Evaluating complications of local anesthesia administration and reversal with phentolamine mesylate in a portable pediatric dental clinic.

This study sought to identify and quantify complications with local anesthetic administration and reversal on consecutive patients seen for comprehensive dental care in a school-based, portable dental clinic, and includes data on the patients seen by the participating portable dental providers. In 923 dental visits where local anesthetic was administered, a standardized form was used to gain further information and identify any complications; this was accompanied by a questionnaire for the student's teacher, in order to quantify the student's distraction and disruption ratings following the dental visit. After statistical analysis of the 923 consecutive cases, the overall complication rate was 5.3%. All of the complications were considered to be mild or moderate, and there were no severe event reports. The complications encountered most frequently (n = 49) were associated with self-inflicted soft tissue injury. The results of this study indicate that comprehensive care with local anesthesia delivered by a school-based portable dental clinic has a low risk of complications. Whereas safe administration of dental care is achievable with or without phentolamine mesylate as a local anesthetic reversal agent, its use was determined to improve safety outcomes. Three factors appeared to directly increase the incidence of complications: the administration of an inferior alveolar nerve block, attention deficit disorder, and obesity. Teacher evaluations demonstrated that children receiving care by a portable dental team were able to reorient back to classwork and were not disruptive to classmates.

Tongue biting in epileptic seizures and psychogenic events: an evidence-based perspective.

Tongue biting (TB) may occur both in seizures and in psychogenic non-epileptic events (PNEEs). We undertook a systematic review to determine sensitivity, specificity, and likelihood ratios (LR) of TB. Five studies (222 epilepsy patients and 181 subjects with PNEEs) were included. There was a statistically significant higher prevalence of TB (both without further specifications on site of lesions and lateral TB) in patients with seizures. Pooled accuracy measures of TB (no further specifications) were sensitivity 38%, specificity 75%, pLR 1.479 (95% CI 1.117-1.957), and nLR 0.837 (95% CI 0.736-0.951). Pooled measures of lateral TB were sensitivity 22%, specificity 100%, pLR 21.386 (95% CI 1.325-345.169), and nLR 0.785 (95% CI 0.705-0.875). Only a pooled analysis of data demonstrated a statistically significant pLR for lateral TB. Lateral TB but not 'any' TB has diagnostic significance in distinguishing seizures from PNEEs, supporting the diagnosis of seizures. Tongue biting without further specifications has, therefore, no value in the differential diagnosis between seizures and PNEEs.

[Skin signs in child abuse]. / Signos cutáneos del maltrato infantil.

Child abuse is far more prevalent today than is generally recognized. Up to 90% of victims suffer physical abuse that can be observed in signs on the skin. Dermatologists are particularly qualified to identify these signs and distinguish them from other conditions that can mimic abuse. This review covers the signs of child abuse that can be observed on the skin. We discuss clues that can help differentiate between lesions caused by abuse and those that are accidental, and we describe the skin conditions that mimic physical abuse.

Pattern of presentation and management of lip injuries in a Nigerian hospital.

AIM: Human lip injuries, although uncommon, present major challenges in terms of reconstructive options and the outcome of surgical management. The reconstructive techniques are usually varied but the ultimate objectives of treatment are to achieve healing, function, and aesthetics. The aim of this study was to report the etiology, pattern of presentation, and surgical management of lip injuries in Lagos University Teaching Hospital (LUTH). MATERIALS AND METHODS: A prospective study of consecutive cases of lip injury was conducted at the Oral and Maxillofacial Surgery Clinic of the Lagos University Teaching Hospital. Data collected included age and sex of patients, etiology, pattern of presentation, and surgical techniques of repair. RESULTS: A total of 13 patients with lip injury to the lip were included in the study (M = 6, F = 7). Human bite (11 cases) was the most common cause of injury followed by electric burns (2 cases). The most (81.8%) frequently affected site was the lower lip. Most patients presented within 72 hours after injury with infected wound. Treatment offered included thorough debridement and primary repair using various surgical techniques. A one-stage surgical technique was employed in all cases. Healing was uneventful in all cases and satisfactory. CONCLUSION: Most of the lip injuries in the present study were due to human bites with almost equal sex distribution. Lower lip was most commonly affected. All cases were successfully treated by debridement, broad spectrum antibiotic coverage, and one-stage surgical repair with a favorable outcome.

