Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth.

BACKGROUND: Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is the surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is performed in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an review originally published in 2005 and previously updated in 2012 and 2016. OBJECTIVES: To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 May 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2019, Issue 4), MEDLINE Ovid (1946 to 10 May 2019), and Embase Ovid (1980 to 10 May 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov)and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. . SELECTION CRITERIA: We included randomised controlled trials (RCTs), with no restriction on length of follow-up, comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We also considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer. DATA COLLECTION AND ANALYSIS: Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently and in duplicate conducted the risk of bias assessments. When information was unclear, we contacted the study authors for additional information. MAIN RESULTS: This review update includes the same two studies that were identified in our previous version of the review: one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom, and one prospective cohort study, which was conducted in the private sector in the USA. Primary outcome No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life Secondary outcomes We found only low- to very low-certainty evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures. One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effects of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal aspect of the adjacent second molar during a follow-up period of three to over 25 years. Very low-certainty evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth. One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch. The included studies did not measure any of our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection). AUTHORS' CONCLUSIONS: Insufficient evidence is available to determine whether asymptomatic disease-free impacted wisdom teeth should be removed or retained. Although retention of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is very low certainty. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the current lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision-making with people who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain these teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Horizontal root fracture in a maxillary central incisor: a case report.

An 80-year-old patient fell while jogging, hitting his face on the concrete trail and causing a horizontal root fracture of his maxillary right central incisor. The fracture separated the root into 2 halves about 0.60-0.84 mm apart, resulting in extrusion of the incisal half. The patient had severe lip swelling and facial injury but no tooth pain. Various options for care were evaluated, but, other than reducing the extrusion, placing local antibiotics, and prescribing periodontal medication, the dentist did not provide or recommend further treatment. At the most recent recall, 8 years after the accident, the root exhibited good bone repair, there was no evidence of abscess, and the patient reported no discomfort. This report aims to remind clinicians that no or minimal treatment may be the best option in certain cases.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.

BACKGROUND: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. METHODS: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations. RESULTS: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion. CONCLUSIONS: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively.

BACKGROUND: The aim of this RCT was to determine whether elective resection following successful non-operative management of a first episode of acute sigmoid diverticulitis complicated by extraluminal air with or without abscess is superior to observation in terms of recurrence rates. METHODS: This was a single-centre, sequential design RCT. Patients were randomized to elective surgery or observation following non-operative management and colonoscopy. Non-operative management included nil by mouth, intravenous fluids, intravenous antibiotics, CT with intravenous contrast on arrival at hospital, and repeat CT with intravenous and rectal contrast on day 3 in hospital. The primary endpoint was recurrent diverticulitis at 24 months. Patients with a history of sigmoid diverticulitis, immunosuppression or peritonitis were not included. RESULTS: Of 137 screened patients, 107 were assigned randomly to elective surgery (26) or observation (81), and underwent the allocated intervention after successful non-operative management. Conservative management failed in 15 patients. Groups were similar in age, sex, BMI, co-morbidities and colorectal POSSUM. Rates of recurrent diverticulitis differed significantly in the elective surgery and observation groups (8 versus 32 per cent; P = 0·019) at a mean(s.d.) follow-up of 37·8(8·6) and 35·2(9·2) months respectively. There was also a significant difference in time to recurrence (median 11 versus 7 months; P = 0·015). A total of 28 patients presented with recurrent diverticulitis complicated by extraluminal air and/or abscess (2 elective surgery, 26 observation), all of whom recovered with repeat non-operative management. CONCLUSION: The majority of patients observed following conservative management of diverticulitis with local extraluminal air do not require elective surgery. Registration number: NCT01986686 (http://www.clinicaltrials.gov).

Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth.

