Efficacy of Codeine When Added to Paracetamol (Acetaminophen) and Ibuprofen for Relief of Postoperative Pain After Surgical Removal of Impacted Third Molars: A Double-Blinded Randomized Control Trial.

PURPOSE: The use of opioids in combination with nonopioids is common practice for acute pain management after third molar surgery. One such combination is paracetamol, ibuprofen, and codeine. The authors assessed the efficacy of codeine when added to a regimen of paracetamol and ibuprofen for pain relief after third molar surgery. MATERIALS AND METHODS: This study was a randomized, double-blinded, placebo-controlled trial conducted in patients undergoing the surgical removal of at least 1 impacted mandibular third molar requiring bone removal. Participants were randomly allocated to a control group (paracetamol 1,000 mg and ibuprofen 400 mg) or an intervention group (paracetamol 1,000 mg, ibuprofen 400 mg, and codeine 60 mg). All participants were treated under intravenous sedation and using identical surgical conditions and technique. Postoperative pain was assessed using the visual analog scale (VAS) every 3 hours (while awake) for the first 48 hours after surgery. Pain was globally assessed using a questionnaire on day 3 after surgery. RESULTS: There were 131 participants (36% men; control group, n = 67; intervention group, n = 64). Baseline characteristics were similar for the 2 groups. Data were analyzed using a modified intention-to-treat analysis and, for this, a linear mixed model was used. The model showed that the baseline VAS score was associated with subsequent VAS scores and that, with each 3-hour period, the VAS score increased by an average of 0.08. The treatment effect was not statistically meaningful, indicating there was no difference in recorded pain levels between the 2 groups during the first 48 hours after mandibular third molar surgery. Similarly, the 2 groups did not differ in their global ratings of postoperative pain. CONCLUSION: Codeine 60 mg added to a regimen of paracetamol 1,000 mg and ibuprofen 400 mg does not improve analgesia after third molar surgery.

A model to predict nodal metastasis in patients with oral squamous cell carcinoma.

Difficulty in precise decision making on necessity of surgery is a major problem when managing oral squamous cell carcinomas (OSCCs) with clinically negative neck. Therefore, use of clinical and histopathological parameters in combination would be important to improve patient management. The main objective is to develop a model that predicts the presence of nodal metastasis in patients with OSCC.623 patients faced neck dissections with buccal mucosal or tongue squamous cell carcinoma (SCC) were selected from patients' records. Demographic data, clinical information, nodal status, Depth of invasion (DOI) and pattern of invasion (POI) were recorded. The parameters which showed a significant association with nodal metastasis were used to develop a multivariable predictive model (PM). Univariate logistic regression was used to estimate the strengths of those associations in terms of odds ratios (OR). This showed statistically significant associations between status of the nodal metastasis and each of the following 4 histopathological parameters individually: size of the tumour (T), site, POI, and DOI. Specifically, OR of nodal metastasis for tongue cancers relative to buccal mucosal cancers was 1.89, P-value < 0.001. Similarly, ORs for POI type 3 and 4 relative to type 2 were 1.99 and 5.83 respectively. A similar relationship was found with tumour size; ORs for T2, T3, and T4 compared to T1 were 2.79, 8.27 and 8.75 respectively. These four histopathological parameters were then used to develop a predictive model for nodal metastasis. This model showed that probability of nodal metastasis is higher among tongue cancers with increasing POI, with increasing T, and with larger depths while other characteristics remained unchanged. The proposed model provides a way of using combinations of histopathological parameters to identify patients with higher risks of nodal metastasis for surgical management.

Retrieval of a root fragment from the maxillary sinus--an appreciation of the Caldwell-Luc procedure.

A 30-year-old man presenting for routine extraction of a carious upper left first permanent molar subsequently underwent the retrieval of a palatal root that had been displaced into the maxillary sinus. This paper illustrates the principles of the Caldwell-Luc procedure and highlights the issues and management of acute oro-antral communication associated with a displaced root into the sinus. This paper was presented at the Clinical Excellence in Patient Care Symposium, Dunedin on 29 September, 2006.

One-Piece Zirconia Ceramic versus Titanium Implants in the Jaw and Femur of a Sheep Model: A Pilot Study.

Reports have documented titanium (Ti) hypersensitivity after dental implant treatment. Alternative materials have been suggested including zirconia (Zr) ceramics, which have shown predictable osseointegration in animal studies and appear free of immune responses. The aim of the research was to investigate the bone-to-implant contact (BIC) of one-piece Zr, compared with one-piece Ti implants, placed in the jaws and femurs of domestic sheep. Ten New Zealand mixed breed sheep were used. A One-piece prototype Ti (control) and one Zr (test) implant were placed in the mandible, and one of each implant (Ti and Zr) was placed into the femoral epicondyle of each animal. The femur implants were submerged and unloaded; the mandibular implants were placed using a one-stage transgingival protocol and were nonsubmerged. After a healing period of 12 weeks, %BIC was measured. The overall survival rate for mandibular and femur implants combined was 87.5%. %BIC was higher for Zr implants versus Ti implants in the femur (85.5%, versus 78.9%) (p = 0.002). Zirconia implants in the mandible showed comparable %BIC to titanium implants (72.2%, versus 60.3%) (p = 0.087). High failure rate of both Zr and Ti one-piece implants in the jaw could be attributed to the one-piece design and surface characteristics of the implant that could have influenced osseointegration. Further clinical trials are recommended to evaluate the performance of zirconia implants under loading conditions.

