Facial cutaneous sinuses of dental origin - a diagnostic challenge.

It is common for practitioners to misdiagnose the cause of facial cutaneous sinus tracts, failing to recognise that many have an odontogenic cause. Chronic infection around the apex of a dental root can drain to the mouth or less commonly to the skin via a sinus tract. Dental symptoms are not always present and this confuses the clinical picture further. Failure to identify an odontogenic cause may result in unnecessary and ineffective treatment. Elimination of dental infection via tooth extraction or root canal treatment leads to resolution of the cutaneous sinus. We present a series of cutaneous draining sinuses of dental origin that resolved rapidly following dental treatment and hope to highlight the importance of including odontogenic infection in the differential diagnosis of such a lesion in the head and neck.

Predicting the choice of anaesthesia for third molar surgery - guideline or the easy-line?

OBJECTIVE: To observe trends in choice of anaesthetic for mandibular third molar surgery in the Combined Department of Oral and Maxillofacial Surgery and Oral Medicine, based at the Edinburgh Dental Institute (EDI) and St John's Hospital (SJH) in Livingston. METHOD: Data were collected retrospectively from electronic patient records for 301 consecutive new referrals for mandibular third molar surgery from general dental practitioners to each of the oral and maxillofacial departments in the EDI and SJH from the 1 September 2009 onwards. Date of consultation, grade of assessing clinician, age, gender, postcode, required surgical procedure, choice of anaesthetic and predicted difficulty of procedure were analysed. RESULTS: One hundred and fifty patients were seen at the EDI and 151 at SJH. There was no statistically significant difference in the proportion of male and female patients or age of patients presenting at each site. Seventeen patients (11.3%) were listed for a general anaesthetic, 21 (14%) for conscious intravenous sedation and 112 (74.7%) for local anaesthetic at EDI. At SJH 57 patients (37.7%) were listed for a general anaesthetic, 30 (19.9%) for conscious intravenous sedation and 64 (42.4%) for local anaesthetic. There was only a small difference in the difficulty of cases at the two sites, though there was a significant difference in socioeconomic deprivation between the two populations. CONCLUSIONS: Significantly more general anaesthetics are being prescribed for mandibular third molar surgery at SJH than the EDI. This finding is not related to difficulty of the cases presenting at each site but may be related to the nature of a maxillofacial clinic compared to a dedicated oral surgery centre. The difference in socioeconomic deprivation may have had an impact on patient decisions.

Dental extractions and bisphosphonates: the assessment, consent and management, a proposed algorithm.

Bisphosphonate-associated osteonecrosis of the jaws (BONJ) is recognised as a significant complication related to the use of bisphosphonates and currently is gaining importance due to the increasingly widespread use of these medications. Patients are placed into low or high risk groups of developing BONJ depending on the systemic condition for which they have received bisphosphonates. Numerically, the largest group worldwide is patients receiving bisphosphonates for osteoporosis and these generally fall into the low risk group for BONJ. The high risk group, while numerically smaller, is composed of those patients receiving bisphosphonates in the management of malignancy affecting the skeleton, either primary or secondary (metastatic disease). A number of additional systemic and local risk factors are proposed, which have the effect of increasing the risk of BONJ following an extraction. These risk factors may have the effect of moving a low risk categorised patient into a medium, or perhaps more realistically an unknown risk category. An example of a systemic risk factor is the concurrent use of corticosteroids and a local risk factor is mandibular molar extraction. The purpose of this paper is to define and validate an algorithm to guide clinicians in the area of patient information, consent and management for patients currently taking or having previously taken bisphosphonates who require dental extractions.

An implant periapical lesion leading to acute osteomyelitis with isolation of Staphylococcus aureus.

