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.

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.

The oral health status of patients on oral bisphosphonates for osteoporosis.

BACKGROUND: The oral health status of patients on bisphosphonates is the key to the patient's ongoing health and well-being. If they are orally healthy, invasive bone procedures, particularly extractions can be avoided, then the risk of osteonecrosis of the jaws (ONJ) is low. METHODS: The records of 49 consecutive patients on oral bisphosphonates, referred to the Oral and Maxillofacial Surgery Unit (OMSU) for an oral health check and probable extractions, were retrospectively reviewed. The DMFT, periodontal and pathologic state were calculated from the OPG radiographs. An age and gender matched control group, from patients referred to the OMSU but who were not on oral bisphosphonates, were similarly assessed. Community data were also obtained. RESULTS: The DMFT score for the oral bisphosphonate group was 29: Decayed 3, Missing 10, Filled 16. The control group DMFT score was 24: Decayed 5, Missing 11, Filled 8. Both groups had advanced periodontal disease (over 95 per cent) and were medically compromised (over 90 per cent). The DMFT for general community data for age matched government pensioners was 19.1: Decayed 0.8, Missing 10.4, Filled 7.9. With severe periodontal disease 23 per cent. Thus, the oral health of the oral bisphosphonate group was similar to the control group and both had more decayed teeth and periodontal disease than community values. CONCLUSIONS: This study confirms that one cannot assume that a patient on an oral bisphosphonate for osteoporosis has a healthy mouth. It supports the view that all patients on bisphosphonates need to be seen by a dentist either before or soon after commencement of bisphosphonate therapy.

A change of heart: the new infective endocarditis prophylaxis guidelines.

New Australian guidelines for the prevention of infective endocarditis were published in July 2008. The guidelines were revised by a multidisciplinary group to reflect recent changes in international recommendations regarding antibiotic prophylaxis for infective endocarditis. The reasons for the changes are explored in this review and the implications for dental practice are discussed.

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.

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.

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.

Pathological changes after the surgical creation of a vertical intracapsular condylar fracture.

The aim of this study was to create in a sheep model an intracapsular oblique vertical split fracture, and observe the histopathological changes in the temporomandibular joint (TMJ) condylar head. In 10 sheep, the right TMJ was operated through the preauricular region. The anterior and posterior attachments of the disc were cut; an oblique vertical osteotomy was made from the lateral pole of the condyle to the medial side of condylar neck. The condylar fragment was pushed anteriorly, inferiorly and medially together with the disc. The non-operated left TMJ served as control. Two sheep were killed at 1 week and four at both 4 and 12 weeks. Computed tomography scans were taken and histopathological changes of the joint observed. There was severe bone erosion and a new bony outgrowth on the lateral side of the condylar stump and temporal bone. The joint spaces were filled with fibrous tissue, cartilage tissue and bone in the 4 and 12 weeks operated groups. These results show that an oblique vertical intracapsular fracture through the lateral condylar pole, combined with an anteriorly and medially displaced condylar fragment and disc and damaged lateral capsule, are likely to result in the pathological changes of osteoarthritis, and the progressive development of ankylosis in a sheep TMJ.

The differential diagnosis of toothache from other orofacial pains in clinical practice.

BACKGROUND: Teeth are a common and obvious source of orofacial pain. There is a risk that endodontic treatment may be initiated in patients that do not have pulp or periapical pathosis. METHODS: A retrospective survey of a sample of patients referred for endodontic treatment was analysed to determine the accuracy of the diagnosis and to identify non-dental cases. A separate prospective study of complex non-dental orofacial pain cases was performed to determine which cases had previously received dental treatment. RESULTS: Seventy-seven (88 per cent) of 88 patients referred for endodontic treatment had been correctly diagnosed with solely endodontic problems. Eight (9 per cent) had endodontic plus other orofacial pain problems and three (3 per cent) had no endodontic problems but other orofacial pain problems. Forty-four (44 per cent) of 100 non-dental orofacial pain patients had previously received either extractions or endodontics. CONCLUSION: Dentists need to carefully evaluate all toothache patients to ensure that the diagnosis is correct prior to the initiation of irreversible treatment.

The role of muscle grafts in temporomandibular joint ankylosis: short-term experimental study in sheep.

The temporalis muscle flap can be used as an inter-positional graft placed into a gap arthroplasty site in temporomandibular joint (TMJ) ankylosis. The purpose of this study was to investigate the role of the muscle graft in sheep. Five pure-bred adult Merino sheep were used and ankylosis was induced in all right TMJs. At 3 months, the ankylosis was released by gap arthroplasty and reconstructed with a masseter muscle graft, because the temporalis muscle is short and poorly vasculized in sheep. The sheep were killed at 3 months after muscle grafting. The maximal mouth opening was recorded before and after operation and at death. The joints were examined radiologically and histologically. In 4 sheep mouth opening remained at the pre-operative level. A clear radiolucent space remained between the smooth temporal and ramus stumps. Histologically, the muscle graft remained vital but with some fibrous tissue formation between the bone ends. One sheep developed an infection at the operative site following the muscle graft; this partly resolved with antibiotics, but the TMJ developed a fibrous reankylosis that was demonstrated clinically, radiologically and histologically. These results indicate that an uncomplicated temporalis muscle graft reconstruction with gap arthroplasty is a successful and stable procedure in human TMJ ankylosis.

