Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior?

BACKGROUND: Paracetamol formulations provide effective analgesia after surgery [Duggan ST, Scott LJ. Intravenous paracetamol (acetominophen). Drugs 2009; 69: 101-13; Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008: CD004602]. I.V. paracetamol is superior to oral for pain rescue (Jarde O, Boccard E. Parenteral versus oral route increases paracetamol efficacy. Clin Drug Invest 1997; 14: 474-81). By randomized, double-blinded trial, we aimed to determine whether preoperative oral paracetamol provides inferior postoperative analgesia to preoperative i.v. paracetamol. METHODS: One hundred and thirty participants received either oral paracetamol and i.v. placebo (Group OP), or oral placebo and i.v. paracetamol (Perfalgan™) (Group IP). Oral preparations were given at least 45 min before surgery; i.v. preparations after induction of anaesthesia. Pain was assessed by a 100 mm visual analogue scale (VAS) 1 h from the end of surgery. Rescue analgesia was given on request. RESULTS: A total of 128 patients completed the study. There were no significant differences in baseline characteristics or intraoperative variables between the groups. The study was designed to reveal whether OP is inferior to IP, with an inferiority margin of 20%. The number of patients reporting satisfactory analgesia at 1 h with VAS ≤ 30 mm were 15 (OP) and 17 (IP), respectively. The secondary outcome measure of the mean (standard deviation) VAS (mm) for the whole of each group was 52 (22) for OP and 47 (22) for IP. Analysis of confidence intervals indicates that oral paracetamol is not inferior to i.v. paracetamol. The median survival (90% CI) to rescue analgesia request was 54.3 (51.2-57.4) min in Group OP and 57.3 (55.4-59.2) min in Group IP; there was no significant difference in this measure. CONCLUSIONS: In this study of lower third molar extraction, oral paracetamol is not inferior to i.v. for postoperative analgesia. ISRCTN Registration http://www.controlled-trials.com/ISRCTN77607163.

Football-related maxillofacial injuries.

Maxillofacial injuries sustained playing sports are becoming increasingly common, and in the UK where football is the most popular team sport, associated maxillofacial injuries are a regular occurrence. This study retrospectively examined data on patients who were referred with facial injuries sustained playing football between 2007 and 2019 (n = 265). Demographics, mechanism of injury, diagnosis, and treatment received were analysed. The mean (SD) age was 25 (11.0) years (range 3-85) and there was a strong male predominance (n = 256, 97% male). Facial fractures were diagnosed in 143 (54%) patients. The most common injury was a midface fracture and the most common mechanism of injury was a clash of heads. Patients with a facial fracture were significantly more likely to have sustained a concurrent head injury (p = 0.006). Those who were elbowed or punched were significantly more likely to have a facial fracture than a soft tissue or dentoalveolar injury (p ≤ 0.05). Players who clashed heads were significantly more likely to have a midface fracture (p ≤ 0.001). In conclusion, football-related maxillofacial injuries predominantly affect young adult males following a clash of heads. An elbow or punch to the face carries a significant risk of facial fracture and concurrent head injury. Therefore, to reduce the percentage of maxillofacial injuries seen in this sport, observed intentional contact between players, using an elbow or fist to the face in particular, must continue to carry the highest sanction.

Neutrophil to lymphocyte ratio as a prognostic marker of deep neck space infections secondary to odontogenic infection.