Facio-mandibular myoclonus: a rare cause of nocturnal tongue biting.

Facio-mandibular myoclonus is a parasomnia characterized by forceful myoclonus of masticatory muscles in sleep. This condition typically presents with recurrent nocturnal tongue biting, which can be misdiagnosed for nocturnal seizures. The use of surface electromyographic channels over the facial muscles during video-EEG monitoring is helpful in confirming the diagnosis based on a typical burst pattern. This case report highlights difficulties in the diagnosis of facio-mandibular myoclonus and useful features which differentiate it from similar conditions.

An unusual pattern of self-inflicted injury after dental local anesthesia: a report of 2 cases.

The local anesthetics used in dentistry are considered very safe and have a low incidence of adverse reactions associated with their administration. A frequent finding by clinicians engaged in treatment of children is, following a dental appointment requiring local anesthesia to treat dental disease, a child may bite his or her lip out of curiosity associated with the unfamiliar sensation of being numb or inadvertently because no pain is felt. We describe two unusual case reports of postanesthetic self-inflicted injuries in this article. The first being the ulceration due to lip biting and the scratch injury on the chin after inferior alveolar nerve block. The second report presents an unusual scratch injury on the ala of nose following maxillary infiltration anesthesia. The common treatment modalities and the possible methods of prevention are discussed.

Effective treatment of self-injurious oral trauma in Lesch-Nyhan syndrome: a case report.

Lesch-Nyhan syndrome (LNS) is an X-linked disorder originating from deficiency of the enzyme hypoxanthine guanine phosphoribosyl transferase. It is characterized by neurological manifestations, including the dramatic symptom of compulsive self-mutilation, which results in destruction of oral and perioral tissues. Several drug trials have been administered to improve the severe self-destructive behaviour, with questionable effectiveness. Invasive treatment approaches, such as extraction of teeth and orthognathic surgery, have been suggested with variable success. A conservative treatment with an intraoral appliance serving to prevent oral and peri-oral self-injury is presented in this report. The patient was a 14-year-old boy demonstrating the typical LNS behaviour, including compulsive self-biting, significant loss of lip and tongue tissue, spasticity and involuntary movements. An acrylic maxillary appliance was designed and constructed with an occlusal plate raising the bite. The appliance was retained by two Adams' clasps on the first premolars, along with three ball clasps between the incisors. Fabrication, insertion, and maintenance were uncomplicated and non-stressful to the patient. Periodic recall over 3-year period has confirmed the effective healing of the oral lesions and a high level of tolerance of the appliance.

Traumatic lesions from congenital insensitivity to pain with anhidrosis in a pediatric patient: dental management.

Congenital insensitivity to pain with anhidrosis is a rare autosomal-recessive disorder characterized by unexplained fever episodes, anhidrosis, pain insensitivity, self-mutilating behavior, and mental retardation. The lack of sensitivity to pain results in traumatic lesions, such as ulcers, fractures, burns, bites, scars, and digital amputations. Several methods have been suggested to treat these patients; however, appropriate management is difficult, especially when the mutilation is particularly severe. This report describes the case of a 2-year-old female patient who had severe self-mutilating injuries to her tongue, hands, lips, and oral mucosa caused by biting. The patient presented digital amputation and also a premature loss of a permanent tooth germ during the treatment. The dental management is described and discussed. It is important to include the dentist on the multidisciplinary team to reduce the frequency and severity of the self-inflicted lesions in these patients, also to prevent complications.

The effect of local anesthetic on quality of recovery characteristics following dental rehabilitation under general anesthesia in children.

This study is a randomized, prospective, double-blind study to evaluate the effects of the combination of local anesthetics and an intravenous nonsteroidal anti-inflammatory drug (NSAID) vs NSAID alone on quality of recovery following dental rehabilitation under general anesthesia (GA). Twenty-seven healthy children aged 3-5.5 years underwent dental rehabilitation under GA. Fifteen children in the experimental group received oral infiltration of local anesthetic in addition to intravenous ketorolac tromethamine, while 12 children in the control group received intravenous ketorolac tromethamine alone for postoperative pain management. Pain behaviors were evaluated immediately postoperatively using a FLACC scale and 4 hours postoperatively by self-report using various scales. Parents reported perception of child pain and comfort and any occurrences of postoperative cheek biting. The use of intraoral infiltration local anesthesia for complete dental rehabilitation under general anesthesia for children aged 3-5.5 years did not result in improved pain behaviors in the postanesthesia care unit (PACU), nor did it result in improved pain behaviors 4-6 hours postoperatively as measured by the FLACC scale, FACES scale, and subjective reports of parents or a PACU nurse. Those children receiving local anesthesia had a higher incidence of negative symptoms related to local anesthetic administration, including a higher incidence of lip and cheek biting, which was of clinical importance, but not statistically significant. Infiltration of local anesthetic for dental rehabilitation under general anesthesia did not improve quality of recovery in children aged 3-5.5 years.

