The role of hyperbaric oxygen in osteoradionecrosis-a prophylactic insight.

BACKGROUND: Osteoradionecrosis (ORN) is an uncommon and debilitating consequence of head and neck radiotherapy and hyperbaric oxygen therapy (HBOT) has been advocated for prophylaxis prior to performing dentoalveolar procedures. The aim of this study was to evaluate a prophylactic HBOT protocol and describe the outcomes of susceptible individuals. METHODS: A retrospective audit of adults who attended the Oral and Maxillofacial Surgery department at the Royal Adelaide Hospital (South Australia) who received dental extractions with a history of radiotherapy to the jaws from 2008 to 2020. Data including demographic information and outcomes of osteoradionecrosis and delayed healing was recorded. RESULTS: A total of 121 individuals were eligible for case note review; 68.6% of individuals were male and 55.4% were aged over 67 years. Osteoradionecrosis occurred in 9.1% of individuals and delayed healing for 3.3%; fifteen individuals (12.4%) were unable to complete the HBOT protocol. The individuals who were diagnosed with ORN had a significant association with age (P = 0.006) and binary analysis showed alcohol consumption to be a significant predictor. CONCLUSIONS: Prophylactic HBOT protocol had a lower proportion of individuals diagnosed with ORN and those who were diagnosed were more likely to be younger males and have current alcohol consumption.

An Anaesthesiology and Emergency Medicine Multidisciplinary Simulation-Based Bootcamp

Aim The fundamental concept of multidisciplinary education is a shared mental model that leads to better interdependent collaboration. The aim of this bootcamp was to create a sustainable induction curriculum for Anaesthesiology and Emergency Medicine trainees and nurses through training in a simulated multidisciplinary environment. Methods The two-day bootcamp consisted of lectures, equipment demonstration, workshops, and high-fidelity simulated scenarios. A pre- and post-course MCQ test was used for assessment of knowledge acquisition. Pre and post confidence scores were used to evaluate procedural skill confidence level. A 5-point Likert scale was used to evaluate qualitative feedback from participants. Results Seven anaesthesiology trainees, two anaesthetic nurses, six emergency medicine trainees and three emergency medicine nurses were enrolled. There was a statistically significant increase (p-value<0.01) in post-MCQ scores, portraying significant knowledge acquisition. The total procedural confidence scores increased from 375 (±9.15) to 550 (±8.43), (p < 0.01). All participants agreed that the stated educational objectives were met and relevant to their clinical practice, and strongly commended team training exercises. Conclusion Multidisciplinary simulation-based training improves team performance as well as transfer of knowledge across two or more disciplines. Overlapped training between Anaesthesiology and Emergency Medicine created an opportunity for sharing of educational resources in the current time-based speciality training system.

Medication-related osteonecrosis of the jaws: a single centre, Far North Queensland case series.

Medication-related osteonecrosis of the jaws (MRONJ) is a painful debilitating condition which is considered rare in the medical literature available to prescribers. Dentists, however, are likely to trigger this condition through extractions and implants. Anecdotally MRONJ appears more common than first thought. This paper presents 13 cases of MRONJ diagnosed and treated by a single oral and maxillofacial surgeon based in Cairns, Far North Queensland, in a 2-year period. The management of these cases is presented. The two cases where MRONJ resulted in the loss of dental implants are highlighted. © 2022 Australian Dental Association.

A Modified Technique of Temporomandibular Joint Arthroscopic Operative Surgery of the Superior and Inferior Joint Spaces.

PURPOSE: This paper describes in detail the first author's technique of performing arthroscopic surgery in both the superior and inferior joint spaces of the temporomandibular joint. METHODS: The key is careful measurement of sagittal and coronal tomograms to determine the individual size and shape of the joint. The joint is then distracted to allow 3-port video arthroscopy. RESULTS: The detailed steps in the procedure are described and illustrated. CONCLUSION: This modified technique is safe and allows procedures in both joint spaces and surgical access to the fossa, condyle and disc.

Cryoneurotomy in the management of intractable trigeminal neuralgia.

In this paper we describe the effects of peripheral cryoneurotomy on a consecutive series of patients with intractable trigeminal neuralgia (TN) who had been treated by a single surgeon over a ten-year period. The results of 55 patients who underwent a total of 102 cryoneurotomies were documented. The age at first cryofreeze was 64 (30-92) years with 24 males and 31 females. Thirty-five had primary TN and 20 secondary TN. The first cryofreeze resulted in 28.2 (5-144) pain free months. Twenty-nine had a second freeze which lasted 34 (2-100) pain-free months and 13 had a third cryofreeze which lasted 26 (1-108) pain free months. Two patients had further freezes. Thirty-four of the primary TN patients had prolonged freedom from pain with one dying perioperatively. The 20 patients with secondary TN had shorter period of pain relief (p<0.05) and one committed suicide. The procedure of peripheral cryoneurotomy is recommended for older, unwell patients with primary TN that is refractory to medical or neurosurgical treatments. It is less effective for dysaesthesia secondary to traumatic nerve injuries.