BACKGROUND: Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is carried out in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an existing review published in 2012. OBJECTIVES: To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults. SEARCH METHODS: We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 24 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 4), MEDLINE Ovid (1946 to 24 May 2016) and Embase Ovid (1980 to 24 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing and unpublished studies to 24 May 2016. We imposed no restrictions on language or date of publication in our search of electronic databases. SELECTION CRITERIA: Studies comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We included randomised controlled trials (RCTs) with no restriction on length of follow-up, if available. We considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer. DATA COLLECTION AND ANALYSIS: Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently conducted risk of bias assessments in duplicate. When information was unclear, we contacted study authors for additional information. MAIN RESULTS: This review includes two studies. The previous review included one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom; our new search for this update identified one prospective cohort study conducted in the private sector in the USA. Primary outcome No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life Secondary outcomes We found only low to very low quality evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures.One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effect of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal of the adjacent second molar during a follow-up period of three to over 25 years. Very low quality evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth.One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch.The included studies did not measure our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection). AUTHORS' CONCLUSIONS: Insufficient evidence is available to determine whether or not asymptomatic disease-free impacted wisdom teeth should be removed. Although asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is of very low quality. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision making with patients who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain asymptomatic disease-free impacted wisdom teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Characteristics, detection methods and treatment of questionable occlusal carious lesions: findings from the national dental practice-based research network.

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

A Long-Term Study Comparing the Quality of Life and Psychological Status of Patients with Highly Suspicious Thyroid Nodules ≤1 cm Undergoing Active Surveillance with Those Undergoing Immediate Surgery.

Background: Limited information is available on the long-term impact of active surveillance (AS) and immediate surgery (IS) on the quality of life (QoL) and psychological status of patients with highly suspicious subcentimeter thyroid nodules. Methods: A prospective study was conducted on 752 patients showing highly suspicious subcentimeter thyroid nodules, among whom 584 chose AS and 168 chose IS. All patients underwent at least two assessments regarding their QoL and psychological status, using three questionnaires: Thyroid Cancer-Specific Quality of Life (THYCA-QoL), Hospital Anxiety and Depression Scale (HADS), and European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (QLQ-C30). Propensity-score matching (PSM) at a ratio of 3:1 was utilized on patients in the AS and IS groups to mitigate selection bias (504 patients in the AS group and 168 in the IS group). Subsequently, the mixed linear model was used to analyze the QoL data. Results: The median time from the initial evaluation to the last follow-up in the AS and IS groups was 24.0 and 14.2 months, respectively. The AS group showed superior QoL outcomes compared to the IS group, mainly manifested in voice (p < 0.001), sympathetic (p = 0.008), throat/mouth (p < 0.001), and problems with scar (p < 0.001) domains, as per the THYCA-QoL questionnaire. Further, the EORTC QLQ-C30 questionnaire highlighted better outcomes in physical function (p = 0.029), role function (p < 0.001), social function (p < 0.001), global health status (p < 0.001), fatigue (p = 0.012), pain (p = 0.028), appetite loss (p = 0.017), and financial difficulties (p < 0.001). Compared to the initial assessment (1 week after surgery), the IS group showed progressive improvements in QoL, especially in voice (p = 0.024), throat/mouth (p < 0.001), physical function (p = 0.004), social function (p = 0.014), nausea and vomiting (p < 0.001), pain (p = 0.006), and appetite loss (p = 0.048) domains as per both questionnaires. Conclusion: Patients with highly suspicious subcentimeter thyroid nodules who choose IS tend to experience a poorer long-term QoL compared to those who choose AS. Although the situation may improve over time, certain issues might persist, making AS a favorable option for these patients.

Observation as an option for epithelial positive margin after partial glossectomy in stage I and II squamous cell carcinoma: analysis of 365 cases.

OBJECTIVE: This study was conducted to assess local recurrence and clinical prognosis in patients diagnosed as having a positive margin in the epithelial layer after a partial glossectomy treated by close observation. METHODS: A total of 365 cases of squamous cell carcinoma of the tongue diagnosed as clinical Stage I or II, treated by partial glossectomy in the National Cancer Center Hospital East between 1992 and 2006, were studied retrospectively. RESULTS: Pathological findings showed that 13 cases had positive margins in the epithelial layer, 4 (30.8%) of whom showed up with local recurrence in 4.4 years (3.0-5.0) on average. Lymph node recurrence was not observed and the 5-year overall survival rate was 76.2% in those 13 cases. The treatment for the recurrent cases was an additional partial glossectomy without neck dissection, which resulted in no recurrence and a survival rate of 100% after an average follow-up of 6.7 years. CONCLUSIONS: We suggest careful observation as one option for cases diagnosed with epithelial positive margin.

What happens to cavitated primary teeth over time? A 3.5-year prospective cohort study in China.

