The panoramic dental radiograph for emergency physicians.

Dental emergencies are common reasons for presenting to hospital emergency departments. Here, we discuss the panoramic radiograph (orthopantomogram (OPG, OPT) as a diagnostic tool for the assessment of mandibular trauma and odontogenic infections. In this article, we review the radiographic principles of image acquisition, and how to conduct a systematic interpretation of represented maxillofacial anatomy. The aim is to equip the emergency physician with the skills to use the OPG radiograph when available, and to rapidly assess the image to expedite patient management. Included is a discussion of a number of cases seen in the emergency setting and some common errors in diagnosis.

[Therapeutic prescription of antibiotics and NSAID's by dentists in the Netherlands]. / Therapeutisch voorschrijven van antibiotica en NSAID's door tandartsen in Nederland.

Late in 2015 the Royal Dutch Dental Association (KNMT) conducted a study of the therapeutic prescription of antibiotics and NSAIDs by dentists in general practice in the Netherlands and the factors influencing their decisions. Of the 1,087 dentists contacted 367 (34%) completed the online questionnaire. In the 4 weeks preceding the study they had prescribed an antibiotic to 1.3% of their patients on average. A fifth (20%) found it difficult to decide whether an anti-inflammatory drug is indicated and/or whether this should be an antibiotic or a NSAID. Questioned about medication decisions (whether or not antibiotics are indicated) in 11 fictional cases, 11% of respondents judged every case correctly. 39% undertreated, 24% overtreated and 26% both undertreated and overtreated. In the last two categories, dentists with non-Dutch degrees are overrepresented. More than half (55%) of the respondents say they need a guideline for prescribing antibiotics in dental treatment and 28% (also) need postgraduate education on this matter.

A systematic review of dental disease management in cancer patients.

INTRODUCTION: This systematic review aims to update on the prevalence of odontogenic-related infections and the efficacy of dental strategies in preventing dental-related complications in cancer patients since the 2010 systematic review. REVIEW METHOD: A literature search was conducted in the databases MEDLINE/PubMed and EMBASE for articles published between 1 January 2009 and 30 June 2016. Each study was assessed by 2 reviewers and the body of evidence for each intervention was assigned an evidence level. RESULTS: After examination of the abstracts and full-text articles, 59 articles satisfied the inclusion criteria. The weighted prevalence of dental infections and pericoronitis during cancer therapy was 5.4 and 5.3%, respectively. The frequency of dental-related infections during intensive chemotherapy after complete, partial, and minimal pre-cancer dental evaluation/treatment protocols ranged from 0 to 4%. Protocols involving third molars extractions had the highest complications (40%). CONCLUSIONS: In view of the low prevalence of infections and the potential for complications after third molar extractions, it is suggested that partial dental evaluation/treatment protocols prior to intensive chemotherapy; whereby minor caries (within dentin), asymptomatic third molars or asymptomatic teeth without excessive probing depth (<8 mm), mobility (mobility I or II) or with periapical lesions of <5 mm were observed; is a viable option when there is insufficient time for complete dental evaluation/treatment protocols. The use of chlorhexidine, fluoride mouth rinses as well as composite resin, resin-modified glass ionomer cement (GIC), and amalgam restorations over conventional GIC in post head and neck radiation patients who are compliant fluoride users is recommended.

Determination and identification of antibiotic-resistant oral streptococci isolated from active dental infections in adults.

OBJECTIVE: To determine and identify antibiotic-resistant bacteria (ARB) of oral streptococci from active dental infections in adults and its association with age and gender. MATERIAL AND METHODS: This cross-sectional study included 59 subjects from 18 to 62 years old. Ninety-eighth samples obtained from the subjects were cultivated in agar plates containing antibiotics amoxicillin/clavulanic acid (A-CA), clindamycin, and moxifloxacin (concentrations of 16, 32 or 64 µg/ml). PCR assay was performed to identify bacterial species. RESULTS: The bacterial species that showed more antibiotic-resistance (AR) was S. mutans (45.9%), followed by S. gordonii (21.6%), S. oralis (17.6%), S. sanguinis (9.5%), S. salivarius (5.4%) and S. sobrinus (0%). Moreover, clindamycin (59.4%) showed the highest frequency of AR. Moxifloxacin and A-CA showed an susceptibility >99.1%, while clindamycin showed the lowest efficacy (93.3%); there was a significant statistically difference (p < .01). The age group between 26 and 50 years old (32.2%) and females (28.8%) showed more multiresistance. Clindamycin showed a statistical difference (p < .05) when comparing groups by gender. CONCLUSIONS: Clindamycin was the antibiotic with the highest frequency of ARB and lower bactericidal effect. Moxifloxacin and A-CA showed the highest efficacy and the lowest ARB frequency. Streptococcus mutans was the bacterial specie that showed an increased frequency of AR.