Neutrophil to lymphocyte ratio (NLR) is a marker of infection and is used as a prognostic marker for cancer and cardiovascular disease. There is little application of NLR as a biomarker for odontogenic infection. C-reactive protein (CRP) is a commonly used marker for odontogenic infection that correlates with length of stay (LOS). The aim of this study was to assess the clinical utility of NLR as a prognostic marker of deep neck space infections secondary to odontogenic infection and to analyse its correlation with admission CRP and LOS. Data from January 2019 to December 2019 were retrospectively examined for patients admitted with a deep neck space infection of odontogenic cause. Data on admission CRP, NLR, sex, age, site of infection, LOS, treatment, ICU admission, and presence of comorbidities were analysed. A total of 161 patients were included, 89 (52.7%) of whom were male, and 72 (42.6%) female. Mean (SD) age was 38.4 (16.8) years (range: 5-86 years). Mean (SD) admission CRP and NLR were 105.9 (93.1) mg/L and 7.5 (7.7). Mean (SD) LOS was 2.9 (3.2) days (range: 0.5-35 days). Both admission CRP (p≤0.01) and admission NLR (p≤0.01). were significantly associated with LOS. Receiver operating characteristics analysis for LOS≥2 days produced an area under the curve for CRP and NLR of 0.666 and 0.639. The optimum cut-off value of NLR for LOS≥2 days was 4.65. In conclusion, NLR can be used as a prognostic marker for patients admitted with deep neck space infection secondary to odontogenic infection. Patients with NLR≥4.65 are likely to require LOS≥2 days.

Verruciform Xanthoma of the Oral Mucosa: A Series of Eight Typical and Three Anomalous Cases.

In this series, there are 8 typical verruciform xanthomas of the oral mucosa and 3 anomalies, 1 polypoid, 1 florid, and 1 carcinomatous. All were characterized by infiltrates of CD68-positive xanthomatous histiocytes in the lamina propria. The 11 patients comprised 6 men and 5 women (mean age = 54.5 years, range = 40-69). Both keratinized and nonkeratinized sites were affected. A history of lichenoid inflammation was recorded in 5 patients. The polypoid xanthoma presented in a woman aged 54 years as a polyp of the labial commissure. The florid lesion affected the dorsum of the tongue of a man aged 54 years and at 20 mm was the largest of the 11 lesions, but the only one with candidal infection. The squamous cell carcinoma manifested as a papilloverrucous hyperkeratosis of the palatal gingiva in a man aged 69 years. The latter 2 (and 1 "typical" verruciform xanthoma) required re-excision, but none has since recurred.

"Run-through" training at specialist training year 1 and uncoupled core surgical training for oral and maxillofacial surgery in the United Kingdom: a snapshot survey.

Training in oral and maxillofacial surgery (OMFS) in the UK has undergone considerable changes during the last 10years, and "core" surgical training has replaced "basic" surgical training. In 2014 a pilot "run-through" training programme from specialist training year one (ST1)-ST7 was introduced to facilitate early entry into the speciality. Run-through training guarantees that a trainee, after a single competitive selection process and satisfactory progress, will be given training that covers the entire curriculum of the speciality, whereas uncoupled training requires a second stage of competitive recruitment after the first one (for OMFS only) or two years of "core" training to progress to higher specialty training. The first two years of run-through training (ST1-ST2) are the same as for core surgical training. Dual-qualified maxillofacial aspirants and those in their second degree course are curious to know whether they should go for the uncoupled core surgical training or the run-through programme in OMFS. The General Medical Council (GMC) has now agreed that run-through training can be rolled out nationally in OMFS. To assess the two pathways we used an online questionnaire to gain feedback about the experience from all OMFS ST3 and run-through trainees (ST3/ST4) in 2016-2017. We identified and contacted 21 trainees, and 17 responded, including seven run-through trainees. Eleven, including five of the run-through trainees, recommended the run-through training programme in OMFS. Six of the seven run-through trainees had studied dentistry first. The overall mean quality of training was rated as 5.5 on a scale 0-10 by the 17 respondents. This survey gives valuable feedback from the current higher surgical trainees in OMFS, which will be useful to the GMC, Health Education England, OMFS Specialist Advisory Committee, and those seeking to enter higher surgical training in OMFS.

The composite radial forearm free flap: an anatomical guide to harvesting the radius.

We made an anatomical study of 100 dried cadaveric radii to establish the dimensions of the maximum possible safe harvest of bone for the composite radial forearm flap and how this may be assessed during the operation. We found that the diameter of the radius from its medial to lateral border is consistently 1-3mm less than 40% of the measured minimum circumference of the radius.

Reinventing the wheel: a modern perspective on the bilateral inverted 'L' osteotomy.