OBJECTIVES: Data showed that among 5-year-old Chinese, 96.7% of cavitated primary teeth were left untreated. The study aimed to report on the course of cavitated primary teeth within the Chinese health-care system over a period of 3.5 years. METHODS: Selection of high caries risk children for inclusion in a sealant comparison study was based on the presence of cavitated dentine lesions in their primary teeth. At the 6-month sealant evaluation point many of these cavitated dentine lesions had not been treated. This necessitated monitoring these cavitated teeth 6-monthly for those exfoliated, restored, with a cavity left open, having caused toothache (symptom) and having (or having had) an abscess or fistulae (symptom). Care-seeking instruction was given at every evaluation point. anova and t-test were used in analysing the data. RESULTS: A total of 1012 cavitated primary teeth in 305 children (7.6 to 9.3 years old), were followed for 3.5 years. A total of 92.9% of cavitated primary teeth were left open, while 7.1% were restored at some stage during the observation period; 98.5% of restored teeth and 95.5% of cavitated teeth left open exfoliated and 93.9% of restored teeth and 81.5% of cavitated primary teeth left open exfoliated without any symptoms. Having (or having had) toothache was the symptom most frequently related to exfoliated restored teeth and to exfoliated cavitated teeth left open. Restored primary teeth survived statistically significantly longer than cavitated primary teeth left open: 1.99 ± 0.07 years and 1.68 ± 0.03 years, respectively. CONCLUSION: The large majority of cavitated primary teeth in this child population exfoliated without symptoms.

Spontaneous regression of a congenital epulis in a newborn.

A 3 day old girl presented with lobulated mass protruding from her mouth. The mass was clinically diagnosed as a congenital epulis. The child had no airway obstruction and was able to feed well. A conservative treatment was proposed with monthly follow up appointments to monitor the lesion. After 10 months the lesion completely regressed and the eruption of maxillary anterior teeth remained unaffected

Guidelines for the assessment of the impacted maxillary canine.

UNLABELLED: Canine impactions are frequently encountered, occurring in 1.7% of the population. The aim of this paper is to provide guidance on the assessment and management of cases which present in general dental practice. Canine position is considered in four categories; canine overlap with adjacent incisor, vertical canine height, angulation to midline and position of canine root apex. Good, average and poor prognostic outcomes are considered for each category and a brief outline of their management is included. CLINICAL RELEVANCE: Canine impactions frequently present during routine examination. Appropriate recognition, investigation and referral, if necessary, are paramount to successful treatment.

Conservative temporomandibular disorder management: what DO I do? -- frequently asked questions.

UNLABELLED: There are many myths and fallacies surrounding the conservative or non-surgical management of patients with temporomandibular disorders (TMD).This paper is not a treatise on splint design and does not champion any one particular treatment philosophy. It is, however, produced as the outcome of many years of lecturing and talking to fellow practitioners and represents the most frequently asked questions and common misconceptions encountered by the authors, who have addressed the topics raised with the intention of helping to avoid pitfalls. The common symptoms encountered in general dental practice are pain, either from muscles or the temporomandibular joint (TMJ) itself, limitation or deviation of mandibular movement, and joint sounds, and the authors have attempted to separate fallacy and fact. When appropriate examples are given. There are general treatment guidelines but, while some methods apply to an individual, there is no panacea - individual patient treatment needs vary. CLINICAL RELEVANCE: It is important that all treatments delivered to a TMD patient should be evidenced-based and should always be in the patient's best interests. Many treatment modalities are proposed that do not fulfil these parameters and can lead to confusion in management. A reference and reading list will be given which will direct the reader to an evidence-based approach to treatment. Some treatment suggestions are founded on the extensive clinical experience of the authors. There will not always be evidence from a randomized, controlled clinical trial to substantiate support for a specific treatment, but the reader should be directed by what the majority of clinicians would undertake as a responsible approach.

Unusual anatomical detection of a third molar in the infratemporal fossa.

Third molar presence in the infratemporal fossa is a rare event and it has been reported previously only two times in the literature, except for the cases which arise from complications occurring during the extraction of the impacted upper third molar. Due to the presence of important vessel bundles and nerves in this area, third molar removal requires a correct surgical management in order to avoid many possible serious side effects. We report an unusual case of upper third molar detected in the infratemporal fossa, which has been thoroughly investigated radiologically and removed through a safe surgical approach.

[Lingual mandibular osteonecrosis]. / Linguale mandibulaire osteonecrose.

