Continuous Dentoalveolar Neuropathic Pain Response to Repeated Intravenous Ketamine Infusions: A Case Report.

This article describes a case of continuous dentoalveolar neuropathic pain in which relief was obtained following repeated administration of intravenous infusions of a subanesthetic dose of ketamine. A 50-year-old female presented in 2006 with a 1-year history of constant sharp pain in the gingiva surrounding the maxillary left second premolar and second molar rated as 10/10 on a pain intensity scale. After multiple systemic medications failed to adequately manage the patient's pain, partial pain reduction was obtained (4/10) with daily use of methadone 50 mg in combination with application of a topical compound including lidocaine, amitriptyline, and carbamazepine to the affected area as needed. In July 2012, for reasons unrelated to the neuropathic pain condition, the patient underwent extraction of the maxillary right second premolar under intravenous sedation. Initially, a subanesthetic dose of ketamine was added to the sedation regimen for postoperative pain management; however, due to subsequent improvement of the dentoalveolar neuropathic pain, repeated intravenous infusions were recommended for further pain management. The patient's neuropathic pain condition was successfully managed by a total of five intravenous ketamine infusions repeated over a 4-year period of time. The patient's daily use of methadone was progressively reduced and finally discontinued. This case suggests a possible role for intravenous infusions of subanesthetic doses of ketamine as an adjuvant management option in patients suffering from intractable dentoalveolar continuous neuropathic pain conditions.

Improving a Dental School's Clinic Operations Using Lean Process Improvement.

The term "lean production," also known as "Lean," describes a process of operations management pioneered at the Toyota Motor Company that contributed significantly to the success of the company. Although developed by Toyota, the Lean process has been implemented at many other organizations, including those in health care, and should be considered by dental schools in evaluating their clinical operations. Lean combines engineering principles with operations management and improvement tools to optimize business and operating processes. One of the core concepts is relentless elimination of waste (non-value-added components of a process). Another key concept is utilization of individuals closest to the actual work to analyze and improve the process. When the medical center of the University of Kentucky adopted the Lean process for improving clinical operations, members of the College of Dentistry trained in the process applied the techniques to improve inefficient operations at the Walk-In Dental Clinic. The purpose of this project was to reduce patients' average in-the-door-to-out-the-door time from over four hours to three hours within 90 days. Achievement of this goal was realized by streamlining patient flow and strategically relocating key phases of the process. This initiative resulted in patient benefits such as shortening average in-the-door-to-out-the-door time by over an hour, improving satisfaction by 21%, and reducing negative comments by 24%, as well as providing opportunity to implement the electronic health record, improving teamwork, and enhancing educational experiences for students. These benefits were achieved while maintaining high-quality patient care with zero adverse outcomes during and two years following the process improvement project.

Chronic focal Langerhans cell histiocytosis of the left mandibular condyle presenting as limited jaw opening: a case report.

Temporomandibular joint (TMJ) disorders are common in the general population, with a particularly high prevalence among girls and women aged 15 to 25 years. The presence of chronic focal Langerhans cell histiocytosis in the mandibular condyle is rare, as only a few cases have been reported in the literature. We present the case of a 23-year-old woman who was referred to the Orofacial Pain Center at the University of Kentucky College of Dentistry with a chief complaint of limited jaw opening of 7 months' duration. She had previously received a preliminary diagnosis of a TMJ disorder and had been treated conservatively, but she did not improve. An initial panoramic film revealed a suspicious radiolucent area at the head of the left mandibular condyle. She was eventually diagnosed on histopathology with chronic focal Langerhans cell histiocytosis. She was treated with condylectomy and surgical curettage of the lesion.

The efficacy of valacyclovir in preventing recurrent herpes simplex virus infections associated with dental procedures.

BACKGROUND: Oral herpes simplex virus, or HSV, infections recur after trauma and stress. The prevalence of these infections after dental procedures is not known. Also, it is unclear whether antiviral agents are effective in preventing dental procedure-induced HSV recurrences. This study determined the efficacy and safety of oral valacyclovir in suppressing dentally related cold sore outbreak and HSV shedding. METHODS: The authors enrolled 125 otherwise healthy HSV-seropositive adults who reported having recurrent herpes labialis (more than one episode per year and at least one episode in the previous year) in a randomized, double-blind, placebo-controlled study and gave them valacyclovir prophylactically (2 grams taken twice on the day of dental treatment and 1 g taken twice the next day) or a matching placebo. To detect the presence of the virus, the authors used clinical examinations, viral cultures and real-time polymerase chain reaction analysis of saliva. RESULTS: During the one-week observation period after treatment, there were more clinical lesions (20.6 percent versus 11.3 percent), more HSV-1-positive culture specimens (7.9 percent versus 1.6 percent) and more HSV-1-positive saliva specimens (7.9 percent versus 4.0 percent) in placebo than in valacyclovir-treated patients, respectively. The percentage of patients who developed recurrences and shed HSV-1 in saliva 72 hours after dental procedures was significantly smaller in the valacyclovir group than in the placebo group (11.3 percent versus 27 percent; P = .026). The mean time to pain cessation was significantly less in the valacyclovir group (3.2 days) than in the placebo group (6.2 days) (P = .006). CONCLUSION: HSV recrudescence after routine dental treatment is suppressed by valacyclovir prophylaxis. CLINICAL IMPLICATIONS: HSV recrudescence is common after routine dental treatment. Clinicians should consider antiviral therapy for patients at risk of experiencing a recurrence, as well as to minimize transmission of the disease.

