Anti-inflammatory steroid use in impacted third molar surgery: a systematic review.

Oral surgery procedures involve traumatization of mucosal and bony tissues, and lengthy interventions can lead to inflammatory post-operative sequelae. In the bony tissues in particular, the inflammatory processes can affect healing. Modern drug therapies provide valid support for lowering the risk of occurrence of post-operative inflammatory signs. The two main types of agents used are nonsteroidal anti-inflammatory drugs and/or corticosteroids, which act on two different molecular pathways in the inflammatiory process. The aim of this systematic review is to examine the different corticosteroids used in oral surgery procedures, their indications for use, and their route of administration, to provide the clinician with a useful scheme for correct pharmacological management of post-operative inflammation. To identify studies eligible for inclusion in this systematic review, we performed a literature search up to April 2017 of the electronic databases, considering published papers from 2007 to 2017. The search terms included steroids, third molar, oral surgery, RCT [randomized controlled trial], human, and clinical trial. Only articles in English language were considered.

A Fatal Aortic Arch Rupture Due to Descending Necrotizing Mediastinitis in a 24-year-old Woman.

Descending necrotizing mediastinitis (DNM) is a life-threatening disease which often develops from a purulent infection of the oral cavity and is associated with high rates of mortality. Here we report the case of a young patient who died from an aortic arch rupture in context of DNM developed from an odontogenic infection caused by Prevotella buccae. Based on the current knowledge on this very rare vascular complication, we discuss factors that may have contributed to this fatal issue and future issues to optimize care provided to patients.

Osteomyelitis of the jaw (with pathological fracture) following extraction of an impacted wisdom tooth. A case report.

Osteomyelitis is an infection and inflammation associated with the bone structures: bone marrow, cortical bone, periosteum, blood vessels and nerves. Although it does not have a frequent presentation, it can sometimes lead to complications such as pathological fractures or even septicemia. We present a clinical case study, to assess the relationship between osteomyelitis of the jaw and pathological fractures, after the extraction of an impacted wisdom tooth. This case highlights a rare complication following the surgical removal of mandibular third molar; a slow evolution of the pathology following an extraction should lead to close monitoring of the patient both clinically and radiographically, albeit osteomyelitis is a rare complication, it should be included as one of the differential diagnosis of persistent post-extraction pain.

Actinomyces-associated calcifications in a dentigerous cyst of the mandible.

Actinomyces-associated lesions in the jaw, such as radicular cyst and osteomyelitis, have been reported by many authors. The lesions are caused by infection from peripheral sites and can be seen to contain Actinomyces druses on pathologic examination. To our knowledge, no previous reports have described Actinomyces-associated calcification in the jaw, although the lesions in the jaw often include druses. We report here a rare case of Actinomyces-associated calcifications in a dentigerous cyst of the mandible.

Molecular analysis of 16S rRNA genes identifies potentially periodontal pathogenic bacteria and archaea in the plaque of partially erupted third molars.

PURPOSE: Small subunit rRNA sequencing and phylogenetic analysis were used to identify cultivable and uncultivable microorganisms present in the dental plaque of symptomatic and asymptomatic partially erupted third molars to determine the prevalence of putative periodontal pathogens in pericoronal sites. MATERIALS AND METHODS: Template DNA prepared from subgingival plaque collected from partially erupted symptomatic and asymptomatic mandibular third molars and healthy incisors was used in polymerase chain reaction with broad-range oligonucleotide primers to amplify 16S rRNA bacterial and archaeal genes. Amplicons were cloned, sequenced, and compared with known nucleotide sequences in online databases to identify the microorganisms present. RESULTS: Two thousand three hundred two clones from the plaque of 12 patients carried bacterial sequences from 63 genera belonging to 11 phyla, including members of the uncultivable TM7, SR1, and Chloroflexi, and difficult-to-cultivate Synergistetes and Spirochaetes. Dialister invisus, Filifactor alocis, Fusobacterium nucleatum, Porphyromonas endodontalis, Prevotella denticola, Tannerella forsythia, and Treponema denticola, which have been associated with periodontal disease, were found in significantly greater abundance in pericoronal compared with incisor sites. Dialister invisus and F nucleatum were found in greater abundance in sites exhibiting clinical symptoms. The archaeal species, Methanobrevibacter oralis, which has been associated with severe periodontitis, was found in 3 symptomatic patients. CONCLUSIONS: These findings have provided new insights into the complex microbiota of pericoronitis. Several bacterial and archaeal species implicated in periodontal disease were recovered in greater incidence and abundance from the plaque of partially erupted third molars compared with incisors, supporting the hypothesis that the pericoronal region may provide a favored niche for periodontal pathogens in otherwise healthy mouths.

Pregnancy complicated by recurrent brain abscess after extraction of an infected tooth.