The bird-face deformity of a severe class II, high Frankfort-mandibular plane angle with significant retrogenia, often associated with diminutive condyles and reduced posterior face height, poses many challenges to the orthognathic surgeon. Of greatest concern in these patients is the degree of mandibular advancement required and the potential for relapse. The sagittal split osteotomy is the workhorse of mandibular surgery but does not allow significant lengthening of the ramus, which is desirable in this group of patients. An inverted 'L' osteotomy of the mandible to facilitate ramus lengthening is therefore indicated in the management of this group, but is a procedure that has largely fallen out of favour due to the need for an extraoral approach and intermaxillary fixation. The advent of distraction osteogenesis promised to be the answer for these cases, but with nearly 20 years of experience with these techniques, it is clear that it does not represent the panacea that was hoped for. We present a series of four cases of bimaxillary surgery consisting of maxillary osteotomy and bilateral inverted 'L' osteotomy of the mandible carried out via an intraoral approach (average advancement 10.5mm), where internal semi-rigid fixation was employed to obviate the need for intermaxillary fixation. We highlight the indications for this procedure and why it is ideally suited to this group of patients and argue that the procedure should be re-introduced to the armamentarium of the orthognathic surgeon.

The effects of bone morphogenetic protein-2, -4, and -6 on differentiation of rat osteoblast cells in vitro.

The effects of bone morphogenetic protein-2 (BMP-2), -4, and -6 were tested on the differentiation of rat osteoprogenitor cells using a bone nodule-forming assay system, and the kinetics of their actions were investigated by double labeling for alkaline phosphatase (ALP) and bromodeoxyuridine (BrdU) uptake in log phase cultures. All BMPs stimulated bone nodule formation, with an optimal concentration of 25 ng/ml resulting in nodule numbers of approximately 250% of controls using BMP-4 and -6. BMP-2 showed reduced potency compared to either BMP-4 or -6. No evidence of chondrocytic differentiation was found in any of the cultures. The effect of BMPs on nodule formation was seen after only 24 h of exposure to BMPs, but only affected nodule numbers when added to early cultures. Nodule size and number of cells per nodule were increased with BMP6 only. Continuous or 24-h exposure to BMP-2 or -4 increased the number of postmitotic ALP-positive cells in log phase cultures, whereas BMP-6 increased the number of postmitotic ALP-negative cells. The results demonstrate that BMP-6, like other BMPs, can stimulate osteoblast differentiation independent of any chondrogenic effects and suggest that an early osteoprogenitor cell is an important target cell for the action of BMPs during bone induction. Overall, BMP-2 and -4 showed differences in potency in the assay systems used, but had qualitatively similar effects. In contrast, the qualitative differences found with BMP-6 suggest that BMP-6 may be acting principally on an early stage osteoprogenitor cell.

Hemimandibulectomy and vascularized fibula flap in bisphosphonate-induced mandibular osteonecrosis with polycythaemia rubra vera.

This report presents the successful management of an advanced and refractory bisphosphonate-related osteonecrosis of the jaws (BRONJ) by hemimandibulectomy and an osteocutaneous fibula flap reconstruction in a patient with polycythaemia rubra vera, a rare haematological condition in which there is increased risk of thrombosis and haemorrhage. Union of the vascularized bone with the mandible depends on obtaining a BRONJ-free margin and rigid fixation of the bony ends. Magnetic resonance imaging can provide accurate delineation of necrotic bone and area of osteomyelitis. Placement of a 1cm margin beyond this can envisage a BRONJ-free margin. Aggressive medical management of polycythaemia rubra vera by venesection, asprin and cytoreduction therapy along with anticoagulant prophylaxis against thromboembolic events in the first 2 weeks following major surgery can provide the basis of a good surgical and flap outcome. Nevertheless, the possibility of unpredictable haemorrhage must be considered throughout.

Navigation-assisted localisation and resection of subclinical metastatic malignant melanoma of unknown primary based on 18-fluorodeoxyglcose positron emission tomography computed tomography fusion imaging.