The Neutrophil-to-Lymphocyte ratio as a marker of recovery status in patients with severe dental infection.

BACKGROUND: The aim of the study was to assess the value of pretreatment neutrophil/lymphocyte (N/L) ratio and mean platelet volume (MPV) and the correlation between these markers with progression in patients with severe odontogenic infection. MATERIAL AND METHODS: A cohort of 100 patients with severe odontogenic infection were divided into 2 groups according to their length of hospital stay. The N/L ratio and MPV was measured in all patients. The correlation in all patients between preoperative fever, preoperative antibiotic doses, postoperative antibiotic doses, total antibiotic doses and hospital stay with N/L ratio and MPV were analyzed. The Youden index was used to identify the optimal cut-off value. RESULTS: There were positive and statistically significant correlations between N/L ratio and prolonged hospital stay and postoperative antibiotic doses and total antibiotic doses. The optimum cut -off level of N/L ratio was 5.19 according to ROC analysis. However, there was no correlation between MPV and any of these parameters. CONCLUSIONS: N/L ratio may be used as a prognostic marker for patients with odontogenic infections. These patients may need a higher dose of antibiotics and stay more than 1 day in hospital for the treatment of odontogenic infection when the N/L ratio is detected to be more than 5.19.

Cardiac Tamponade Due to Actinomyces odontolyticus Originating From a Dentigerous Cyst.

This report describes a rare case of pericardial effusion owing to Actinomyces odontolyticus in a 52-year-old woman that originated from a dentigerous cyst, which developed on the distal aspect of a lower left third molar. The cyst had remained asymptomatic for a long period, with no specific functional complications. This is the first case report of a patient with acute pericarditis in which the same strain of A odontolyticus was detected in an asymptomatic dentigerous cyst and in the pericardial fluid.

In vivo prediction of tuberculosis-associated cavity formation in rabbits.

The presence of cavitary lesions in patients with tuberculosis poses a significant clinical concern due to the risk of infectivity and the risk of antibiotic treatment failure. We describe 2 algorithms that use noninvasive positron emission tomography (PET) and computed tomography (CT) to predict the development of cavitary lesions in rabbits. Analysis of the PET region of interest predicted cavitary disease with 100% sensitivity and 76% specificity, and analysis of the CT region of interest predicted cavitary disease with 83.3% sensitivity and 76.9% specificity. Our results show that restricting our analysis to regions with high [(18)F]-fluorodeoxyglucose uptake provided the best combination of sensitivity and specificity.

Detecting Gram-positive anaerobic cocci directly from the clinical samples by multiplex polymerase chain reaction in odontogenic infections.

PURPOSE: Gram-positive anaerobic cocci (GPAC) can be isolated as pathogens from odontogenic infections. Culturing GPAC is time consuming and labor intensive. The objectives of the present study were to examine the utility of polymerase chain reaction (PCR) in directly detecting the presence of GPAC in clinical samples obtained from patients with odontogenic infections and to compare the distribution of GPAC in infected and healthy tissue. MATERIALS AND METHODS: In the present case-control study, the infected tissue from patients and oral mucosal swabs from healthy control subjects were subjected to anaerobic culture and direct PCR analysis for the presence of GPAC. The McNemar, chi-square, and Fisher exact tests and kappa analysis were used for the statistical analyses. P < .05 was regarded as significant. RESULTS: The patient group included 13 men and 14 women, including 9 patients diagnosed with granulation of tooth extraction, 6 with impacted tooth follicles, 4 with peri-implantitis, 3 with abscesses, 2 with epithelial cysts, 2 with infected cysts, and 1 with an oroantral fistula. The control group included 14 men and 12 women. All the patient and control samples contained at least 1 GPAC. The groups did not differ by method of determining GPAC presence, but more microorganisms were detected when clinical samples were directly used for PCR analysis than when cultured bacteria were used (P = .001). CONCLUSIONS: The presence of GPAC in infected tissue cannot be directly related to the development of odontogenic infections. PCR performed directly on clinical material is a sensitive and specific method that can detect GPAC and save time.

Effect of Causative Tooth Extraction on Clinical and Biological Parameters of Odontogenic Infection: A Prospective Clinical Trial.