BACKGROUND: Odontogenic infections are quite common and, in unusual cases, can extend beyond the oral cavity with potentially life-threatening complications. CASE: A 35-year-old woman, G3P0020, underwent extraction of an infected left maxillary third molar tooth at 19 3/7 weeks of gestation and later presented with mental status changes. Computed tomography revealed left pterygoid muscle abscess, which progressed to brain abscess. She underwent multiple partial lobectomies to drain her recurrent brain abscess. The pregnancy continued until term, and she underwent a cesarean delivery. CONCLUSION: Brain abscess is a rare but life-threatening complication of pregnancy. This case illustrates the potential complications after extraction of an infected tooth in pregnancy.

Unilateral facial nerve paralysis following an infected lower third molar.

The authors report the case of a 35-year-old Arab man who presented with unilateral facial nerve palsy in the presence of an infected lower third molar. The paralysis occurred within hours of the development of a left-sided facial swelling. Surgical removal of the tooth and drainage of the abscess produced significant improvement in facial nerve function, and total resolution occurred prior to clinical follow-up 10 days later. The authors discuss the aetiology of this hemifacial paralysis and its significance as a clinical sign of third molar odontogenic infection.

Third molars and the efficacy of mechanical debridement in reducing pathogen levels in pregnant subjects: a pilot study.

PURPOSE: To assess the impact of mechanical debridement (scaling and root planing), without adjunctive therapy, on reducing the numbers of periodontal pathogens detected in pregnant subjects with and without visible third molars. PATIENTS AND METHODS: Sixty-seven subjects in the second trimester of pregnancy were enrolled in an institutional review board-approved study. Full mouth periodontal exams of all teeth were conducted at baseline and postpartum. Presence or absence of third molars was noted. Subgingival biofilm samples were obtained from the mesiobuccal of all first molars at enrollment and postpartum. Subjects' total counts for periodontal pathogens in biofilm samples were determined by DNA-DNA checkerboard hybridization. We analyzed data from a subsample of 26 subjects. All subjects in the study were treated at enrollment by mechanical debridement of all teeth, including third molars. Differences between subjects' baseline and postpartum demographic and clinical characteristics were analyzed by chi(2) and t tests by presence or absence of third molars. Statistical significance for differences in pathogen levels was determined by Rank analysis of covariance. Significance was set at 0.05 without correction for multiple comparisons. RESULTS: Most of the 26 subjects were African American (61%), on Medicaid (92%), and did not smoke during pregnancy (88%). The 15 subjects with visible third molars were significantly older (28.0 years [SD 6.4] vs 23.7 years [SD 3.9]). In the 11 subjects with no third molars noted, all pathogen counts were reduced postpartum. In the 15 subjects with visible third molars, total counts for each pathogen analyzed were higher postpartum as compared with subjects with no visible third molars, and their bacterial counts were increased for 5 of the 8 pathogens, including all "red cluster" pathogens. Differences between study groups were observed by the presence or absence of third molars for T. forsythia and P. nigrescens (P = .04), and for P. gingivalis, F. nucleatum, total "orange cluster" bacteria, and total pathogens (P < .06). CONCLUSION: The efficacy of mechanical debridement to lower periodontal pathogen counts during pregnancy was limited by the presence of visible third molars and should be analyzed further in larger scale trials.

Periodontal pathogens in erupting third molars of periodontally healthy subjects.

The presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia and Tannerella forsythensis in bacteriologic samples of 5-7-mm deep mandibular third-molar pericoronal pockets was analysed by polymerase chain reaction, to test the hypothesis that these sites would harbour the bacteria. The patients were periodontally healthy 20-year-old Finnish male conscripts. Sixteen had acute pericoronitis, 28 chronic pericoronitis, and 15 were symptom-free controls. A. actinomycetemcomitans was detected in only 7% of the samples from chronic pericoronitis cases, whereas P. gingivalis was positive in 20% of the symptom-free versus 69% (P = 0.018) of the acute and 57% (P = 0.044) of the chronic cases. The percentages for P. intermedia were 93, 94 and 93%, and for T. forsythensis 47, 63 and 57%, respectively. These results confirm that, apart from A. actinomycetemcomitans, periodontopathogens are common in third-molar sites in periodontally healthy individuals.

Severe odontogenic infections, part 2: prospective outcomes study.