The diagnostic value of oral lacerations and incontinence during convulsive "seizures".

PURPOSE: Oral lacerations and urinary incontinence have long been considered useful clinical features for the diagnosis of epileptic seizures; however, both are also reported in patients with psychogenic nonepileptic seizures (PNES). The aims of the study were (1) to investigate whether the presence and nature of oral lacerations or incontinence during convulsive seizures of patients with epilepsy differed from those with PNES, and (2) whether the side of the oral laceration has any correlation with the epilepsy syndrome or lateralization. METHODS: Eighty-four consecutive patients who experienced at least one convulsive event during video-EEG monitoring (VEM) were questioned and examined for oral lacerations and incontinence. Seizure classification was determined by a team of epileptologists based on the VEM findings and other clinical and investigational data, blinded to the oral laceration and incontinence information. RESULTS: The presence of oral lacerations among patients with epileptic seizures was 26% (17/66), in contrast it was 0% (0/18) with PNES (p = 0.01). Of the oral lacerations sustained by patients during an epileptic seizure, 14 were to the side of the tongue, one to the tip of the tongue, two to the cheek, and three to the lip. No significant relationships were observed between seizure lateralization and oral lacerations. Incontinence occurred in 23% (15/66) of epilepsy patients and 6% (1/18) of PNES patients (p = 0.09). There was no relationship between epilepsy type or lateralization and the prevalence of incontinence. CONCLUSIONS: Despite frequent reports of oral lacerations and incontinence by patients with PNES, objective evidence for this is highly specific to convulsive epileptic seizures.

Violent Parasomnia With Recurrent Biting and Surgical Interventions: Case Report and Differential Diagnosis.

ABSTRACT: A case is reported of recurrent, injurious self-biting during sleep, requiring surgical interventions, in a 55-year-old obese man with a 20-year history of violent complex parasomnia, with greatly increased frequency and severity of episodes induced by work stress during the preceding 3 years. After clinical evaluation and overnight, hospital-based video-polysomnography, the cause of the chronic injurious parasomnia was deemed to be a non-rapid eye movement (NREM) sleep parasomnia comorbid with severe obstructive sleep apnea. Therapy with bedtime clonazepam and bilevel positive airway pressure was effective, with injurious parasomnia relapse occurring with cessation of either or both of these therapies. The differential diagnosis of sleep-related biting should now include NREM sleep parasomnia (with or without comorbid obstructive sleep apnea), besides previously reported cases of REM sleep behavior disorder (RBD), sleep-related dissociative disorder, sleep-related rhythmic movement disorder and anticipated cases of parasomnia overlap disorder (RBD + NREM sleep parasomnia), sleep-related biting seizures, and sleep-related eating disorder.

The human bite injury: a clinical audit and discussion regarding the management of this alcohol fuelled phenomenon.

BACKGROUND: Human bite injuries are both deceptive and challenging in their presentation and management. They remain a frequent presentation to our unit, most often following late night alcohol fuelled aggression. AIMS: To audit the management of these wounds, with particular focus on infective complications and outcomes. METHODS: A three year retrospective chart review was undertaken on all patients referred to the plastic surgery unit from 1 January 2003 through to 31 December 2005. RESULTS: A total of 92 patients with 96 human bite wounds were identified. The majority were male (92%). Alcohol consumption was documented in 86% of cases. The majority (70%) occurred over the weekend or on a public holiday. Facial injuries made up 70% of injuries with the remainder being to the upper limb. The ear was the most common target of all facial injuries (65%). Infection was documented in 18 cases (20%), with bite injuries to the upper limb and those presenting late (>12 h) having a higher incidence of infection. CONCLUSIONS: Human bite wounds present a challenge to any emergency department, given the many issues involved in their management. Underestimation of the complexity and potential sequelae of these wounds will result in a suboptimal outcome for the patient.