A technical application using a stereotactic navigation system with fusion images of [18F]-2-fluorodeoxyglucose (FDG) positron tomography and computed tomography (PET-CT) in the case of a metastatic melanoma of unknown primary site is described. A 50-year-old woman presented with a slow, growing level V neck lump which was cytologically proved to be a metastatic melanoma despite the absence of prior or existing history of skin malignancy. Whilst detailed physical examination failed to yield the site of the primary lesion, full body FDG-PET images isolated FDG-avid subclinical scalp lesions. Fused PET-CT data provided the navigation system with accurate localisation of the subclinical metastatic lesion. Histopathological examination of the navigation-guided resection specimen confirmed that the lesion was excised with acceptable margins. This case illustrates the feasibility of navigation-assisted resection of a subclinical malignant melanoma lesion and may have a role to play in the management of the melanoma of unknown primary.

Stereotactic navigation in oral and maxillofacial surgery.

Navigation is an adjunct to existing surgical procedures. It is potentially useful in any procedure where it is possible to make a three-dimensional surgical plan from computed tomography (CT) or magnetic resonance imaging (MRI) data, but is not easy to translate this plan into surgical reality because of absolute limitations of access or lack of anatomical landmarks. For navigational surgery to be successful it is essential to have a sound understanding of its limitations in terms of intraoperative changes in tissue position, and how the registration process works, to achieve optimum surgical accuracy with minimal impact on time. In maxillofacial surgery one of the best examples of the benefit of navigation is in the field of secondary orbital reconstruction. As with many areas of surgery careful attention to planning will yield good results.

The mesioangular third molar--to extract or not to extract? Analysis of 776 consecutive third molars.

Introduction Distal caries in lower second molars has been associated with mesioangular third molars. Caries detection and restoration can be difficult. If caries progresses, root canal treatment or extraction of the second molar can be necessary.Aims To identify the prevalence of caries in lower third molars and the distal aspect of corresponding lower second molars in patients referred for lower third molar assessment.Methods Analysis of OPG X-rays for 420 consecutive patients (776 third molars) referred to three maxillofacial centres over a five month period.Results Thirty-four percent of third molars were mesioangular. There was radiographic evidence of distal second molar caries in 42% of these. When unerupted mesioangular third molars were excluded this increased to 54%. There was no difference in age or dental health of these patients compared to the whole group. There was no angulation of the mesioangular third molar for which distal caries in the second molar was more likely.Conclusion Distal caries in lower second molars related to a mesioangular third molar is a common finding in oral and maxillofacial patients in secondary care, especially if the third molar is fully or partially erupted. If such a third molar is left in situ, close monitoring and regular bitewing radiographs are recommended.

Preoperative planning for DIEP breast reconstruction: early experience of the use of computerised tomography angiography with VoNavix 3D software for perforator navigation.

The deep inferior epigastric perforator (DIEP) flap is normally the first choice in breast reconstruction; however, due to the considerable vascular anatomical variation and the learning curve for the procedure, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps are still frequently performed to reduce the rate of complications. Accurate preoperative investigation of the perforators would allow better operative preparation and possibly shorten the learning curve. In an effort to increase accuracy of preoperative planning and to aid preoperative decision-making in free abdominal flap breast reconstruction, we have acquired the use of VoNavix, software that creates three dimensional images from computerised tomography angiography (CTA) data. The use of the VoNavix software for analysis of CTA provides superior imaging that can be viewed in theatre. It, together with CTA, enables decisions to be made preoperatively, including: which side to raise the flap; whether to aim for a medial or lateral row perforator; whether to take a segment of muscle and whether to expect an easy or difficult dissection. We have now performed over 60 free abdominal flap breast reconstructions aided with CTA, and 10 of these cases also used VoNavix technology. This paper presents our initial experience with the use of this software, illustrated with three patient examples. The advantages and disadvantages are discussed.

The unhappy fat woman.

Obesity is a psychosomatic illness; treating the emotional illness first gives a much better chance of success in weight reduction. In this study, older, fatter, calmer and happier, more realistic patients with fewer associated illnesses did best of all (37 lb. weight loss).