PURPOSE: The purpose of this study was to identify significant predictors of 4 outcomes in patients with severe odontogenic infections: abscess formation, penicillin therapeutic failure (PTF), length of hospital stay (LOS), and need for reoperation. PATIENTS AND METHODS: We used a prospective case series study design and enrolled 37 consecutive patients admitted for severe odontogenic infection between March 1996 and June 1999. Treatment consisted of intravenous penicillin (PCN) or clindamycin in PCN-allergic patients, surgical incision and drainage, and extraction(s) as soon as possible. Study variables were categorized as demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications. The primary outcome variables were abscess formation, PTF, LOS, and reoperation. Multivariate linear and logistic regression techniques were used to measure associations between study variables and the outcome variables. RESULTS: The sample consisted of 37 subjects (23 male, 14 female) with a mean age of 34.9 +/- 15.8 years. Multivariate analyses, controlling for confounding variables, indicated that culture of Peptostreptococci was a negative predictor of abscess formation. LOS was predicted by the number of infected spaces and duration of operation. There was no significant predictor of PTF or reoperation on multivariate analysis, although PCN-resistant organisms were isolated in all cases of PTF. CONCLUSION: Increased LOS in severe odontogenic infections is predicted by the anatomic extent and severity of the infection and the occurrence of complications such as PTF and the need for reoperation. PTF is significantly associated with later identification of PCN-resistant organisms. The role of Peptostreptococci in abscess formation warrants further investigation.

Severe odontogenic infections, part 1: prospective report.

PURPOSE: The purpose of this study was to prospectively evaluate a series of patients with severe odontogenic infections (OI). PATIENTS AND METHODS: In this study, 37 consecutive hospitalized patients with odontogenic infection were treated with intravenous penicillin (PCN) (unless allergic), and prompt incision and drainage. Standardized data collection included demographic, preadmission, time-related, preoperative, anatomic, treatment, microbiologic, and complications information. Appropriate descriptive statistics were computed. RESULTS: The sample consisted of 37 subjects (38% female) with a mean age of 34.9 years. Three subjects (8%) had immunocompromising diseases. Caries was the most frequent dental disease (65%) and the lower third molar was the most frequently involved tooth (68%). Trismus and dysphagia were present on admission in over 70% of cases. The masticator, perimandibular (submandibular, submental, and/or sublingual), and peripharyngeal (lateral pharyngeal, retropharyngeal, and/or pretracheal) spaces were infected in 78%, 60%, and 43% of cases, respectively. Abscess was found in 76% of cases. PCN-resistant organisms were identified in 19% of all strains isolated and in 54% of patients with sensitivity data. PCN therapeutic failure occurred in 21% of cases and reoperation was required in 8%. Length of hospital stay was 5.1 +/- 3.0 days. No deaths occurred. CONCLUSIONS: This study indicated that PCN resistance, resulting in PCN therapeutic failure, was unacceptably high in this sample. Alternative antibiotics, such as clindamycin, should be considered in hospitalized patients with OI. Masticator space infection occurred much more frequently than previously reported. Trismus and dysphagia should be appreciated as significant indicators of severe OI.

Bacteremia following surgical dental extraction with an emphasis on anaerobic strains.

Our aim was to investigate bacteremia caused by surgical extraction of partly erupted mandibular third molars. From 16 young adults, bacterial samples were taken from the third-molar pericoronal pocket and post-operatively from the extraction socket, and blood samples were drawn from the ante-cubital vein up to 30 min after surgery. Of the subjects, 88% had detectable bacteremia-50% 1 min after the incision, 44% immediately after extraction. The respective percentages at 10, 15, and 30 min were 44%, 25%, and 13%. Blood cultures contained 31 species (74% anaerobes), with 3.9 +/- 2.6 species isolated per subject. Most prevalent were the anaerobes Prevotella, Eubacterium, and Peptostreptococcus sp. and the aerobes viridans-group streptococci and Streptococcus milleri group. Any species found in the blood was also isolated from the mouth, from 93% of the pericoronal pockets and from 43% of the extraction sockets. Surgical dental extraction clearly causes bacteremia of a high frequency and lasting longer than thus far assumed.

Microbiology of mandibular third molar pericoronitis: incidence of beta-lactamase-producing bacteria.

OBJECTIVES: The purpose of this study was to evaluate the predominant flora associated with pericoronitis in third molars and to investigate the presence of beta-lactamase-producing strains. STUDY DESIGN: The third molars in 26 adults were evaluated by cultures with nonselective media and with selective media containing amoxicillin, pristinamycin, spiramycin, metronidazole, and spiramycin plus metronidazole. RESULTS: In the majority of cases (19/26), the flora found in an anaerobic atmosphere predominated. Obligate anaerobes were present in 21 of the 26 samples. The bacteria most commonly detected were alpha-hemolytic streptococci (26/26) and the genera Prevotella (15/26), Veillonella (15/26), Bacteroides (9/26), and Capnocytophaga (9/26). Amoxicillin and pristinamycin were the most active in reducing the anaerobic cultivable counts. beta-Lactamase-producing strains were detected in 9 samples and were mostly bacteria of the genera Prevotella, Staphylococcus, and Bacteroides. CONCLUSIONS: These results highlight (1) the diversity of the microflora associated with pericoronitis and the importance of the anaerobic flora and (2) the existence of selection pressure related to the use of beta-lactams that may culminate in failure of prescribed penicillins.

