Comparative Efficacy of Obstructive Sleep Apnea Patients Undergoing Multilevel Surgery Followed by Upper Airway Stimulation Versus Isolated Upper Airway Stimulation.

PURPOSE: Upper Airway Stimulation (UAS) of the hypoglossal nerve is a rapidly growing management option for patients with obstructive sleep apnea (OSA). Our study compares the treatment efficacy of UAS between those who were initially ineligible for UAS but subsequently met eligibility after multilevel surgery versus those who underwent isolated UAS for the treatment of moderate to severe OSA. METHODS: The investigators implemented a retrospective single-center cohort study of patients aged 18+ years who presented for surgical evaluation of OSA from 2016-2019 and underwent UAS implantation. The predictor variable was eligibility status for UAS. Initially ineligible subjects were defined as having an apnea-hypopnea (AHI) > 65 events/hr, body mass index (BMI) > 32 kg/m2, or complete concentric collapse (CCC) on drug-induced sleep endoscopy. Eligible subjects were defined as having an AHI between 15 and 65, with no CCC on drug-induced sleep endoscopy. The primary outcome was change in AHI which was measured preoperatively and 6 months post UAS implantation. Secondary outcomes were change in Epworth sleepiness scale and Fatigue severity scale. Covariates were age, sex, and BMI. Data analysis involved descriptive statistics and multivariable statistical models; P < .05 was considered significant. RESULTS: Thirty six patients underwent UAS implantation from 2016-2019. Eighteen patients who were initially ineligible for UAS underwent multilevel surgery, including uvulopalatopharyngoplasty, distraction osteogenesis maxillary expansion, or maxillomandibular advancement. Mean age was 62.4 ± 9 years and BMI of 29.1 ± 4 kg/m2 with 5 female patients. The cohort of 17 patients who met criteria for UAS from the start had a mean age of 62.9 ± 14 years and mean BMI of 26.7 ± 4 kg/m2 with 2 female patients. Mean AHI reduction for the multilevel group was 37.6 ± 21.2 events per hour (P < .001). Mean AHI reduction for the UAS-only group was 31.5 ± 13 events per hour (P < .001). When adjusted for age, BMI, and sex, the multilevel group had a more significant reduction (18 AHI events) compared to the isolated group (P < .001). CONCLUSIONS: For patients who are ineligible for UAS due to severity of OSA or CCC of the velum, multilevel surgery including maxillomandibular advancement followed by UAS confers effective post-treatment results, which was superior to the UAS-only group.

When disaster strikes in the ring: a 20-year study of head and neck injuries secondary to boxing.

The purpose of this study was to explore the patterns of head and neck injuries secondary to boxing. We conducted a 20-year retrospective cross-sectional study using the National Electronic Injury Submission System (NEISS). We derived the predictor variables from both patient and injury characteristics. The principal outcome variable was the probability of hospital admission from the ED. We used bivariate analysis to determine if an association existed between two variables of interest. We created a multiple logistic regression model to model the probability of admission using all significant univariate predictors. The final sample consisted of 1,919 patients. Children were most likely to injure their heads (p < 0.01). Young adults were also most likely to injure their heads (p < 0.05). Adults were most likely to injure their faces (p < 0.01). Children were most likely to incur facial contusions (p < 0.01) and internal organ injuries (p < 0.01). Young adults were most likely to suffer concussions (p < 0.01). Adults were most likely to suffer lacerations (p < 0.01). Certain age groups were more/less likely to injure a particular anatomical site and more/less likely to incur a particular type of injury. Relative to young adults, seniors had an increased odd of admission. Head injuries had an increased odds of admission relative to mouth injuries. Fractures and internal organ injuries proved to be the most dangerous injuries.

How has the COVID Pandemic Impacted the Clinical Volume and Variety of an Academic Oral and Maxillofacial Surgery Program?