PURPOSE: To prospectively compare changes of body temperature, white blood cell count, fibrinogen, and C-reactive protein between odontogenic infections in which the responsible tooth was removed and odontogenic infections in which the treatment included no extraction. MATERIALS AND METHODS: The sample was composed of patients admitted to the authors' maxillofacial unit for odontogenic infection from 2010 through 2013. One hundred seventy-nine patients were categorized into an extraction or a non-extraction group based on whether the causative tooth was non-restorable or restorable, respectively. Non-restorable teeth were extracted at admission of the patient. Otherwise, the treatment protocol, including incision of the involved space in conjunction with intravenous antibiotics, was the same for the 2 groups. The parameters were measured and recorded at admission and 2 days later. Data records were statistically analyzed by comparing the change of the parameters studied between the extraction and non-extraction groups. P values less than .05 were regarded as statistically significant. RESULTS: One hundred seventy-nine patients fulfilled the inclusion criteria and were enrolled in the study. The mean age of the patients was 39.1 years (minimum, 14 yr; maximum, 81 yr; standard deviation, 15.4 yr). One hundred nine patients (60.9%) were male, and 70 (39.1%) were female. Differences in the mean decrease of axillary temperature, white blood cell count, fibrinogven, and C-reactive protein between the 2 groups were 0.178, 2,300, 1.01, and 0.64, respectively. All these differences were statistically significant (P =.02, .001, .001, and .001, respectively). Also, the mean hospital stay in the extraction group was 1.05 days shorter than in the non-extraction group, with the difference being statistically significant (P = .006). CONCLUSIONS: In odontogenic maxillofacial infections, extraction of the causative tooth is associated with a faster clinical and biological resolution of the infection.

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.

Orbital Cellulitis of Odontogenic Origin.

Odontogenic orbital cellulitis, although uncommon, has the potential to cause severe vision loss if unsuspected and untreated. Compared to non-odontogenic bacteriology, odontogenic orbital abscesses typically feature a heavy mixed growth with anaerobic organisms. We review the literature and discuss the case of a 26-year-old male who presented with anaerobic orbital cellulitis for treatment.

Deep Neck infections of Odontogenic Origin and Their Clinical Significance. A Retrospective Study from Hradec Králové, Czech Republic.

INTRODUCTION: Cellulitis remains a very serious disease even today. Mortality, which varied between 10-40%, has been reduced owing to the standard securing of airway patency and use of an appropriate surgical treatment approach. MATERIALS AND METHODS: A total of 195 patients were hospitalised for cellulitis at the University Hospital in Hradec Králové during 2007-2011. The following parameters were evaluated: age, gender, dependence of incidence of the disease on the season of the year, frequency of attacks of the particular areas and their clinical characteristics, aetiology of the inflammation, types of patient complaints, prevalence of current systemic diseases, results of microbiological and selected laboratory analyses, socio-economic status of the patients, and duration of patient stay at the hospital. Statistical analysis was performed by using Pearson's correlation coefficient, the statistical significance level was p < 0.05. RESULTS: The mean age of the patients was 39.8 years. The group of 195 patients included 108 (55%) males and 87 (45%) females. The mean time between the first symptoms of the disease and admission to the Department was 5 days. From among the 195 patients, 116 (59.5%) were working persons, 79 (40.5%) were non-working (children, students, unemployed persons, women on maternity leave, retired people). The odontogenic origin of the disease was verified in 173 (88.7%) patients. In total, 65 (33.3%) patients had no coinciding complicating systemic disease, 22 (11.3%) patients had diabetes mellitus. The most frequent symptom of cellulitis was painful swelling, found in 194 (99.5%) patients, followed by jaw contracture, found in 153 (78.5%) patients. CONCLUSION: The results are largely very similar to those of previous studies performed in other countries, except that we found no correlation between the prevalence of cellulitis and the socio-economic status, nor have we confirmed Klebsiella pneumoniae sp. as the cause of cellulitis in patients with diabetes mellitus.

Odontogenic Infections: A 1-year Retrospective Study.

