Treatment planning concepts for the ageing patient.

There is an ageing imperative in Australia as in many other industrialized nations, and these populations are extremely heterogeneous. In young adults, the factors which influence decision making for oral health care are whether the patient has the will, the time or the finances to pay for care, while for clinicians, the decisions are whether they have the skill and the resources to carry out the treatment plan. For older adults, the decision making includes all of the previous identified factors, but they are now complicated by the patient's medical and medication problems, the side effects of the medications they are taking, their cognitive status as well as the cumulative effects of a lifetime of physiological, traumatic and iatrogenic effects on the dentition and the oral cavity. The decision-making process which has evolved has been called many names, from cost-effective care to minimal invasive dentistry to rational dental care. Fundamentally, they are similar. Rational dental care has been defined as the process of decision making, which develops a treatment plan that is in the best interest of the patient after evaluating all of the modifying factors. This article will discuss the various concepts, and the strengths and weaknesses of some of these systems. It will also illustrate some of the clinical problems as there is very little evidence-based data to support any of these concepts. However, treatment planning is still an art, which can only be carried out for an individual and not a group, and the result must serve the needs of the patient and enhance the quality of his or her life.

Incidence and management of severe odontogenic infections-a retrospective analysis from 2004 to 2011.

The management of odontogenic infections is a typical part of the spectrum of maxillofacial surgery. Normally these infections can be managed in a straight forward way however under certain conditions severe and complicated courses can arise which require interdisciplinary treatment including intensive care. A retrospective analysis of all patients affected by an odontogenic infection that received surgical therapy from 2004 to 2011 under stationary conditions was performed. Surgical treatment consisted in incision and drainage of the abscess supported by additional i.v. antibiotic medication in all patients. Detailed analysis of all patients that required postoperative intensive medical care was additionally performed with respect to special risk factors. During 8 years 814 patients affected by odontogenic infections received surgical treatment under stationary conditions representing 4% of all patients that have been treated during that period (n = 18981). In 14 patients (1.7%) intensive medical therapy after surgery was required, one lethal outcome was documented (0.12%). In all of these 14 patients a history of typical risk factors was present. According to these results two patients per week affected by an odontogenic infection required stationary surgical treatment, about two patients per year were likely to require additional intensive medical care. If well-known risk factors are present in patients affected by odontogenic infection appropriate interdisciplinary management should be considered as early as possible.

Determinants of length of hospitalization due to acute odontogenic maxillofacial infections: a 2009-2013 retrospective analysis.

OBJECTIVES: To investigate the determinants of the length of hospitalization (LOH) due to acute odontogenic maxillofacial infections (AOMIs) from 2009 to 2013. MATERIALS AND METHODS: Dental records of adult patients with AOMIs and related data were retrieved from the Vilnius University's dental hospital. The LOH was related to several determinants in each of the following domains: outpatient primary care, severity of AOMIs, lifestyle and disease domains. Determinants were also associated with the LOH using multivariate analysis. RESULTS: A total of 285 patients were hospitalized with AOMIs, of which 166 (58.2%) were males and 119 (41.8%) were females. The mean LOH was 8.3 ± 4.9 days. The bivariate analysis did not reveal any statistically significant differences in LOH between patients with AOMIs who received urgent outpatient primary care and those who did not receive such care prior to hospitalization. All AOMI severity-related determinants were associated with the LOH. The LOH was related to coexisting systemic conditions but not to the higher severity of dental or periodontal diseases. Both bivariate and multivariate analyses revealed similar trends, where the most significant determinants of a longer LOH were related to the severity of AOMIs. CONCLUSION: The most important determinants regarding longer hospitalization were indicators of infection severity such as an extension of the odontogenic infection and the need for an extraoral incision to drain the infection.

A minimally invasive surgical approach for large cyst-like periapical lesions: a case series.

Various conservative approaches have been utilized to manage large periapical lesions. This article presents a relatively new, very conservative technique known as surgical fenestration which is both diagnostic and curative. The technique involves partially excising the cystic lining, gently curetting the cystic cavity, performing copious irrigation, and closing the surgical site. This technique allows for decompression and allows the clinician the freedom to take a biopsy of the lesion, as well as perform other procedures such as root resection and retrograde sealing, if required. As the procedure does not perform a complete excision of the cystic lining, it is both minimally invasive and cost-effective. The technique and the concepts involved are reviewed in 4 cases treated with this novel surgical approach.