A 47-year-old man was referred to an oral and maxillofacial surgeon by his dentist because ofa painful ulcer with exposed bone at the lingual side of teeth 47 and 48. The lesion was diagnosed as lingual mandibular osteonecrosis. Characteristics of lingual mandibular osteonecrosis are exposed bone in the molar area and sequestration. The disorder can appear spontaneously or following damage to the mucous membrane. Treatment options are surgical smoothening of exposed bone, surgical removal of necrotic bone and awaiting spontaneous sequestration.

Active surveillance versus immediate surgery: A comparison of clinical and quality of life outcomes among patients with highly suspicious thyroid nodules 1 cm or smaller in China.

INTRODUCTION: Active surveillance (AS) is considered an alternative to immediate surgery (IS) for low-risk papillary thyroid microcarcinoma (PTMC) patients. However, it is difficult to decide between AS and IS due to limited evidence regarding risks and benefits for patients in China. METHODS: This study prospectively enrolled 485 patients with highly suspicious thyroid nodules

Surveillance as a management strategy for retained third molars: is it desirable?

The purpose of the present report was to define and advocate active surveillance compared with follow-up as needed (prn follow-up), as the preferred management strategy for patients who elect to retain their third molars (M3s). Active surveillance, a nonoperative management strategy for retained M3s, is characterized as a prescribed, regularly scheduled set of follow-up visits that include both clinical and radiographic examinations. Given that the risk of complications with M3 removal are age related, the rationale for recommending active surveillance instead of "prn follow-up" is that the frequency of future disease among retained M3s is sufficiently high to warrant routine scheduled follow-up visits to detect and treat disease before it becomes symptomatic. Symptomatic disease is a late finding. Patients electing active surveillance as their preferred management strategy might not avoid operative treatment in the future, but it should increase their chances of being diagnosed at the youngest age possible, thus minimizing the age-related operative complications. The author recommends that the frequency of follow-up visits be approximately every 24 months and the examination be completed by a specialist or general dentist. Active surveillance as a management strategy is based on level 5 evidence (ie, expert opinion).

What is the effect of timing of removal on the incidence and severity of complications?

PURPOSE: The purpose of this article is to summarize the literature that addresses the following question: "Among patients undergoing third molar removal, do patients who are younger, eg, <25 years, when compared with older patients, have a decreased risk for postoperative complications and more rapid recovery?" MATERIALS AND METHODS: For the purposes of this study, relevant articles were identified through a search of PubMed, Scopus, and the Cochrane Database, using the Medical Subject Headings search terms "third molars" or "wisdom teeth," "complications" and "age," linked to "recovery," "infections," "periodontal conditions," "temporomandibular joint problems," "nerve involvement," "sinus communication," and "mandibular fracture." RESULTS: Relevant studies have been identified and are reported for the following complications and their relationship to the patient's age: 1) time to recovery; 2) incidence of fractures; 3) rates of infection; 4) periodontal complications; 5) nerve involvement; 6) temporomandibular joint complications; 7) nerve injury; and 8) sinus-related complications. CONCLUSIONS: Studies indicate that as one becomes older, third molars (M3s) become more difficult to remove, may take longer to remove, and may result in an increased risk for complications associated with removal. The age of 25 years appears in many studies to be a critical time after which complications increase more rapidly. Conversely, there are no studies indicating a decrease in complications with increasing age. It also appears that recovery from complications is more prolonged and is less predictable and less complete with increasing age. As such, many clinicians recommend removal of M3s in patients as young adults. Advocates of M3 retention need to review carefully with their patients the risks of delaying M3 removal with the same degree of emphasis as the risks associated with operative treatment.

What costs are associated with the management of third molars?