The financial burden of acute odontogenic infections: the South Australian experience.

BACKGROUND: Acute odontogenic infections are a common surgical emergency managed by public hospitals in Australia which cause considerable patient morbidity and occasionally, mortality. Despite posing a significant public health burden, Australian data evaluating the cost of the management of these patients are lacking. This study assessed the patient and treatment variables associated with inpatient management of deep odontogenic infections, and their respective financial impact, at a statewide Oral & Maxillofacial service. METHODS: A retrospective audit was carried out of patients with deep odontogenic infections at our institution, over a 7-year period. The primary outcome was the total cost of admission. Secondary outcomes included treatment received, operating room time, return-to-theatre, length of admission (LOS), and intensive care unit (ICU) use. Cost variables were assessed against the total LOS and ICU use to determine clinical predictors affecting outcome. RESULTS: Four hundred and sixty two patients met the inclusion criteria. The average cost per patient was $12 228 Australian Dollars. After multivariate analysis, variables most significantly associated with increased cost of care and LOS were high-risk infections with airway compromise, high admission white cell count and age. CONCLUSION: Hospital-based management of deep-space odontogenic infections engender significant costs compared to early primary care intervention such as a dental extraction ($181/extraction).

Physical Function and Strength in Relation to Inflammation in Older Adults with Obesity and Increased Cardiometabolic Risk.

BACKGROUND: Inflammation is implicated in functional decline and the development of disability in aging. This study aimed to investigate the association of inflammation with physical function and muscle strength in older adults with obesity and increased cardiometabolic risk. DESIGN: In baseline assessments from the CROSSROADS randomized controlled trial, serum interleukin-6 (IL-6), tumor necrosis factor-α (TNFα) and C-reactive protein (hs-CRP) were assayed in 163 older adults (37% males, 24% African American, BMI 34±3, age 70±5yrs) with hypertension, dyslipidemia and/or diabetes. Physical function was assessed by six-minute walk test (6MWT), chair sit-and-reach (CSR), hand-grip and knee-extension strength; specific-strength as muscle strength/mass ratio. Analyses included ANCOVA and multiple linear regression adjusted for thigh skeletal muscle (MRI), arm lean mass (DXA) and moderate-to-vigorous intensity physical activity (MVPA; accelerometry). RESULTS: Higher hs-CRP (p<0.01) and IL-6 (p=0.07) were associated with lower 6MWT and CSR, respectively. A composite inflammation score combining all 3 inflammatory markers showed the strongest inverse association with 6MWT (p<0.01). MVPA moderated associations such that amongst participants who engaged in low MVPA, 6MWT distances and CSR scores were significantly lower in those with high IL-6 and TNFα (p<0.05), respectively. In participants with high MVPA, higher hs-CRP (p<0.05) and TNFα (p=0.07) were associated with poorer upper-extremity specific-strength. CONCLUSIONS: Chronic inflammation was associated with poorer physical function and specific strength in older adults with obesity and increased cardiometabolic risk. This association was strongest in participants with multiple elevated inflammatory markers. Physical activity levels below current recommendations mitigated the deleterious effects of inflammation on lower body mobility, underscoring the benefits of exercise for preserving physical function with age.

Mandibular advancement splints for obstructive sleep apnoea - a cautionary tale.

BACKGROUND: Obstructive sleep apnoea is a serious medical condition of increasing prevalence that has a multitude of treatment modalities. The aim of this study was to review the results of patients treated with mandibular advancement splints in the Oral and Maxillofacial Surgery Unit of South Australia to inform ongoing practice in this area. METHODS: The casenotes of patients who received a splint for obstructive sleep apnoea between January 2008 and June 2014 were audited. Data collection included referral and demographic details, sleep study results, splint type and follow-up details. RESULTS: Three hundred and four patients were identified as having been provided a mandibular advancement splint for obstructive sleep apnoea, of which 82 had diagnostic and splint-in-situ sleep studies available for comparison. It was observed that 27 had clinically significant objective improvement, 40 had no clinically significant change and 15 had clinically worse OSA following MAS therapy. Mean reductions in Apnoea-Hypopnoea Index and Respiratory Disturbance Index were eight events (27%) and 13 events (33%) per hour respectively with treatment. CONCLUSIONS: Based on this study, mandibular advancement splint therapy is a viable treatment for a subset of patients with obstructive sleep apnoea. Protocol driven, multi-disciplinary care with auditing of results is recommended.

