Osteomylelitis and necrosis of the jaw in patients treated with bisphosphonates: a comparative study focused on multiple myeloma.

It was reported that multiple myeloma (MM)-patients suffer from a higher incidence of osteomyelitis and necrosis of the jaws than patients treated with bisphosphonates for other reasons. The aim of this study is to report about 57 cases of bisphosphonate-related osteomyelitis and necrosis of the jaws (BON) and to investigate the differences between BON in MM and non-MM patients. Clinical and laboratory data of 57 cases were assessed. The features of BON and clinical-outcome were compared between the two groups. Treatment approach was assessed as a contributing-factor to treatment-outcome. Clinical presentation included exposed bone, pain, swelling and suppuration with little variation between the two groups. Past dento-alveolar surgery was common in both study-groups. Treatment outcome was poor (33% and 25% responded to treatment in MM group and non-MM group, respectively). Treatment modality did not affect the treatment outcome. The clinical presentation described in this case series should alert the physician to the possibility of BON. Although the literature shows a higher incidence of BON in MM patients compared to non-MM patients, our study suggests that the severity of the clinical presentation and the response to treatment are not worse in MM patients compared with non-MM patients. The predisposition of MM patients to BON should be further investigated.

[The use of conscious sedation versus general anesthesia in modern dentistry: rising ethical dilemmas].

Conscious sedation and general anesthesia have been in the use of the dental profession since the first half of the 19th century. Although seemingly appealing to use due to alleviation of pain and anxiety induced by the dental treatment, the alteration of consciousness level of dental patients is not without risk. Morbidity and mortality due to dental treatment performed under general anesthesia were investigated at the last decades of the 20th century. The mortality rates found in these investigations were surprisingly high comparing to researches of morbidity and mortality due to other medical procedures, performed under general anesthesia. Therefore, although general anesthesia is sometimes the only way to treat certain patients, maintaining strict indications for dental treatment under general anesthesia is necessary. Conscious sedation was found as a safer alternative for achieving a level of consciousness enabling dental treatment in those patients who are unable to receive treatment in normal dental clinic settings. We therefore believe that conscious sedation should be the golden standard for the treatment of those patients. The practicing of dentistry in patients who have need of dental treatment under special settings such as general anesthesia and sedation raises ethical dilemmas to the caregiver. The following review will summarize the available data on morbidity and mortality due to dental treatment given under general anesthesia and conscious sedation. The ethical questions arising from their practicing will be discussed and some answers shall be proposed.

Delayed breast cellulitis following breast conserving operation.

A complication of breast conservation, which has been increasingly reported in the literature, is 'delayed cellulitis' in the treated breast. This is to be distinguished from wound infection in the breast following lumpectomy. This study reports 16 cases diagnosed with delayed cellulitis following breast conserving surgery, unresponsive to antibiotic therapy. Diagnostic criteria included: pain, erythema and edema in the operated breast. Symptoms appeared up to 10 months after surgery and time to resolution was seven and a half months. No patients had positive cytology and bacteriology tests were negative. Thirteen patients were observed, and three patients were treated with antibiotics with no apparent immediate effect. The appearance of breast cellulitis after surgery poses a problematic diagnostic and management dilemma. It is important to distinguish between this entity and infection, or inflammatory carcinoma. The picture may be attributed to impairment or occlusion of the lymphatic circulation in the breast. This seems to be a newly defined complication with an incidence of 3-5%.