PURPOSE: Attempts to mitigate the coronavirus disease of 2019 (COVID) have disrupted the delivery of non-pandemic care. The purpose of this study was to evaluate the effects of the COVID pandemic on surgical volume and variety at an academic oral and maxillofacial surgery program. MATERIALS AND METHODS: A retrospective cohort study was conducted using the surgical logs of the University of Pennsylvania, Department of Oral and Maxillofacial Surgery from January 2012 through January 2021. Each record identified patient demographics and case classifications. The study predictor was timing of care, which was divided into pre-pandemic, peak pandemic, or post-peak pandemic. The primary study outcomes were the monthly procedure count and the procedure categories. The secondary dependent variables were patient age and race. Multivariate and univariate analyses of variance were used to determine whether pandemic effects existed within outcome groups. RESULTS: The final sample included 64,709 surgical procedures. Before, during, and after the pandemic peak, there were means of 691.0, 209.0, and 789.4 procedures per time period, respectively (P < .01). There was significantly more infection (baseline 2.2%, peak 6.0%, post-peak 2.0%, P < .01) and trauma (baseline 5.3%, peak 26.7%, post-peak 3.9%, P < .01) cases during the pandemic peak. The mean percentage of pediatric patients increased during the peak and post-peak periods (baseline 2.4%, peak 12.9%, post-peak 10.2%, P < .01). No differences were observed among the mean percentage of White (P = .12), Black (P = .21), and Hispanic (P = .25) patients treated. CONCLUSIONS: Along with a predictable decline in surgical numbers, a greater proportion of infection and trauma procedures were performed at the pandemic's peak. Despite these changes, surgery volume normalized and case variety returned to pre-pandemic levels in the post-peak period. Our study suggests that the addition of COVID restrictions did not change the case volume or variety in the months' after the initial crisis.

Variability in the Analgesic Response to Ibuprofen Is Associated With Cyclooxygenase Activation in Inflammatory Pain.

The mechanisms underlying interindividual variability in analgesic efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) are not well understood. Therefore, we performed pain phenotyping, functional neuroimaging, pharmacokinetic/pharmacodynamic assessments, inflammation biomarkers, and gene expression profiling in healthy subjects who underwent surgical extraction of bony impacted third molars and were treated with ibuprofen (400 mg; N = 19) or placebo (N = 10). Analgesic efficacy was not associated with demographic or clinical characteristics, ibuprofen pharmacokinetics, or the degree of cyclooxygenase inhibition by ibuprofen. Compared with partial responders to ibuprofen (N = 9, required rescue medication within the dosing interval), complete responders (N = 10, no rescue medication) exhibited greater induction of urinary prostaglandin metabolites and serum tumor necrosis factor-α and interleukin 8. Differentially expressed genes in peripheral blood mononuclear cells were enriched for inflammation-related pathways. These findings suggest that a less pronounced activation of the inflammatory prostanoid system is associated with insufficient pain relief on ibuprofen alone and the need for additional therapeutic intervention.

Prevention of Opioid-Induced Nausea and Vomiting During Treatment of Moderate to Severe Acute Pain: A Randomized Placebo-Controlled Trial Comparing CL-108 (Hydrocodone 7.5 mg/Acetaminophen 325 mg/Rapid-Release, Low-Dose Promethazine 12.5 mg) with Conventional Hydrocodone 7.5 mg/Acetaminophen 325 mg.

OBJECTIVES: To evaluate the prevention of opioid-induced nausea and vomiting (OINV) and the relief of moderate to severe acute pain by CL-108, a novel drug combining a low-dose antiemetic (rapid-release promethazine 12.5 mg) with hydrocodone 7.5 mg/acetaminophen 325 mg (HC/APAP) was used. METHODS: This was a multicenter, randomized, double-blind, placebo- and active-controlled multidose study. After surgical extraction of two or more impacted third molar teeth (including at least one mandibular impaction), 466 patients with moderate to severe pain (measured on a categorical pain intensity scale [PI-CAT]) were randomized to CL-108, HC/APAP, or placebo. Over the next 24 hours, patients used the PI-CAT to assess pain at regular intervals whereas nausea, vomiting, and other opioid-related side effects were also assessed prospectively. Study medications were taken every four to six hours as needed; supplemental rescue analgesic and antiemetic medications were permitted. Co-primary end points were the incidence of OINV and the time-weighted sum of pain intensity differences over 24 hours (SPID24). RESULTS: Relative to HC/APAP treatment alone, CL-108 treatment reduced OINV by 64% (P < 0.001). Treatment with CL-108 significantly reduced pain intensity compared with placebo (SPID24 = 16.2 vs 3.5, P < 0.001). There were no unexpected or serious adverse events. CONCLUSIONS: CL-108 is a safe and effective combination analgesic/antiemetic for the prevention of OINV during treatment of moderate to severe acute pain.