A retrospective clinical and microbial analysis of 32 patients with bilomas.

BACKGROUND: Bilomas are defined collections of bile fluids mainly caused by iatrogenic injuries of the bile duct system. Owing to the infrequency of this disease, studies addressing bilomas are rare. METHODS: By using an endoscopic database, this retrospective study identified 32 patients with bilomas treated between 2004 to 2015, in order to analyse aetiology, clinical presentation, spectrum of pathogens, and resolution rate of bilomas. RESULTS: 65.6% of the study population (21/32) developed bilomas after surgery and 21.9% (7/32) after endoscopic retrograde cholangiography (ERC). Icterus, fever, and abdominal pain were the leading symptoms. 93.9% (46/49) of microbiological bile cultures revealed a positive microbiology. The predominant microorganisms were the group of Enterobacteriaceae (43.0%, 52/121), followed by Enterococcus spp. (32.2%, 39/121), and Candida spp. (9.1%, 11/121). Multiresistant bacteria like Enterobacteriaceae were isolated from one quarter of all patients. Single or multimodal treatment resulted in an overall complication rate of 4.8% (9/188). Clinical follow-up analysis showed a complete resolution rate of 78.3% for interventional therapy and 80% in the non-interventional group. CONCLUSIONS: Pathogen spectrum of bilomas mainly comprises the group of Enterobacteriacae and Enterococcus spp., with a high proportion of multiresistant bacteria. Different interventional approaches are available for biloma drainage, which seem to be safe and effective for most patients. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015208 , retrospectively registered.

Effect of peripheral cryoneurotomy and nerve transection on the trigeminal ganglion in rats.

In this experimental study, we did peripheral neurectomyand peripheral cryoneurotomy of the mental nerve in rats and histologically assessed their effects on the trigeminal ganglion at timed intervals for six months. There were marked irreversible changes in the neurectomy group whereas the cryoneurotomy group made a full recovery. These results help to explain the differing effects of these procedures on trigeminal neuralgia.

The healing of dental extraction sockets in insulin-dependent diabetic patients: a prospective controlled observational study.

BACKGROUND: The aim of this study was to determine whether there was a difference in delayed healing following dental extractions for insulin-dependent diabetics as compared to non-diabetic patients. METHODS: Prospective patients referred to the Adelaide Dental Hospital exodontia clinic for dental extractions were recruited into two groups: Known insulin-dependent diabetics and healthy non-diabetics. All had a random blood glucose level (BGL). Delayed healing cases were identified, and statistical evaluation was performed. RESULTS: There were 56 insulin-dependent diabetic patients (BGL 10.03, range 4.9-26) and 49 non-diabetic, age- and sex-matched patients. Seven patients (12.5%) in the study group showed delayed healing following extraction, while only four patients (8.2%) in the control group suffered delayed healing. This difference was not statistically significant. Two of the study group developed postextraction infections, requiring incision, drainage and antibiotics. CONCLUSION: The study shows that Type 1 and insulin-dependent Type 2 diabetic patients, if well controlled, tend to heal up well following dental extractions but with a small but not statistically different rate of postextraction complications including infection. This is contrary to what is usually taught. Clinicians should take great care with management of insulin-dependent diabetic patients, as compared to non-insulin dependent diabetics or non-diabetic patients.

Arthrocentesis in the management of internal derangement of the temporomandibular joint.

BACKGROUND: Temporomandibular disorders (TMD) cover a wide spectrum of disorder; myalgic, arthralgic and psychogenic. The procedure of TMJ arthrocentesis has a role in managing patients with arthralgic pain and limitation if they fail to respond to non-surgical therapy. METHOD: The patient records of a single private specialist OMS were searched over the 9-year period of 2006-2014 to identify patients who had arthrocentesis as part of their multidisciplinary management. The detailed demographic, diagnosis, pre and post arthrocentesis procedure were identified and put on a database. Appropriate statistics were performed. RESULTS: Seventy-six patients had 115 arthrocentesis procedures performed in the study period. Fifty of 76 had improvement in their pain and 16 of 41 had an increased jaw opening of more than 10 mm. There were no complications or morbidity. Analysis of patient variables generally showed no correlations. CONCLUSIONS: Temporomandibular joint arthrocentesis has a role in the multidisciplinary, multimodality treatment of arthralgic TMD.

New species of Amanita subgen. Lepidella from Guyana.