Severe tongue injury in an adolescent with epilepsy: a case report.

Epilepsy and other neurological disorders can have profound social, physical and psychological consequences, especially when they begin in childhood. Moreover, seizure episodes may cause fractures, burns, head injuries and oral injuries. This report presents a case history of an adolescent with a severe tongue injury related to epileptic seizures and outlines the proposed treatment, which included use of a maxillary silicone bite guard that allowed healing of the tongue injury within a few months.

Primary reconstruction of major human bite wounds of the face.

Primary reconstruction of 36 major human bite wounds of the face without clinical infection has been carried out successfully as late as the fourth day after the initial injury. Primary healing was achieved in all patients. The postoperative period was free from major infection in all patients except one, including the latecomers. Extensive bacteriologic studies reveal that the infection in human bite wounds occurs secondarily as invasion to devitalized tissue. We therefore consider that debridement of wound edges to eliminate the crushed devitalized tissue is the key to success.

Comparative review of bitemark cases from Pretoria, South Africa.

Bitemark evidence has become more scientifically based and is currently widely accepted in the legal process. Bitemarks can be inflicted by humans or animals on humans, animals and a variety of inanimate objects and can be found on any part of the body, with their quality and appearance being influenced by a variety of factors. The purpose of this study was to record the experiences with bitemark cases presented to forensic odontologists at the University of Pretoria from 1983-1993 and to compare them with trends and findings elsewhere. Sixteen cases are presented, of which 14 were bitemarks inflicted by humans and two by dogs. Thirteen cases occurred in human tissues, three in inanimate objects. Of the bitemarks in human skin, most were present on the arms, followed by the face, thorax and back. Bitemarks over the entire body were seen in the two victims bitten by dogs. The male:female ratio was 4:1 and in 46% of cases single marks were present while the rest were multiple. Eight of the victims had been assaulted. Two cases were associated with sexual behaviour (rape), two were inflicted by dogs, and the circumstances surrounding one case were unknown. A variety of factors complicated the investigations. The major factors responsible for disqualifying bitemarks as evidence included mutilation, removal of tissues, inexperience of officials involved and multiple bitemarks. The results of the study confirm the importance of bitemarks as forensic evidence. Humans are the primary victims with the arm being the anatomical site most often involved. Inexperience on the part of the investigating officers and other officials in the handling of these cases strongly emphasises the need for proper training and education of these personnel.

Self-inflicted bite injuries associated with intracerebral haemorrhages.

A case of self-inflicted bite injuries of the fingers with an episode of small intracerebral haemorrhages is presented. There were many injuries on the right fingers. The tip of the right forefinger was bitten off, and some small pieces of the finger had been aspirated and swallowed. This unusual case seemed to be an emotional response to pain from cerebral episode.

Lip biting in a patient with Chiari type II malformation: case report.

Self mutilation of lips and tongue is considered a common type of Self-Injurious Behavior (SIB). Treatment of SIB in the form of Lip-Biting in developmentally disabled individuals has been the focus of several related reports using different oral appliances preventing or inhibiting the SIB. In this paper we report a case of SIB in the form of Lip-Biting on an infant with Chiari Type II Malformation which was treated with a Lip-bumper. The Lip-bumper demonstrated to be a viable option in treating transient and acute episodes of SIB involving the lower lip and buccal mucosa.

Two faces of nocturnal tongue biting.

Tongue biting associated with tonic/clonic movements of the limbs is common in epileptic patients, however nocturnal tongue biting as the only manifestation of epilepsy is rare. It can be found in frontal lobe epilepsy. Two cases with the same manifestation of nocturnal tongue biting were presented. One was the result of parasomnias-rhythmic movement disorders (RMD) and the other was a result of nocturnal frontal lobe epilepsy. The definite diagnosis of these abnormal nocturnal events was documented by prolonged EEG monitoring and polysomnography with simultaneous video studies. To our knowledge, RMD presenting with nocturnal tongue biting has never been reported in Thailand. Even in the foreign journals it has rarely been reported. It is crucial to make a definite diagnosis of RMD and nocturnal epilepsy to avoid overtreatment in the former and undertreatment in the latter. Symptomatology, diagnostic approach with therapy of these disorders were reviewed.