A Proof-of-concept Study Using Quantitative Sensory Threshold Analysis to Compare Two Intraoral Topical Anesthetics.

PURPOSE: CTY-5339A is an investigational topical anesthetic spray containing 14% benzocaine/2% tetracaine in a metered canister. Each spray delivers ∼0.2 mL of solution. This double-blind, randomized, crossover study compared the local anesthetic effect of CTY-5339A versus 14% benzocaine alone by using 2 quantitative sensory threshold experimental pain paradigms on the maxillary gingiva: pin prick test pain intensity (PPT PI) and heat pain threshold (HPT). METHODS: American Society of Anesthesiology Class 1 and 2 subjects (N = 50) were enrolled in this study. To qualify for the study, subjects were tested on the anterior maxillary gingiva with both PPT and HPT. Subjects had to report a PPT PI of ≥3 on a 0 to 10 numeric pain intensity scale on 1 of 2 consecutive pin pricks separated by 10 s, with at least one score ≥4. After PPT, mean HPT following 2 ramps in the same location had to be ≤ 46.5 °C, with each ramp beginning at 35 °C and an automatic cutoff of 50.6 °C. For treatment visits, subjects were randomly administered either 1 spray of CTY-5339A or 14% benzocaine to the anterior maxillary gingiva within 3 weeks of screening and then the alternative treatment 5 days to 2 weeks later. PPT PI and HPT were recorded immediately before drug application. After drug administration, PPT PI was recorded every minute through 5 min. Commencing at 5 min, PPT PI and HPT were recorded every 5 min through 60 min. For assessment of methemoglobin concentrations, venous blood (5 mL) was drawn from the antecubital fossa both before and 60 min after drug application. Oxygen saturation was recorded via pulse oximetry at baseline and every 10 min. FINDINGS: The AUCs for pain intensity difference from 0-30 and 0-60 min after PPT and HPT differences were significantly greater (P < 0.0001) for CTY-5339A compared with 14% benzocaine. Multiple time points on the time-action curves for PPT PI difference and HPT difference statistically (P < 0.05) favored CTY-5399A. Methemoglobin and oxygen saturation levels did not change compared with baseline after dosing with either treatment. IMPLICATIONS: Recommended doses of CTY-5339A provided significantly more profound and sustained local anesthesia than 14% benzocaine when applied to the maxillary gingiva. Significant changes in methemoglobin or oxygen saturation concentrations did not occur for either drug. ClinicalTrials.gov identifier: NCT03233737.

Cardiovascular considerations for the dental practitioner. 2. Management of cardiac emergencies.

Medical emergencies are not uncommon in dental practices. Syncope has commonly been found to account for the majority of these emergencies in a dental setting, but some studies have reported cardiovascular events as the most common type of emergency. It is critical that every dentist be prepared with the knowledge and equipment necessary to respond in emergency situations. This article aims to provide dentists with essential knowledge about management of cardiovascular emergencies.

Cardiovascular considerations for the dental practitioner. 1. Review of cardiac anatomy and preoperative evaluation.

Cardiovascular disease is the most prevalent chronic medical condition in patients treated in a dental setting. Therefore, dental practitioners must have a sound understanding of cardiovascular anatomy and physiology. Dentists also should be equipped to perform an effective preoperative cardiovascular examination and determine when medical consultation is necessary in higher risk patients. This article provides an overview of cardiovascular anatomy and physiology and discusses evaluation of cardiac risk factors with the aim of enabling dentists to effectively assess patients for potential cardiovascular events, thereby avoiding cardiovascular emergencies in the dental setting.

Lack of Methemoglobin Elevations After Topical Applications of Benzocaine Alone or Benzocaine Plus Tetracaine to the Oral Mucosa.

PURPOSE: This study evaluated changes in methemoglobin and oxygen saturation concentrations after the administration of recommended doses of 14% benzocaine alone or 14% benzocaine combined with 2% tetracaine. METHODS: American Society of Anesthesiology class 1 and 2 subjects (n = 40) were enrolled in this modified crossover study. Subjects were administered 0.2 mL of 14% benzocaine alone, 0.2 mL of 14% benzocaine plus 2% tetracaine, or 0.4 mL of 14% benzocaine plus 0.2% benzocaine to their cheek mucosa. Venous blood (5 mL) was drawn from the antecubital fossa before and 60 minutes after drug application for methemoglobin analyses. Oxygen saturation was also recorded via pulse oximetry at baseline and every 10 minutes through 60 minutes after drug application. FINDINGS: Methemoglobin and oxygen saturation levels did not change from baseline after the administration of benzocaine alone or when combined with tetracaine. IMPLICATIONS: Recommended doses of benzocaine or benzocaine combined with tetracaine when applied to the cheek mucosa do not induce even clinically insignificant elevations in methemoglobin levels. Metered dosing, such as that used in this study, can help avoid this overdose phenomena with these drugs. ClinicalTrials.gov identifier: NCT02908620.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short Term for Improving Function and Quality of Life After Arthrocentesis? Part 2.