Microbial complexes detected in the second/third molar region in patients with asymptomatic third molars.

PURPOSE: Our goal was to report the detection and levels of pathogenic bacteria in subgingival plaque samples taken from the distal of all second molars in 295 patients with asymptomatic third molars. PATIENTS AND METHODS: Data assessing oral health were collected from each of these healthy patients (ASA Classes I and II). Probing depth (PD), at 6 sites per tooth, including third molars, was obtained to determine periodontal status. Subgingival plaque samples were taken from the distal of all second molars before periodontal probing. The presence and levels of 11 bacterial species were determined using whole chromosomal DNA probes and checkerboard DNA-DNA hybridization. Detected bacterial species were grouped into clusters of periodontal pathogens designated as "red" or "orange" complex microorganisms as described by Socransky et al (J Clin Periodontal 25:134, 1998) who found an association of these specific microorganisms with periodontitis. RESULTS: As a group these relatively young patients were periodontally healthy. "Orange and red" complex microorganisms were detected at levels equal to or greater than 10(5) more often if patients had a PD equal to or greater than 5 mm with periodontal attachment loss at the distal of second molars or around third molars at their entry examination. In patients with no PD equal to or greater than 5 mm in the third molar region, "orange and red" complex microorganisms were detected at levels equal to or greater than 10(5) more frequently than would be anticipated in patients with little clinical evidence of periodontal disease. CONCLUSIONS: The clinical findings of increased periodontal PDs and periodontal attachment loss coupled with colonization of periodontal pathogens support the concept that clinical and microbial changes associated with the initiation of periodontitis may present first in the third molar region in young adults.

Investigation of infectious organisms causing pericoronitis of the mandibular third molar.

PURPOSE: The purpose of the study was to identify the most frequently encountered pyogenic organisms involved in pericoronitis to permit more targeted antibiotic therapy. PATIENTS AND METHODS: Pericoronal pockets of mandibular third molars from 37 patients showing symptoms of acute, severe pericoronitis were sampled and subjected to microbiologic analysis, including primary evaluation by phase-contrast microscopy. To avoid overgrowth with faster-growing, less fastidious organisms, specimens were cultured on a wide variety of selective media (supporting growth of fastidious bacteria, protozoa, and fungi). RESULTS: Microscopic examination indicated spirochetes in 55% and fusiform bacteria in 84% of the samples. A total of 441 microorganisms were isolated and identified from the 37 cultured samples. Besides obligate anaerobic bacteria, including various Actinomyces and Prevotella species, a predominantly facultative anaerobic microflora was cultivated, that is, Streptococcus milleri group (78% of samples), Stomatococcus mucilaginosus (71%), and Rothia dentocariosa (57%). CONCLUSION: It was concluded that the Streptococci milleri group bacteria, well-known for their ability to cause suppurative infections, are most likely involved in the pathogenesis of acute severe pericoronitis of the lower third molar.

Effect of extraction of partly erupted third molars on subgingival microorganisms.

This study was made to investigate the effect of extraction of third molars on subgingival microbes in 39 generally and gingivally healthy men with an average age of 20.2 years (SD 0.9). Microbial samples were taken from the pericoronal space of symptom-free partly erupted lower third molars and from the adjacent gingival pockets of the second molars. The samples were cultivated anaerobically. All partly erupted third molars were extracted from 20 subjects. A control group of 19 subjects was left untreated. Microbe sampling was repeated 2 and 5 months postoperatively with highly significant results. It was shown that at baseline the number of black-pigmented gram-negative bacteria and Fusobacterium species was more frequent in third molar than in second molar sites. The total bacterial count decreased significantly at the second molar sites after extraction of the third molars when compared with the control group. Before the extractions, black-pigmented gram-negative bacteria were detected in 45% of the test subjects and Actinobacillus actinomycetemcomitans in 20%. The respective postoperative figures were 30% for black-pigmented gram-negative bacteria and 10% for Actinobacillus actinomycetemcomitans. Capnocytophaga species were not affected by the extractions. The findings suggest that erupting third molars may harbor harmful bacteria that can be reduced by eradicating the foci.

A scanning electron microscopic study on the microflora of chronic pericoronitis of lower third molars.

In nine cases of chronic pericoronitis of lower third molars, the affected teeth were carefully removed with the follicles in situ and prepared for scanning electron microscopic (SEM) study. The study disclosed great heterogeneity in the distribution and density of microorganisms on hard as well as soft tissues surrounding the pericoronal pouch. Common features were presence of discrete microenvironments with clusters of bacteria, a decrease in the number of organisms toward the bottom of the pericoronal pouch, and the high proportion of spirochetes, which tended to increase in an apical direction. The study showed leukocytic activity in all areas, and phagocytosis apparently took place on the tissue surfaces within the pericoronal space.