A case of an implant periapical lesion (IPL) proceeding to acute osteomyelitis is presented, most likely due to surface contamination of the implant. Five weeks post placement of two anterior mandibular implants, symptoms of acute pain from one implant presented. This symptom and later swelling were unresponsive to antibiotics. On removal of the implant, there was a purulent discharge which, following microbial analysis, proved to be a pure growth of Staphylococcus aureus. A replacement implant was positioned in the site of the previously lost implant ten weeks later, with no recurrence of infection. Staphylococcus aureus can be isolated commonly from the mouths of denture wearers. When an IPL affects a recently placed implant its removal should be accepted but its replacement also considered.

Oral bisphosphonate associated osteonecrosis of the jaws: three case reports.

Bisphosphonate associated osteonecrosis of the jaws (BONJ) has been well documented recently in relation to intravenous preparations of the drug. These are most commonly used as part of the management of hypercalcaemia of malignancy and metastatic bone disease but BONJ can also occur in association with oral bisphosphonate use. The oral preparations can also be prescribed in the management of metastatic bone disease but are more commonly used for the prevention and treatment of osteoporosis. Three case reports are presented in which alendronate, risedronate and ibandronate have been associated with osteonecrosis of the jaws. A review of the recent literature is used in the discussion of the management of these cases. The authors conclude, in agreement with other published authors, that prevention and early detection could be improved to reduce the occurrence and severity of this condition. However when BONJ is diagnosed, the early application of a closely monitored conservative regimen, with consideration given to discontinuation of the bisphosphonate, may give the best chance of containing or resolving the condition.

Variable presentation of temporalis hypertrophy--A case report with literature review.

A case of painful, initially bilateral, and then unilateral temporalis hypertrophy in a 33-year-old Caucasian woman is presented in a primary care setting; the aetiology of the hypertrophy was considered reactive in nature. Medical and supportive treatment was successful in providing symptomatic relief. Further treatment including an intramuscular botulinum injection was considered by the patient with a view to reduction of the chronic enlargement of her temporalis and masseter musculature. A review of the literature and previous treatment regimes is also presented.

A radiographic review of bone levels around Calcitek dental implants supporting mandibular over-dentures. Preliminary results at 3 to 6 years.

This retrospective study aimed to measure marginal bone resorption around cylindrical hydroxyapatite-coated implants retaining mandibular overdentures and compares this between two- and four- implant supported overdentures. Twenty three edentulous patients received 66 implants in their anterior mandible and were restored with overdentures. Panoramic radiographs one week post-operatively and at last recall were compared and marginal bone loss calculated. The mean recall interval was 51.22 months. The mean cumulative bone loss was 1.08 mm and the mean annual bone loss 0.263 mm. There was no significant difference between two- and four- implant overdentures. The results were comparable with other reports.

Lingual nerve injury subsequent to wisdom teeth removal--a 5-year retrospective audit from a high street dental practice.

Lingual nerve damage subsequent to lower wisdom tooth removal affects a small number of patients, sometimes producing permanent sensory loss or impairment. A number of surgical techniques have been described which are associated with low incidences of this distressing post-operative complication. When a technique is adopted by an individual clinician then a personal audit may be prudent to establish how effective it is in relation to established nerve injury rates. This audit looks at a technique involving the minimal interference of lingual soft tissues during lower wisdom tooth removal in a high street practice situation for patients having mild to moderate impacted wisdom teeth removed under local anaesthetic. It was concluded that the technique employed was associated with a low incidence of lingual nerve trauma, comparable with that reported elsewhere.

Surgical forceps techniques.

This paper considers two new elevator and dental forceps techniques for the atraumatic removal of teeth to avoid a surgical procedure where possible. The techniques described should be applicable in relatively well defined but commonly occurring situations. The two techniques involve the unconventional use of conventional dental extraction forceps, with the aim of facilitating removal of the retained roots of certain teeth: the first for incisors, canines and premolars and the second for lower first molars. The term 'surgical forceps technique's is tentatively put forward as a description of these hybrid procedures.

Rapid cystic involvement of a lower third molar.

Cystic change can occur in association with partially and unerupted lower third molars. This case report describes an inflammatory paradental cyst which developed over a relatively short period of time and presented with acute symptoms.