PURPOSE: Although arthrocentesis has been used for the management of patients with temporomandibular joint pain, the benefit of hyaluronic acid (HA) or corticosteroid (CS) remains uncertain. The purpose of this study was to assess the efficacy of HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis for changes in quality of life (QoL), jaw function (Jaw Function Limitation Scale [JFLS] score), and maximum incisal opening (MIO). MATERIALS AND METHODS: This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then instillation of HA, CS, or LR. All patients were evaluated clinically at 1 and 3 months. The outcome variables were QoL, JFLS score, and MIO. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. RESULTS: One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for analysis of data at 1 month. An additional 51 were lost to follow-up at 3 months, leaving 51 patients for data analysis at this time point. There was no difference among groups for QoL Mental Health Composite score at 1 month (P = .70) or 3 months (P = .69). There was no difference among groups for JFLS score at 1 month (P = .71) or 3 months (P = .98). There was no difference among groups for MIO at 1 month (P = .47) or 3 months (P = .31). All groups showed within-group improvements in JFLS score and MIO at 1 and 3 months. CONCLUSION: Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in improving jaw function and MIO at 1 and 3 months. QoL is not improved with arthrocentesis alone or in combination with CS or HA.

Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short-Term Reduction of Temporomandibular Joint Pain After Arthrocentesis? Part 1.

PURPOSE: Arthrocentesis has been used for the management of patients with temporomandibular joint (TMJ) pain, with good success. The additional use of hyaluronic acid (HA) or corticosteroid (CS) remains controversial. The purpose of this study was to compare HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis. MATERIALS AND METHODS: This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then the instillation of HA, CS, or LR. Patients were evaluated clinically at 1 and 3 months. The primary outcome variable was pain at 1 month (by visual analog scale). Secondary outcome variables were pain at 3 months and analgesic consumption. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. RESULTS: One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for the final analysis. The mean age of patients in the HA, CS, and LR groups was 39.6, 44.3, and 51.8 years, respectively (P = .02). There was no difference among groups in time to follow-up at 1 month (P = .11). The mean decrease in pain in the CS group was 19% for right-side procedures (P = .12) and 36% for left-side procedures (P = .02). The mean decrease in pain in the HA group was 31% for right-side procedures (P = .01) and 34% for left-side procedures (P = .01). The mean decrease in pain in the LR group was 43% for right-side procedures (P < .01) and 37% for left-side procedures (P < .01). There was no difference in pain decrease among groups (P = .55). There was no difference in the use of narcotic (P = .52) or nonsteroidal anti-inflammatory drugs (P = .71) among groups. CONCLUSION: Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in decreasing TMJ pain.

Retrospective study of facial nerve function following temporomandibular joint arthroplasty using the endaural approach.

The aim of this retrospective case-control study is to evaluate the incidence of facial nerve injury associated with temporomandibular joint (TMJ) arthroplasty using the endaural approach for the treatment of TMJ pathology. The sample consisted of 36 consecutive patients who underwent TMJ arthroplasty. A total of 39 approaches were performed through an endaural incision. Patients undergoing total joint replacement and/or with preexisting facial nerve dysfunction were excluded from the study. Five patients were lost to follow-up and were excluded from the study. Facial nerve function of all patients was clinically evaluated by resident physicians preoperatively, postoperatively, and at follow-up appointments. Facial nerve injury was determined to have occurred if the patient was unable to raise the eyebrow or wrinkle the forehead (temporalis branch), completely close the eyelids (zygomatic branch), or frown (marginal mandibular branch). Twenty-one of the 36 patients or 22 of the 39 approaches showed signs of facial nerve dysfunction following TMJ arthroplasty. This included 12 of the 21 patients who had undergone previous TMJ surgery. The most common facial nerve branch injured was the temporal branch, which was dysfunctional in all patients either as the only branch injured or in combination with other branches. By the 18th postoperative month, normal function had returned in 19 of the 22 TMJ approaches. Three of the 22 TMJ approaches resulted in persistent signs of facial nerve weakness 6 months after the surgery. This epidemiological study revealed a low incidence of permanent facial nerve dysfunction. A high incidence of temporary facial nerve dysfunction was seen with TMJ arthroplasty using the endaural approach. Current literature reveals that the incidence of facial nerve injury associated with open TMJ surgery ranges from 12.5 to 32%. The temporal branch of the facial nerve was most commonly affected, followed by 4 of the 22 approaches with temporary zygomatic branch weakness. Having undergone previous TMJ surgery did not increase the incidence of facial nerve injury using the endaural approach. This information is important for patients and surgeons in the postoperative period, as a majority of patients will experience recovery of nerve function.