OBJECTIVES: The purpose of this study was to analyze the prevalence, demographic patterns and management of odontogenic infections in patients undergoing treatment in an outpatient dental emergency service of a university hospital. MATERIALS AND METHODS: In a retrospective study of the year 2012, all patients suffering from odontogenic infections were included. Demographic data, diagnosis and the conducted treatment were analyzed. Odontogenic infections were defined as pulpitis, apical and marginal periodontitis, abscesses and pericoronitis. RESULTS: A total of 2,058 out of 4,209 emergency patients suffered from odontogenic infections. The majority (45.0%) had an apical periodontitis, 20.8% abscesses, 17.3% a marginal periodontitis, 16.3% a pulpitis and 5.8% a pericoronitis. Mean age was 37.5 ± 17.0 years standard deviation (SD) (1.2-96.4). Most patients were 20 to 29 years (24.6%), followed by the age group of 30 to 39 year old patients (21.0%). Males were affected more frequently (55.5%) than females (45.5%). Most of the patients (64.5%) of the patients received a dental or surgical treatment. Antibiotics were prescribed in 31.7% of cases. Amoxicillin was the most common prescribed antibiotic (54.5%). CONCLUSION: Odontogenic infections represent one of the main reasons for consulting the emergency service. Due to the high number of cases and the severe complications, dentists have to be familiar with the surgical management of odontogenic infections as well as the appropriate use of antibiotics. CLINICAL SIGNIFICANCE: Nearly half of all patients who sought, treatment in the emergency service had an odontogenic infectious disease. This should be considered for the organization and planning of the service.

Radiography-based score indicative for the pathogenicity of bacteria in odontogenic infections.

OBJECTIVE: To develop a new radiography-based score to assess the potential of bacteria to cause odontogenic infections derived from the occurrence of bacteria at small or large radiographical lesions. MATERIALS AND METHODS: The patients analyzed were a sub-population from a large randomized clinical trial comparing moxifloxacin and clindamycin in the treatment of inflammatory infiltrates and odontogenic abscesses. Routine radiographs were used to analyze the area of the periapical radiolucent lesions. Lesions were stratified by their radiographically measured area as large (>9 mm(2)) or small (≤9 mm(2)). A risk ratio was calculated for each species from the frequency of their occurrence in large vs in small lesions. RESULTS: Fifty-one patients, 19 with abscesses and 32 with infiltrates, were evaluated. Overall, the radiographical lesion areas ranged from 0.4-46.2 mm(2) (median = 9 mm(2)). An increased risk (risk ratio >1) to occur at large abscess lesions was observed for Prevotella (P.) oralis, P. buccae, P. oris, P. intermedia, Fusobacterium nucleatum and Streptococcus (Strep.) anginosus group. An increased risk to occur at large infiltrate lesions was found for Strep. salivarius, Strep. parasanguis, Strep. anginosus group, Capnocytophaga spp., Neisseria (N.) sicca, Neisseria spp., Staphylococcus (Staph.) aureus, P. intermedia, P. buccae, Prevotella spp. and P. melaninogenica. CONCLUSIONS: The radiography-based score suggests that certain Prevotella spp., F. nucleatum and Strep. anginosus groups play a crucial role in the pathogenesis of odontogenic abscesses, and that various streptococci, Neisseria spp., Capnocytophaga spp., Staph. aureus and Prevotella spp. are involved in the pathogenesis of odontogenic infiltrates.

Oral osteosarcoma: a case report and analysis of previously reported cases.

Osteosarcoma is the most common malignancy of mesenchymal cells after hematopoietic neoplasms. Most originate within bones, but the occurrence of this malignancy in the jaw bones is rare. There is controversy about the characteristics of this tumor in the literature. The aim of this paper was to collect the previous reported data and provide a statistical analysis of them. Additionally, we have reported a case of mandibular osteosarcoma.

Microbial flora in oral diseases.

The oral cavity being the hub of gamut of microbes, promotes the establishment of distinct microbial communities, such as on the mucosa and teeth. Metabolism of these organisms facilitates the attachment and growth of the subsequent colonisers. A delicate balance is maintained in the microbial ecosystem, with these organisms contributing to normal development and defences. However, any change or disruption in the microbial profile due to either intrinsic or extrinsic factors can result in an unfavorable shift toward pathogenic organisms triggering various diseases like dental caries or periodontitis. Furthermore, recent findings also state that these microorganisms may lead to systemic diseases like diabetes or atherosclerosis. This article is an attempt to give an overview of the altered flora in diseased states.

[Complex dental care in children and adolescents with chronic gastroduodenitis].