The management of acute dental pain in the recovering alcoholic.

Although there have been many advances in our understanding of the neurophysiology of pain, the management of acute pain continues to be a challenge. When the need arises to provide adequate and effective pain management for the recovering alcoholic, the problem becomes much more complex. The clinician must provide the patient with adequate analgesia without causing a relapse. In the US, 6% to 10% of the population has attended Alcoholics Anonymous at some point, increasing the likelihood of the clinician being faced with the need to manage acute pain in a recovering alcoholic. The purpose of this article is to suggest guidelines for the management of acute dental pain in the recovering alcoholic based on current principles of acute pain management and for the treatment of pain in addicted patients.

Case report: dental considerations for managing a patient undergoing I-131 treatment for Graves' disease.

General dentists face many challenges when managing patients in an urgent care situation. Patients undergoing radioactive iodine therapy for Graves' disease pose a particular challenge, as they may exhibit a wide variety of symptoms during the active treatment phase. Proper management during the quarantine phase of treatment also involves a specific protocol for effective patient care.

A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains.

AIMS: To identify differences between 2 groups of patients with temporomandibular disorders (TMD), those with masticatory muscle pain (MMP) versus intracapsular pain (ICP), and to compare these differences on behavioral and psychosocial domains. METHODS: There were 435 patients in the MMP group and 139 patients in the ICP group. The overall sample was 88.2% female and had an average age of 36.1 years (SD = 11.7). Patients completed measures of psychological symptoms (SCL-90), pain severity (MPI), sleep (PSQI), activity (MBI), and life stressors (PCL). Heart rate and blood pressure were also measured, and a complete medical/dental history was taken for each patients. RESULTS: Results indicated no significant difference in pain severity or duration between the 2 groups (P > 05). The ICP group, however, reported fewer affective symptoms of pain than the MMP group (t = 6.8, P = .01). The ICP group had twice as many adaptive copers as dysfunctional patients (chi 2 = 7.84, P < .01), while there was no significant difference between these 2 categories for the MMP group (P > .05). Finally, the ICP group reported fewer psychological symptoms (P < .05), better sleep quality (F = 7.54, P = .01), and fewer life stressors (F = 7.00, P = .01) than the MMP group. CONCLUSION: In contrast to many previous studies, the data set in this study showed no differences in pain severity and duration between the MMP and the ICP groups. Even though pain severity levels were equivalent, the MMP diagnostic group of chronic TMD patients demonstrated more dysfunctional behavioral profiles and significantly higher psychological distress than the ICP subgroup.

Routine dental care in patients with temporomandibular disorders.

AIMS: While a significant number of therapeutic models have been suggested for management of orofacial pain and limited opening in patients experiencing temporomandibular disorders (TMD), little attention has been given to the issue of routine daily care activities, such as toothbrushing and flossing. The purpose of this study was to develop an understanding of the extent to which TMD patients experience difficulty in performing routine daily mouth care. METHODS: Forty patients seeking care for TMD in the Orofacial Pain Center at the University of Kentucky College of Dentistry were age- and gender-matched to a group of general dentistry patients not experiencing TMD. Participants completed a survey of oral health habits, and a clinical exam. RESULTS: Results indicated that TMD patients felt their discomfort had created more difficulty with daily mouth care as compared with the general dentistry patients (P < .000). Most TMD patients, however, continued with routine daily mouth care, except for 15% who reported an inability to floss on a regular basis. Also, a majority of TMD patients (63%) reported a change in seeking routine professional care because of their disorder (P < .000). CONCLUSION: The present data indicate the need for TMD patients to receive information concerning routine daily mouth care and visits for professional dental care. The results are discussed in terms of the strategies that dental care providers need to develop in order to address the significant consequences of orofacial pain on regular dental care.

Reduction of pain and EMG activity in the masseter region by trapezius trigger point injection.

In this open, uncontrolled trial, 20 patients with upper trapezius muscle trigger point pain and ipsilateral masseter muscle pain received a single trigger point injection of 2% lidocaine solution (without epinephrine) in the upper trapezius muscle. Following the trapezius injection, there was a significant (P < 0.001) reduction in pain intensity ratings for pain in the masseter region. In addition, there was a significant (P < 0.03) reduction in EMG activity in the masseter muscle. Overall, however, a significant relationship between EMG activity in the masseter and the self-report of pain was not found with the present data set. These clinical findings support the contention that sources of deep pain can produce heterotopic sensory and motor changes in distant anatomical regions.