Pigmented villonodular synovitis of the temporomandibular joint.

Pigmented villonodular synovitis (PVNS) is a proliferative disorder that affects synovium-lined joints, bursae, and tendon sheaths. It appears in both diffuse and localized forms, depending on the extent of synovial involvement. PVNS rarely involves the temporomandibular joint (TMJ); when it does, it manifests clinically as a slowly growing and painless preauricular mass that resembles a parotid tumor. TMJ dysfunction, paresthesia, and/or hearing loss can result. We present a case of a large extra-articular PVNS of the TMJ, and we review the literature.

The cardiovascular effects and pharmacokinetics of intranasal tetracaine plus oxymetazoline: preliminary findings.

BACKGROUND: The authors evaluated the cardiovascular effects and pharmacokinetics of an intranasal 3 percent tetracaine/0.05 percent oxymetazoline spray developed to provide needle-free anesthesia of maxillary teeth. METHODS: The authors administered to 12 participants a proposed maximum recommended dose (MRD) (18 milligrams tetracaine/0.3 mg oxymetazoline) as three bilateral pairs of 0.1-milliliter nasal sprays. They administered two times this dose (36 mg tetracaine/0.6 mg oxymetazoline) as six bilateral pairs one to three weeks later. The authors recorded the patients' heart rate, blood pressure and oxygen saturation. They drew blood samples at baseline and 15 times during the two hours after drug administration. RESULTS: Physiological measures remained fairly stable throughout the two-hour period, with small but significant decreases (P < .05) in heart rate at 40 and 50 minutes for the two-times MRD (6.1 beats/minute) and MRD (7.5 beats/minute) administrations, respectively, and a significant increase in diastolic blood pressure (5.9 millimeters of mercury) for the two-times-MRD administration at 90 minutes. Mean oxygen saturation remained above 99 percent. Tetracaine plasma levels were undetectable in most participants, whereas concentrations of its major metabolite parabutylaminobenzoic acid from the two-times-MRD administration were approximately twice that from the MRD administration. Oxymetazoline concentrations from the two-times-MRD administration were approximately 50 percent greater than those from the MRD administration, with a half-life of 1.72 to 2.32 hours. CONCLUSIONS: Intranasal tetracaine/oxymetazoline mist generally was well tolerated in study participants. CLINICAL IMPLICATIONS: The safety profile and pharmacokinetics of this intranasal formulation indicate that it appears to be generally well tolerated in patients for achieving anesthesia of the maxilla. Additional safety and efficacy data are required, particularly in patients with cardiovascular disease and other comorbidities.

Biomet Microfixation Temporomandibular Joint Replacement System: a 3-year follow-up study of patients treated during 1995 to 2005.

PURPOSE: To assess the safety and efficacy of a stock alloplastic total temporomandibular joint (TMJ) implant system, the Biomet Microfixation TMJ Replacement System. MATERIALS AND METHODS: During a 10-year multicenter clinical trial from 1995 to 2005, 442 Biomet Microfixation TMJ Replacement Systems were implanted in 288 patients (154 bilaterally and 134 unilaterally). Patients were followed at landmark times, including the date of surgery and at 1 month, 3 months, 1 year, 1 year 6 months, and 3 years. The 3 major metrics that were evaluated were preoperative and postoperative pain, interference with eating, and maximal incisal opening. Paired t tests and comparison analyses were used to assess outcomes. RESULTS: There was statistically significant improvement in pain level (P = .0001), jaw function (P = .0001), and incisal opening (P = .0001). Although there were complications necessitating the removal of 14 of 442 implants (3.2%), there were no device-related mechanical failures. CONCLUSIONS: The clinical study presented supports the conclusion that a stock TMJ alloplastic replacement, based on sound orthopedic and biomedical principles, is a safe and efficacious option when alloplastic reconstruction of the TMJ is indicated.

