenging. In this paper we explore contemporary issues of the full process of exodontia including diagnosis, technique, complication minimization as well as management of medically compromised patients with appropriate post-operative care, including pharmacotherapy.

Severe odontogenic infection in pregnancy: a timely reminder.

Dental practitioners often treat patients that are pregnant. Understanding the altered physiology in the pregnant patient, especially changes in immune function, is vital in effective management of orofacial infections. We present a case of rapidly spreading odontogenic infection in a pregnant patient requiring surgical management. We also discuss the physiological changes of pregnancy relevant to dentistry, and the principles of managing such infections in the gravid patient.

The healing of dental extraction sockets in patients with Type 2 diabetes on oral hypoglycaemics: a prospective cohort.

BACKGROUND: The aim of this study was to determine whether there is a difference in delayed healing following dental extractions for Type 2 diabetics on oral hypoglycaemics and non-diabetic patients. METHODS: Prospective patients referred for dental extractions were recruited into two groups: known diabetics and non-diabetics with no conditions associated with poor healing. All had a random blood glucose level (BGL). Extractions were performed using local anaesthesia. Delayed healing cases were identified and statistical evaluation performed to identify risk factors. RESULTS: There were 224 Type 2 diabetics on oral hypoglycaemics (BGL 7.51, range 4.1-17.4) and 232 non-diabetics. The diabetic group were older, more males and less smokers than the control group. Twenty-eight patients, 12 (5%) diabetic and 16 (7%) control group, had socket healing delayed for more than one week but all healed in four weeks. There were no statistical differences between delayed healing and age, gender, diabetic state, BGL or smoking. The younger control group had more healing problems. CONCLUSIONS: The traditional view that diabetics have increased delayed healing was not supported. Type 2 diabetics on oral hypoglycaemics should be treated the same as non-diabetic patients for extractions.

Management of severe odontogenic infections in pregnancy.

BACKGROUND: The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant. METHODS: A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy. RESULTS: A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion. CONCLUSIONS: Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.

The treatment of oral cancer: an overview for dental professionals.

Oral cancer is a serious life-threatening disease. Dental professionals may be the first individuals to identify/suspect these lesions before referring to oral and maxillofacial surgeons and oral medicine specialists. Because the general dentist will likely follow on with the patient's future oral health, it is important that he or she has a basic understanding of the various treatments involved in treating oral malignancies and their respective outcomes. The four main modalities discussed in this review include surgery alone, radiotherapy alone, surgery with radiotherapy, and chemotherapy with or without surgery and radiotherapy. Chemotherapy has become an area of great interest with the introduction of new 'targeted therapies' demonstrating promising results in conjunction with surgery. Despite these results, the toxicities associated with chemotherapy regimens are frequent and can be severe, and therefore may not be suitable for all patients. Treatment modalities have improved significantly over the decades with overall decreases in recurrence rates, improved disease-free and overall survival, and an improved quality of life. Prognosis, however, is still ultimately dependent on the clinical stage of the tumour at the initial diagnosis with respect to size, depth, extent, and metastasis as recurrence rates and survival rates plummet with disease progression.

Severe adverse reactions to dental local anaesthetics: systemic reactions.

BACKGROUND: Occasionally, patients suffer systemic adverse effects from injections of local anaesthetic solutions. This may range from minor transient vasovagal attacks to life-threatening collapse. METHODS: The suspected adverse reactions reported to the Office of Product Review of the Therapeutic Goods Administration (TGA) were analysed in detail. RESULTS: There was a high incidence (70%) of adverse reactions associated with prilocaine, which is much greater than its market share (less than 20%). There is a tendency to consider all systemic adverse reactions as being 'allergic' reactions although this is rarely the case. Syncope, cardiovascular and central nervous system reactions are much more common. There is also a risk of methaemoglobinaemia to prilocaine and articaine. A small series of cases referred to one of the authors were also reported. CONCLUSIONS: Recommendations are made as to the prevention, acute care and subsequent investigation of adverse reactions. The most important conclusion is not to just label the response as allergic and to use an alternative agent. Detailed investigation and reporting should be made for all cases of suspected severe adverse reaction to local anaesthetic agents.