The parts of pathogenesis gastrointestinal diseases form relationship with changes in oral cavity. High microbial density bacterial community, consisting of conditionally-pathogenic type and occupying oral mucosa and other parts to oral cavity permits the quick development of the different forms of the pathological processes in oral cavity. The Concept preventive and medical action, conducted in oral cavity of children with chronic gastrodyodenitis, includes: undertaking the diagnostics of the change of microbiocenosis, estimations of the factors of local homeostasis with determination degree of the changes of disbiosis, the individual planning and strictly realization pathogenesis motivated complex action on treatment and preventive maintenance, observation with recommended frequency, including all mentioned elements. One of the significant problems solved by dentist and physician is a shaping among children and teenager with chronic gastritis and gastrodyodenitis, as well as their parents, installation on sound lifestyle. The Advisable frequency observations by dentist this children: in 1 year of the disease: 1 once at 3 months (4 times per annum); in 2 year of the disease: - not less 3 once a year; in 3 and the following years: not less 2 once a year.

Microflora in maxillofacial infections--a changing scenario?

PURPOSE: Advances in isolation and culturing techniques have brought the role of anaerobic bacteria-causing maxillofacial infections to the fore. Recent literature also favors the role of anaerobes in maxillofacial infections. A prospective clinical and microbiological study was designed to check the validity of such claims. PATIENTS AND METHODS: This study included 88 patients who fulfilled the inclusion criteria. Pus was obtained by aspirating the involved spaces and culture and sensitivity tests were performed to determine the microbes involved and their sensitivity to various antibiotics. RESULTS: Upon isolating the various organisms causing infection, it was found that 68.2% were aerobes, 13.6% were mixed infections, and 9.1% were anaerobes. Streptococcus and Peptostreptococcus species were the most common among aerobes and anaerobes, respectively. On determining sensitivity to penicillin, 81.3% were sensitive and 18.8% were resistant. Coagulase-negative Staphylococcus and Staphylococcus aureus were predominantly resistant to penicillin. CONCLUSION: Analysis of the results indicated no change in microflora-causing infections in the maxillofacial region and penicillin remains the drug of choice in treating these infections.

Molecular methods for diagnosis of odontogenic infections.

PURPOSE: Historically, the identification of microorganisms has been limited to species that could be cultured in the microbiology laboratory. The purpose of the present study was to apply molecular techniques to identify microorganisms in orofacial odontogenic infections (OIs). MATERIALS AND METHODS: Specimens were obtained from subjects with clinical evidence of OI. To identify the microorganisms involved, 16S rRNA sequencing methods were used on clinical specimens. The name and number of the clones of each species identified and the combinations of species present were recorded for each subject. Descriptive statistics were computed for the study variables. RESULTS: Specimens of pus or wound fluid were obtained from 9 subjects. A mean of 7.4 ± 3.7 (standard deviation) species per case were identified. The predominant species detected in the present study that have previously been associated with OIs were Fusobacterium spp, Parvimonas micra, Porphyromonas endodontalis, and Prevotella oris. The predominant species detected in our study that have not been previously associated with OIs were Dialister pneumosintes and Eubacterium brachy. Unculturable phylotypes accounted for 24% of the species identified in our study. All species detected were obligate or facultative anaerobes. Streptococci were not detected. CONCLUSIONS: Molecular methods have enabled us to detect previously cultivated and not-yet-cultivated species in OIs; these methods could change our understanding of the pathogenic flora of orofacial OIs.

Is dental treatment of an infected tooth a risk factor for locally invasive spread of infection?

PURPOSE: To determine the impact of antecedent dental procedures and dental health on the course of odontogenic maxillofacial infections requiring hospital care. PATIENTS AND METHODS: In this retrospective cohort study in a referral center, we evaluated medical records and panoramic radiographs of all patients admitted because of odontogenic maxillofacial infection (n = 84). The predictor variables were preceding dental treatment, antimicrobial therapy, and dental health. The outcome variables comprised infection parameters, length of stay, need for intensive care, and management during hospitalization. RESULTS: The mean age of the patients was 43.2 ± 16.5 years and 60% were men. Dental procedure preceded the spread of the infection in 49 cases (58%): endodontic treatment (n = 22), tooth extraction (n = 19), and minor first aid (n = 8). Twenty-seven patients had not received any dental or antimicrobial treatment in the recent past. Antimicrobial treatment alone had been given to 8 patients. Patients without preceding treatment had the highest C-reactive protein levels on admission and at maximum (P = .020 and P = .011) and the highest white blood cell counts on admission (P = .011). Their length of stay was also longer, and they needed intensive care more often than the other patients. Maximum C-reactive protein levels and white blood cell counts between treatment groups did not significantly differ from each other. CONCLUSIONS: The systemic response to the infection was strongest and the course of the infection most severe in the absence of preceding dental treatment and in patients with poor dental health. All types of dental treatment contributed to a less severe course of infection.