What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last?

In the everyday practice of oral and maxillofacial surgeons, empiric antibiotics are prescribed in the face of uncertainty. Is there a highly resistant organism present? Are the old-line antibiotics no longer effective? Should a broad-spectrum antibiotic be used just to cover all the bases in this case? The surprising result of this systematic review is that when combined with appropriate surgery, the usual antibiotics are all effective. Safety and cost become the differentiating factors in this clinical decision.

Standing oral extraction of cheek teeth in 100 horses (1998--2003).

REASONS FOR PERFORMING STUDY: Extraction of cheek teeth (CT) by the conventional repulsion technique requires general anaesthesia and carries a high rate of post operative complications. Consequently, an alternative method of extraction, i.e. orally in standing horses, was evaluated. HYPOTHESIS: The need for and risks of general anaesthesia could be avoided and post extraction sequelae reduced by performing extractions orally in standing horses. METHODS: One hundred mainly younger horses (median age 8, range 2-18 years) with firmly attached CT that required extraction because of apical infections, displacements, diastemata, idiopathic fractures and the presence of supernumerary CT had the affected teeth (n = 111) extracted orally under standing sedation. Follow-up information was obtained for all cases, a median of 16 months later. RESULTS: Oral extraction was successful in 89 horses and unsuccessful in 11 due to damage to the CT clinical crown (n = 9) during extraction, for behavioural reasons (n = 1) and because the apex of a partly extracted CT fell back into the alveolus following sectioning (n = 1). Predispositions to extraction-related CT fractures were present in 5 of the 9 cases, i.e. advanced dental caries (n = 2) and pre-existing 'idiopathic' fractures (n = 3). The iatrogenically fractured CT were later repulsed under standing sedation (n = 3) and under general anaesthesia (n = 6). Eighty-one of the remaining 89 horses had successful oral CT extraction with no or minimal intra- or post operative complications occurring. Post operative complications in the other 8 cases included post extraction alveolar sequestration (n = 3), alveolar sequestration and localised osteomyelitis (n = 1), localised osteomyelitis (n = 1), incorporation of alveolar packing material into alveolar granulation tissue (n = 1), and nasal discharge due to continued intranasal presence of purulent food material (n = 1) and to ongoing sinusitis (n = 1). The above sequelae were treated successfully in all cases, with general anaesthesia required in just one case. Following oral extraction, significantly (P<0.001) fewer post operative problems developed in 54 horses with apically infected CT in comparison with 71 previous cases that had repulsion of apically infected CT at our clinic. CONCLUSIONS AND POTENTIAL RELEVANCE: Oral extraction of cheek teeth is a successful technique in the majority of younger horses with firmly attached CT and greatly reduces the post operative sequelae, compared with CT repulsion. Additionally, the costs and risks of general anaesthesia are avoided. Further experience and refinement in the described protocol could potentially increase the success of this procedure and also reduce the incidence of post operative sequelae.

Using subjective oral health status indicators to screen for dental care needs in older adults.

A study was undertaken to assess the ability of a number of subjective oral health status indicators to identify community-dwelling older adults who need dental treatment. The indicators consisted of a single-item self-rating of treatment need, a 15-item psychosocial impact index and the 49-item Oral Health Impact Profile (OHIP). Data for the study were collected as part of an oral health survey of Canadians aged 50 years and over. The associations between these subjective indicators and clinically defined dental treatment needs were assessed using statistics for determining the predictive power of a diagnostic test. Although there were statistically significant associations between the subjective and clinical measures, values for statistics such as sensitivity, positive predictive values and positive likelihood ratios were low. Although the measures did not perform well as screening tests, they did identify a sub-group of individuals whose clinical conditions impacted significantly on daily life and who would probably benefit the most from dental treatment. In this respect, the subjective measures assessed here can themselves be interpreted as indicators of need which complement conventional clinical measures of needs for dental care.

Oral surgery: assessment and treatment.

In arriving at a diagnosis, a dentist will have employed much skill and expertise, but there can be no doubt that in formulating a treatment plan, in addition to skill and expertise, intuition and wisdom (and sometimes inspiration) are required. Whereas the road to diagnosis is paved with objectivity, the road to treatment is paved with subjectivity and instinct.