Antibiotic prophylaxis for dentoalveolar surgery: is it indicated?

Usually dentists in Australia give patients oral antibiotics after dentoalveolar surgery as a prophylaxis against wound infection. When this practice is compared to the principle of antibiotic prophylaxis in major surgery it is found to be at variance in a number of ways. In major surgery, the risk of infection should be high, and the consequences of infection severe or catastrophic, before antibiotic prophylaxis is ordered. If it is provided then a high dose of an appropriate spectrum antibiotic must be present in the blood prior to the first incision. Other factors which need to be considered are the degree of tissue trauma, the extent of host compromise, other medical comorbidities and length of hospitalization. Standardized protocols of administration have been determined and evaluated for most major surgical procedures. Dentoalveolar surgery is undoubtedly a skilled and technically challenging procedure. However, in contrast to major surgical procedures, it has a less than five per cent infection rate and rarely has severe adverse consequences. Dentoalveolar surgery should be of short duration with minimal tissue damage and performed in the dental chair under local anaesthesia. Controlled studies for both mandibular third molar surgery and placement of dental implants show little or no evidence of benefit from antibiotic prophylaxis and there is an adverse risk from the antibiotic. This review concludes that there is no case for antibiotic prophylaxis for most dentoalveolar surgery in fit patients. In the few cases where it can be considered, a single high preoperative dose should be given.

Severe odontogenic infections.

BACKGROUND: Severe odontogenic infections are serious potentially lethal conditions. Following the death of a patient in the authors' institution this study was initiated to determine the risk factors, management and outcome of a consecutive series of patients. METHODS: All patients admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with odontogenic infections in calendar year 2003 were investigated. Detailed information relative to their pre-presentation history, surgical and anaesthetic management and outcome was obtained and analysed. RESULTS: Forty-eight patients, 32M, 16F, average age 34.5, range 19 to 88 years were treated. All presented with pain and swelling, with 21 (44 per cent) having trismus. Forty-four (92 per cent) were as a result of dental neglect and four (8 per cent) were regular dental patients having endodontic treatment which failed. Of those known to have been treated prior to presentation, most had been on antibiotics. Most patients had aggressive surgical treatment with extraction, surgical drainage, high dose intravenous antibiotics and rehydration. The hospital stay was 3.3 (range 1-16) days. Patients requiring prolonged intubation and high dependency or intensive care (40 per cent) had longer hospitalization. No patient died and all fully recovered. CONCLUSION: Severe odontogenic infections are a serious risk to the patient's health and life. Management is primarily surgical with skilled anaesthetic airway management. Antibiotics are required in high intravenous doses as an adjunct and not as a primary treatment.

Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic prophylaxis for dental treatment.

BACKGROUND: Traditionally patients who indicate that they have a heart murmur or who indicate that they have had rheumatic fever are given antibiotic prophylaxis for dental treatment. This is commonly done without further assessment of the patient's actual endocarditis risk. Echocardiography is a non-invasive method of assessing cardiac valve function and haemodynamics. METHODS: Consecutive patients who were referred to a private practice oral and maxillofacial surgeon for dentoalveolar surgery and indicated that they had a cardiac problem and usually had antibiotic prophylaxis, were evaluated. Those with a clear indication for prophylaxis, for example had prosthetic heart valves or previous infective endocarditis, received antibiotic prophylaxis. Where there was uncertainty, they were referred for an echocardiogram, and if abnormal, a formal cardiology review. RESULTS: Three hundred and seventy patients out of approximately 20 000 (1.85 per cent) indicated that they had a cardiac murmur and usually received antibiotic prophylaxis for dental treatment between 1 February 1997 and 1 February 2005. Two hundred and sixty-two (71 per cent) were female and 108 (29 per cent) were male; age range 0.7 to 98 years, average 37.6 years. Two hundred and seventy (72 per cent) had normal hearts with no indication for antibiotic prophylaxis. Of the 100 (28 per cent) patients with abnormal findings, they were on average older; 49.5 years, range 0.7 to 87 years. Of these, 50 (14 per cent) met current indications for antibiotic prophylaxis. CONCLUSION: Patients who present for dental treatment indicating that they require antibiotic prophylaxis for cardiac condition need to be fully evaluated. In this study only 50 of 370 patients (14 per cent) required antibiotic prophylaxis. The remaining 320 (86 per cent) would have no benefit but a risk of adverse reaction to the antibiotic.