New species of Amanita subgen. Lepidella are described from Guyana. Amanita cyanochlorinosma sp. nov., Amanita fulvoalba sp. nov., and Amanita guyanensis sp. nov. represent the latest additions to the growing body of newly described ectomycorrhizal fungi native to Dicymbe-dominated tropical rainforests. Macro- and micromorphological characters, habitat, and DNA sequence data for the ITS, nrLSU, rpb2, and ef1-α are provided for each taxon, and ß-tubulin for most. Distinctive morphological features warrant the recognition of the three new species and a molecular phylogenetic analysis of taxa across Amanita subgen. Lepidella corroborates their infrageneric placements.

Contemporary exodontia.

Exodontia is a cardinal skill of all dentists. Patients expect extractions to be skillfully and painlessly accomplished every time. It's not necessarily so simple and can be challenging. In this paper we explore contemporary issues of the full process of exodontia including diagnosis, technique, complication minimization as well as management of medically compromised patients with appropriate post-operative care, including pharmacotherapy.

The teaching of oral & maxillofacial surgery to dental students in Australia & New Zealand.

The teaching of OMS to dental students in Australia & New Zealand was surveyed. Generally the established schools had well developed curricula with good didactic and clinical experience conducted by specialist OMS educators. There was a much greater array of teaching in some of the newer schools with some appearing to barely meet the current minimalist professional competencies of the ADC. The critical element was whether or not the school was associated with a speciality OMS Unit at a Teaching Hospital. Proposals addressing these deficiencies are presented.

Extractions to reconstruction: The Development of Oral & Maxillofacial Surgery in Australian and New Zealand.

Oral and Maxillofacial Surgery developed initially from Dentistry as exodontia. It then expanded into the surgical management of jaw disorders. As the specialty evolved, it came into increasing conflict with related surgical disciplines. In the 1960s and 1970s these external criticisms were well-founded as training in oral surgery was individual, solely University-based and highly variable. In the 1980s the speciality developed a plan which involved hospital-based surgical training, a mandatory high level college surgical examination and detailed workforce and training studies. These were progressively implemented over the next twenty years with a dual degree (medicine and dentistry) and a final fellowship (FRACDS (OMS)). This resulted in accreditation by the Australian Medical Council and the Australian Dental Council and recognition as a Principal Surgical Speciality by the Commonwealth Department of Health. This development was monitored by published workforce studies over three decades that are important yardsticks to inform the credentialing of dental specialists.

Antibiotic resistance in severe odontogenic infections of the South Australian population: a 9-year retrospective audit.

BACKGROUND: The aims of this study were to evaluate the microbiological trends in severe odontogenic infections requiring hospital admission in the South Australian Oral and Maxillofacial Surgery Unit. Rates of antibiotic resistance to empirical antibiotic regimens were determined to quantify the clinical implications of antibiotic-resistant odontogenic infections. METHODS: A retrospective case audit was performed on all odontogenic infections admitted to the Royal Adelaide Hospital over a 9-year period. Data was collected regarding demographics, microbiological culture and sensitivity results, and clinical outcome variables. RESULTS: Of a total of 672 patients, microbiology data was available for 447 cases. Penicillin-resistant organisms were identified in 10.8% of patients, who required a significantly longer length of hospital admission (mean, 9.93 days) and higher rates of non-response to initial surgical therapy (40%). CONCLUSIONS: There were moderate rates of antibiotic-resistant odontogenic infections within the South Australian population. Patients within this subgroup demonstrate markedly poorer clinical outcomes. Effective treatment of odontogenic infections involves early operative intervention, with adjunctive use of appropriate antibiotic therapy that involves close monitoring of response to removal of the cause and use of first-line antibiotic agents. Cases that fail to respond require urgent specialist review in order to reduce morbidity and mortality outcomes.

Peri-implant squamous cell carcinoma.

Peri-implant squamous cell carcinoma is an uncommon pathological manifestation, whereas peri-implantitis is commonly found in association with dental implants. Both present similarly with loss of supporting soft and hard tissue around dental implants; therefore, a careful differential diagnosis is required. The present case concerns a 62-year-old Japanese man who had a dental implant which had been in the left maxillary incisor region for 4 years who apparently developed peri-implantitis. This did not respond to localized therapy and antibiotics so was referred for specialist surgical management. A biopsy confirmed it to be a squamous cell carcinoma rather than an inflammatory lesion. A literature review shows that this is an unusual presentation without a previous history of malignancy, mucosal disease or risk factors for cancers. Although rare, the possibility of peri-implant squamous cell carcinoma should be borne in mind by all practitioners who monitor implant patients.