Double-blind, placebo-controlled, randomized pilot study of cerebral blood flow patterns employing SPECT imaging in dental postsurgical pain patients with and without pain relief.

BACKGROUND: Single-photon emission computed tomography (SPECT) has been employed in the study of altered regional cerebral blood flow (CBF) in experimental and chronic pain. CBF patterns have not been evaluated in patients with acute postoperative pain. OBJECTIVE: The purpose of this pilot study was to employ SPECT to measure CBF distribution associated with postoperative dental pain and to compare these CBF patterns to subsequent images in the same patients who were experiencing pain relief versus continued or worsening pain who had received active or placebo analgesic interventions. The primary outcome measure was the percentage change in blood flow in various regions of interest. METHODS: Twenty-two healthy individuals (10 males and 12 females, age range 20-29 years) who underwent the removal of ≥1 partial or full bony impacted mandibular third molars were evaluated for pain intensity as the local anesthesia dissipated, employing a 0 to10 numeric rating scale (0 = no pain; 10 = worst imaginable). When the subjects' pain level reached ≥4/10, they were injected intravenously with 260 MBq of technetium Tc 99m bicisate (ethyl cysteinate dimer). Under double-blind conditions and 10 minutes before being placed in the SPECT scanner, the first 10 subjects were randomized to receive intravenous ketorolac 15 mg or saline while the remaining 12 subjects were randomized to receive by mouth either ibuprofen 400 mg, ibuprofen 200 mg, acetaminophen 1000 mg, or placebo. One hour after drug administration, subjects were reevaluated for pain, injected with 925 MBq of technetium Tc 99m bicisate, given rescue medication if required, and then rescanned. CBF ratios were obtained for regions of interest and by normalizing to average whole brain activity. RESULTS: Subjects generally had a moderate degree (mean [SD], 7.3% [4.0%]) of thalamic asymmetry on initial scans with pain; after treatment, subjects reporting worsening pain regardless of the intervention had higher thalamic asymmetry (8.1% vs 2.8%) than those reporting relief of pain. Subjects who reported reduced pain after the intervention had significantly different (P < 0.05) mean CBF changes compared with those reporting worsening pain in the left prefrontal cortex, left sensorimotor area, right anterior cingulate, and right caudate. CONCLUSIONS: Acute postoperative dental pain was associated with moderate thalamic asymmetry that improved following successful pain management. Sustained or worsening pain was associated with increased CBF in brain regions associated with pain pathways, whereas pain relief was associated with decreased activity in the same areas.

Beta-adrenergic blocking agents and dental vasoconstrictors.

A clinically significant interaction between epinephrine or levonordefrin with nonselective beta-adrenergic blocking agents, although apparently rare in the dental setting, is potentially serious and can lead to significant hypertension with a concomitant reflex bradycardia. Based on the results of epinephrine infusion studies, the severity of the interaction seems dose related; small epinephrine doses cause less of a pressor response than larger doses. The interaction can be seen after intraoral submucosal injections but is generally of a smaller magnitude, at least with only 1 or 2 cartridges of lidocaine plus 1:100,000 epinephrine. However as demonstrated by 1 case report, some individuals are hypersensitive to this interaction. Inadvertent intravascular injections of local anesthetic plus vasoconstrictor and the use of high doses of vasoconstrictor are likely to result in a more pronounced response. Patients with significant cardiovascular disease may be especially vulnerable to the most serious sequelae resulting from the pressor reactions of the drug combination.

Posttraumatic temporomandibular joint disorders.

The temporomandibular joint (TMJ) has many essential functions. None of its components are exempt from injury. Facial asymmetry, malocclusion, disturbances in growth, osteoarthritis, and ankylosis can manifest as complications from trauma to the TMJ. The goals of initial treatment include achievement of pretraumatic function, restoration of facial symmetry, and resolution of pain. These same objectives hold true for late repairs and reconstruction of the TMJ apparatus. Treatment is demanding, and with opposing approaches. The following article explores various treatment options for problems presenting as a result of a history of trauma to the TMJ.