PURPOSE: The purpose of this study was to estimate the treatment costs directly related to operative and nonoperative management of asymptomatic, disease-free, third molar (M3) teeth. MATERIALS AND METHODS: The data reviewed were limited to claims submitted by oral and maxillofacial surgeons. The data collected included charges for consultations, radiographs, surgical removal of bony impacted teeth, and general anesthesia, using the 2009 data extracts from Delta Dental of Virginia. The median charges were used as a proxy for the actual costs attributable to the removal or retention of M3 teeth. Three clinical scenarios were executed using the available claims data to calculate the treatment costs associated with nonoperative and operative M3 management. An assumption made in the computation of expenses was that for subjects who elected to retain their M3s, the recommended management strategy was active surveillance. Active surveillance is a prescribed treatment to monitor the retained M3s characterized by performing a clinical examination and panoramic imaging every 2 years. The author assumed a 3% increase in charges per annum. RESULTS: The 3 scenarios were as follows: scenario 1 (nonoperative management), retention of asymptomatic, disease-free M3s and monitoring for 20 years from age 18 to 38 years; scenario 2 (operative management), removal of 2 asymptomatic, disease-free, bony impacted M3s for 18-year-old patients using general anesthesia (30 minutes) in an office-based ambulatory setting; and scenario 3 (failure of non-operative management), removal of 1 previously asymptomatic, disease-free, bony impacted M3 after 10 years of follow-up in a now 28-year-old patient using general anesthesia (30 minutes) in an office-based ambulatory setting. The estimated charges for managing M3s were $2,342, $1,184, and $1,997 for scenarios 1, 2, and 3, respectively. CONCLUSIONS: A simplified financial analysis derived from the dental claims data suggests that during the course of the patient's lifetime, the charges associated with non-operative management of asymptomatic, disease-free M3s will exceed the charges of operative management. The difference in costs might be important to patients when choosing between operative and non-operative management of their M3s.

What has been the United Kingdom's experience with retention of third molars?

BACKGROUND: In 2000, the first National Institute of Clinical Excellence (NICE) guidelines related to third molar (M3) surgery, a commonly performed operation in the United Kingdom, were published. This followed research publications and professional guidelines in the 1990 s that advised against prophylactic surgery and provided specific therapeutic indications for M3 surgery. The aim of the present report was to summarize the available evidence on the effects of guidelines on M3 surgery within the United Kingdom. MATERIALS AND METHODS: Data from primary care dental services and hospital admissions in England and Wales during a 20-year period (Hospital Episode Statistics 1989/1990 to 2009/2010), and from private medical insurance companies were analyzed. The volume and, where possible, the nature of the M3 surgery activity over time were assessed together, as were the collateral effects of the guidelines, including patient age at surgery and the indications for surgery. RESULTS: The volume of M3 removal decreased in all sectors during the 1990 s before the introduction of the NICE guidelines. During the 20-year period, the proportion of impacted M3 surgery decreased from 80% to 50% of admitted hospital cases. Furthermore, an increase occurred in the mean age for surgical admissions from 25.5 to 31.8 years. The change in age correlated with a change in the indications for M3 surgery during that period, with a reduction in "impaction," but an increase in "caries" and "pericoronitis" as etiologic factors, in accordance with the NICE guidelines. CONCLUSION: The significant decrease in M3 surgery activity occurred before the NICE guidelines. Thus, M3 surgery has been performed at a later age, with indications for surgery increasingly in accordance with the NICE guidelines. The importance of clinical monitoring of the retained M3s is discussed.

Primary oral mucosal melanoma: advocate a wait-and-see policy in the clinically N0 patient.

PURPOSE: Oral mucosal melanoma (OMM) is a rare disease associated with a very poor prognosis. Because well-established treatment protocols for OMM are in short supply, prognostic information regarding recent treatment modalities for this disease were sought. PATIENTS AND METHODS: A retrospective chart review was performed of 61 patients who were treated for OMM from 1998 through 2005. The clinical features and treatment modalities were identified and correlated with the outcomes. RESULTS: There were 41 male and 20 female patients (ratio, 2.1:1) with a mean age of 54.1 years. The mean follow-up was 31.9 months, and the overall 2-year and 5-year survival rates were 51.1% and 30.3%, respectively. According to the seventh edition of the American Joint Committee on Cancer staging system, there were 31 patients (50.8%) with stage III tumors. A more advanced stage and a tumor of at least 2 cm were associated with worse survival (P < .001 and P = .036, respectively). Elective lymph node dissection and biochemotherapy were not associated with a higher total survival rate (P = .53 and P = .76, respectively). CONCLUSIONS: OMM has a male predilection. The seventh edition of the American Joint Committee on Cancer stage and tumor size are effective prognostic parameters for patients with OMM. The American Joint Committee on Cancer staging system provides useful information for predicting the ultimate outcome and should be used as the primary staging system. Elective node dissection and adjuvant biochemotherapy offer no additional advantage in increasing the patient survival rate. A wait-and-see policy is advocated for patients with clinical stage N0 cancer.