Severe adverse reactions to dental local anaesthetics: prolonged mandibular and lingual nerve anaesthesia.

BACKGROUND: Prolonged anaesthesia may occur following dental local anaesthetic blocks. This paper reviews the possible mechanisms of injury. Direct injury to the nerve by the needle, although commonly thought to be the mechanism, is unlikely. It is much more likely that the injury is from neurotoxicity and/or interference with the vascularization of the nerve. METHODS: Estimation of the frequency of injury was complicated by the fact that although local anaesthetics are prescription-only (S4) drugs, they are supplied without prescription by dental supply houses. Unlike all other S4 drugs, there is no statutory requirement to record supply. The pharmaceutical and supply houses relied on that and 'commercial confidentiality' to not supply information. RESULTS: An informed estimate of 1 in 27 415 was made but this figure has wide confidence limits. Management of cases of prolonged anaesthesia following local anaesthetic injection is discussed. CONCLUSIONS: Patients who suffer this uncommon complication suffer considerable distress and feel injured, so care must be exhibited in their management. Specialist referral is recommended.

Antibiotic prophylaxis for dentoalveolar surgery: is it indicated?

Usually dentists in Australia give patients oral antibiotics after dentoalveolar surgery as a prophylaxis against wound infection. When this practice is compared to the principle of antibiotic prophylaxis in major surgery it is found to be at variance in a number of ways. In major surgery, the risk of infection should be high, and the consequences of infection severe or catastrophic, before antibiotic prophylaxis is ordered. If it is provided then a high dose of an appropriate spectrum antibiotic must be present in the blood prior to the first incision. Other factors which need to be considered are the degree of tissue trauma, the extent of host compromise, other medical comorbidities and length of hospitalization. Standardized protocols of administration have been determined and evaluated for most major surgical procedures. Dentoalveolar surgery is undoubtedly a skilled and technically challenging procedure. However, in contrast to major surgical procedures, it has a less than five per cent infection rate and rarely has severe adverse consequences. Dentoalveolar surgery should be of short duration with minimal tissue damage and performed in the dental chair under local anaesthesia. Controlled studies for both mandibular third molar surgery and placement of dental implants show little or no evidence of benefit from antibiotic prophylaxis and there is an adverse risk from the antibiotic. This review concludes that there is no case for antibiotic prophylaxis for most dentoalveolar surgery in fit patients. In the few cases where it can be considered, a single high preoperative dose should be given.

The diagnosis and surgical management of major salivary gland pathology.

BACKGROUND: Major salivary gland pathology is an uncommon but important finding which may initially present to general dental and medical practitioners. The consequences of misdiagnosis are important, as acute obstruction and neoplasia are the main pathological lesions diagnosed. The purpose of this study was to analyze a consecutive series of major gland pathologies treated surgically to determine diagnostic and treatment problems. METHODS: A retrospective analysis of all cases of the major salivary glands treated on an inpatient surgical basis over a five-year period by the Oral and Maxillofacial Surgery Unit of the Royal Adelaide Hospital was performed. Particular emphasis was placed on the referring diagnosis as compared to the final diagnosis. RESULTS: Fifty-four patients had surgical management of 62 major salivary glands over the five-year period. By gland, 18 (33.3 per cent) were parotid, 35 (51.1 per cent) submandibular and nine (16.6 per cent) were sublingual. Fifty-one (82 per cent) of all lesions were inflammatory and 11 (18 per cent) neoplastic. The most common presentations were swelling (72 per cent) and pain (33 per cent). Most patients were referred by general dentists (37 per cent), followed by general medical practitioners (32 per cent) and specialists (28 per cent). The referring diagnosis was correct for only 45 per cent of the dentists but 76 per cent for the general medical practitioners and 87 per cent for the specialists. Only two of the 11 gland neoplasms were correctly identified as neoplasms, both by specialists. The morbidity of the surgical treatment was low. CONCLUSION: The general dental practitioner is often the first health professional with the opportunity to assess salivary gland pathology, and therefore needs to be aware of the presenting signs and symptoms of major salivary gland lesions.