VEGF and VEGFR2 in dentigerous cysts associated with impacted third molars.

The aims of this study were to determine the presence and distribution of vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-2 (VEGFR2) in dentigerous cysts compared with normal dental follicles as a control tissue and to evaluate endothelial cells and proliferating cells as indicators of angiogenic activity in these tissues.Twenty specimens histologically diagnosed as dentigerous cysts and 20 dental follicle specimens were included. Immunohistochemistry (IHC) using anti-VEGF and anti-VEGFR2 antibodies stained for the growth factor and its receptor, while anti-CD34 and anti-CD146 antibodies were used to identify endothelial cells. Anti-proliferating cell nuclear antigen (PCNA) antibody detected proliferating cells within the specimens. Slides were examined microscopically and results evaluated using kappa statistics, negative binomial regression and ordinal logistic regression.The mean age for patients with dentigerous cysts was 23 years and they were more common in males. Proteins for VEGF, VEGFR2, PCNA, CD34, and CD146 were expressed in all dentigerous cysts and dental follicles. VEGF and VEGFR2 were expressed on several cell types within the tissues, however there was a significantly greater percentage of positive staining in dentigerous cysts compared with dental follicles (odds ratio = 31.24, p < 0.001). CD34(+), CD146(+), and PCNA(+) cells were observed in both dentigerous cysts and dental follicles but for all markers there were significantly more positive cells in dentigerous cysts (p < 0.001); this was especially evident in cases associated with inflammation. PCNA was seen in most endothelial cells lining small thin walled blood vessels suggesting endothelial proliferation. There was a high level of intra- and inter-examiner agreement (kappa 0.77 and 0.75, respectively).VEGF and VEGFR2 and angiogenic activity are present in dental follicles and dentigerous cysts and may contribute to local bone resorption for tooth eruption or the development and progression of dentigerous cysts.

Multivariate assessment of site of lingual nerve.

Injury to the lingual nerve can cause debilitating symptoms. The nerve lies in the retromolar region and its anatomical site can vary within patients and according to sex, age, and dentate status. To our knowledge, no previous studies have recorded its course from multiple bony landmarks and examined the association between age, dentate status, and sex, in the same sample. We dissected 30 white cadavers and took primary and secondary reference points from the internal oblique ridge. We measured the distance to the lingual nerve in sagittal, vertical, and horizontal planes, and recorded the position where the nerve was closest to the lingual plate. We dissected 46 hemimandibles (23 male, mean age 79 years, range 52-100) of which 26 were from the left side. Mean (SD) sagittal, vertical, and horizontal distances from the primary reference point were 9.29 (3.41)mm, 9.15 (3.87)mm, and 0.57 (0.56)mm, respectively. Mean (SD) vertical and horizontal distances from the secondary point were 7.79 (5.45) mm and 0.59 (0.64)mm, respectively. The proximity of the nerve to the lingual plate varied widely (range -13.00 to 15.17mm from the primary reference point). Dentate status was significant for the sagittal measurement from the primary point, and the vertical measurement from the secondary point. Differences in age, sex, or site of the contralateral nerve were not significant (n=16 pairs). Our findings suggest that the site of the nerve is consistent between and within subjects for sex and age, but not for dentate status. The association between the nerve and the lingual plate varied, which suggests that care must be taken when operating in the area.

Comparative safety and efficacy of two high dose regimens of oral paracetamol in healthy adults undergoing third molar surgery under local anaesthesia.

This study compared the efficacy and safety of single oral doses of 60 mg/kg and 90 mg/kg paracetamol in fit young adult patients undergoing third molar extractions. The study was a randomised, blinded, crossover design on 20 young, fit adults. Paracetamol was administered 30 minutes prior to the surgical extraction of the teeth, which was done under intravenous sedation and local anaesthesia. There were no clinically or statistically significant differences in the pain scores between 60 mg/kg or 90 mg/kg doses until the intake of rescue analgesics. There was a reduction in factor VII activity with 90 mg/kg dose compared to 60 mg/kg dose. It may be concluded that the 90 mg/kg dose, though safe, does not offer any advantages over 60 mg/kg dose of paracetamol in young fit adults undergoing third molar surgery.

A randomized crossover trial of tenoxicam compared with rofecoxib for postoperative dental pain control.

Two non-steroidal anti-inflammatory drugs, tenoxicam and rofecoxib, were compared for the control of postoperative pain following surgical extraction of bilaterally and symmetrically impacted wisdom teeth performed under intravenous sedation and local anaesthesia. Thirty-five young fit adult patients received each analgesic treatment for four days in a randomized, crossover design. The results suggest statistically better pain relief for the selective COX-2 inhibitor rofecoxib compared to tenoxicam, a traditional NSAID. There were side-effects with both treatments. Abdominal discomfort was significantly more common following rofecoxib compared to tenoxicam. Both analgesics were acceptable to most participants in the trial.