Antibiotic prophylaxis for endocarditis: time to reconsider.

Some cardiac conditions require antibiotic prophylaxis for some types of dental treatment to reduce the risk of infective endocarditis (IE). All medical and dental practitioners are familiar with this practice but tend to use different regimens in apparently similar circumstances. Generally, the trend has been to prescribe antibiotics if in doubt. This review explores the evidence for antibiotic prophylaxis to prevent IE: does it work and is it safe? The changing nature of IE, the role of bacteraemia of oral origin and the safety of antibiotics are also reviewed. Most developed countries have national guidelines and their points of similarity and difference are discussed. One can only agree with the authority who describes antibiotic guidelines for endocarditis as being 'like the Dead Sea Scrolls, they are fragmentary, imperfect, capable of various interpretations and (mainly) missing!' Clinical case-controlled studies show that the more widely antibiotics are used, the greater the risk of adverse reactions exceeding the risk of IE. However, the consensus is that antibiotic prophylaxis is mandatory for a small number of high-risk cardiac and high-risk dental procedures. There are a large number of low-risk cardiac and dental procedures in which the risk of adverse reactions to the antibiotics exceeds the risk of IE, where prophylaxis should not be provided. There is an intermediate group of cardiac and dental procedures for which careful individual evaluation should be made to determine whether IE or antibiotics pose the greater risk. These categories are presented. All medical and dental practitioners need to reconsider their approach in light of these current findings.

Patients with artificial joints: do they need antibiotic cover for dental treatment?

This study reviews whether patients with artificial joints need antibiotic cover for dental treatment. Generally in Australia the practice has developed of giving most patients with artificial joints antibiotic prophylaxis for a wide range of dental procedures. This is partly on anecdotal grounds, partly historical and partly for legal concerns. It has been encouraged by some guidelines. Scientifically, the risk and the benefit of each step in the process needs to be analysed. This review shows that the risk of an artificial joint becoming infected from a bacteraemia of oral origin is exceedingly low whereas the risk of an adverse reaction to the antibiotic prophylaxis is higher than the risk of infection. If all patients with artificial joints receive antibiotic prophylaxis then more will die from anaphylaxis than develop infections. Factors which balance the risk benefit are if the patient is seriously immunocompromised, if the joint prosthesis is failing or chronically inflamed and if the dental procedures, such as from extractions and deep periodontal scaling, produce high level bacteraemias. Recommendations to rationalize antibiotic prophylaxis for patients with artificial joints are presented.

The dental implications of bisphosphonates and bone disease.

In 2002/2003 a number of patients presented to the South Australian Oral and Maxillofacial Surgery Unit with unusual non-healing extraction wounds of the jaws. All were middle-aged to elderly, medically compromised and on bisphosphonates for bone pathology. Review of the literature showed similar cases being reported in the North American oral and maxillofacial surgery literature. This paper reviews the role of bisphosphonates in the management of bone disease. There were 2.3 million prescriptions for bisphosphonates in Australia in 2003. This group of drugs is very useful in controlling bone pain and preventing pathologic fractures. However, in a small number of patients on bisphosphonates, intractable, painful, non-healing exposed bone occurs following dental extractions or denture irritation. Affected patients are usually, but not always, over 55 years, medically compromised and on the potent nitrogen containing bisphosphonates pamidronate (Aredia/Pamisol), alendronate (Fosamax) and zolendronate (Zometa) for non-osteoporotic bone disease. Currently, there is no simple, effective treatment and the painful exposed bone may persist for years. The main complications are marked weight loss from difficulty in eating and severe jaw and neck infections. Possible preventive and therapeutic strategies are presented although at this time there is no evidence of their effectiveness. Dentists must ask about bisphosphonate usage for bone disease when recording medical histories and take appropriate actions to avoid the development of this debilitating condition in their patients.

Intractable facial pain and illness behaviour.

Management of intractable facial pain (IFP) patients is time consuming and potentially frustrating. Earlier identification of IFP patients may be helped by considering such cases in terms of their illness behaviour rather than a large rang of other diagnostic labels. A group of 24 IFP patients, with diagnoses including temporomandibular joint dysfunction pain, atypical facial pain and facial neuralgia, completed a questionnaire designed to measure illness behaviour. Compared to a control group of patients with minor odontogenic pain, IFP patients were more somatically preoccupied, could not accept reassurance from a doctor as easily, and were less likely to acknowledge psychological aspects of illness. These attitudes, similar to those reported by other intractable pain patients, are unlikely to be related to degree of organic pathology or chronicity of pain. Use of a discriminant function resulted in three-quarters of the total sample being correctly separated into the two clinical groups on the basis of their IBQ scores.