The influence of deep (odontogenic) pain intensity, quality, and duration on the incidence and characteristics of referred orofacial pain.

This study examined the effects of the intensity, quality, and duration of odotogenic pain on the incidence, pattern, and clinical characteristics of pain referral in the orofacial region. Four hundred consecutive patients reporting with posterior toothache to the dental emergency clinic were included. Patients completed a standardized clinical questionnaire consisting of a numerical rating scale for pain intensity and chose verbal descriptors from a list of adjectives describing the quality of their pain. In addition, patients indicated sites to which pain referred by drawing on a mannequin* of the head and neck. Pain intensity was found to significantly affect the presence of referred pain (P < .005). However, neither duration nor quality of pain influenced the incidence of referred pain. Finally, pain referral occurred in vertical laminations as indicated on mannequin drawings, but these were not found to be diagnostic because of extensive horizontal overlap. The association of intensity and referral is attributed to central nervous system hyperexitability causing expansion of receptive fields and spread and referral of pain.

Comparison of psychologic and physiologic functioning between patients with masticatory muscle pain and matched controls.

This study explored the physiologic and psychologic distinctions between masticatory muscle pain patients and age and sex-matched normal controls. Subjects completed several standardized psychologic tests. They then underwent a laboratory stress profile evaluation to obtain physiologic measures (EMG, heart rate, systolic and diastolic blood pressure) under conditions of rest, mental stress, and relaxation. The pain patients reported greater anxiety, especially cognitive symptoms, and feelings of muscle tension than did the controls. Under stress, pain patients had higher heart rates and systolic blood pressure than the controls. Electromyogram activity in the masseter regions was not significantly different between the pain and control group. The results are discussed in terms of the likely mechanisms that might account for the observed differences between masticatory pain patients and normal subjects.

Salivary cortisol response to dental treatment of varying stress.

The physiologic stress of various dental procedures (dental examination, dental prophylaxis, restoration, root canal therapy, and tooth extraction) was measured in 50 nonsmoking healthy men between the ages of 18 and 55 years (mean 34.6 years, range 21 to 53 years) with a salivary cortisol assay. Expectorated saliva was collected at four time points: 10 minutes before the start of the procedure, 15 minutes after the patient was seated, at the end of the procedure, and 1 hour after the completion of the procedure. Of the 196 samples included for analysis, mean cortisol values ranged from 0.1 to 3.8 micrograms/dl with a recovery of 100% +/- 8.4%. The mean cortisol value for the extraction group (1.09 +/- 0.42 microgram/dl) was significantly different (p < 0.05) from the mean values of the examination (0.46 +/- 0.10 microgram/dl), prophylaxis (0.64 +/- 0.64 microgram/dl), root canal (0.49 +/- 0.07 microgram/dl), and restorative (0.60 +/- 0.04 microgram/dl) groups as determined by the Duncan's multiple range test. Cortisol levels decreased from the initial reading to the end of the procedure by about 15% for patients undergoing an examination, root canal, and restorative procedure. Cortisol levels at the end of the procedure were elevated in the prophylaxis (55%) and extraction (148%) groups compared with the baseline cortisol recording. A minority of patients in the prophylaxis group had elevated cortisol levels throughout dental treatment, whereas cortisol levels were elevated during treatment in 80% of patients undergoing extraction. These data suggest that the adrenal stress response associated with tooth extraction(s) is greater than that associated with other routine dental procedures.

Need and Demand for Oral Medicine Services in 1996. A report prepared by the Subcommittee on Need and Demand for Oral Medicine Services, a subcommittee of the Specialty Recognition Committee, American Academy of Oral Medicine.

The need and demand for oral medicine services in the United States and Canada was determined by a prospective survey of American Academy of Oral Medicine practitioners who attended the Academy's 1996 annual meeting. Of the 50 surveys returned from 149 eligible registrants, it was determined that, on the average, oral medicine practitioner respondents practiced 2.3 days per week and treated 8.7 patients per day; this amounts to more than 40,000 patient-care visits per year. Almost 90% of patients were treated because of medically compromising conditions, oral mucocutaneous disease, or chronic orofacial pain. Most of the care (52%) was provided in non-university settings. Most treatment involved the comprehensive evaluation of complex oral problems (36.7%), the prescription of medications (24.2%), or comprehensive dental treatment (21.8%) for patients with severe and life-threatening medical conditions. These results suggest that oral medicine services are needed and that demand for these services is high.

An evaluation of the clinical laboratory as an adjunct to dental practice.

A study was completed at the University of Kentucky College of Dentistry in which 172 randomly selected adult dental patients were subjected to a battery of laboratory screening tests as a part of the initial examination procedure. The tests performed included rapid plasma reagin test, complete blood cell count, and determinations of serum glucose, blood urea nitrogen, and serum cholesterol values. Nearly 17% of the patients had at least one abnormal laboratory value. Thirty-three percent of the values were so abnormal that the patients required medical care. For the total group, the rate of detection of previously undiagnosed medical problems was 6.9%. Elevated serum glucose values were found most frequently.

Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem.

BACKGROUND: Dental patients with primary or secondary adrenal insufficiency, or AI, may be at risk of experiencing adrenal crisis during or after invasive procedures. Since the mid-1950s, supplemental steroids in rather large doses have been recommended for patients with AI to prevent adrenal crisis. METHODS: To evaluate the need for supplemental steroids in these patients, the authors searched the literature from 1966 to 2000 using MEDLINE and textbooks for information that addressed AI and adrenal crisis in dentistry. Reference lists of relevant publications and review articles also were examined for information about the topic. RESULTS: The review identified only four reports of purported adrenal crisis in dentistry. Factors associated with the risk of adrenal crisis included the magnitude of surgery, the use of general anesthetics, the health status and stability of the patient, and the degree of pain control. CONCLUSIONS: The limited number of reported cases strongly suggests that adrenal crisis is a rare event in dentistry, especially for patients with secondary AI, and most routine dental procedures can be performed without glucocorticoid supplementation. CLINICAL IMPLICATIONS: The authors identify risk conditions for adrenal crisis and suggest new guidelines to prevent this problem in dental patients with AI.

Prevalence of infective endocarditis in patients with systemic lupus erythematosus.

BACKGROUND: Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions. These lesions may place patients with SLE at risk of developing infective endocarditis, or IE. METHODS: The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE. They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE. RESULTS: Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed. Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made. CONCLUSIONS: The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance. Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures. However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE. CLINICAL IMPLICATIONS: Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown. Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.

Nonodontogenic toothache.

Toothache is a common complaint in the dental office. Most toothaches have their origin in the pulpal tissues or periodontal structures. These odontogenic pains are managed well and predictably by dental therapies. Nonodontogenic toothaches are often difficult to identify and can challenge the diagnostic ability of the clinician. The most important step toward proper management of toothache is to consider that the pain may not be of dental origin. Signs and symptoms suggestive of nonodontogenic toothache are as follows: 1. Inadequate local dental cause for the pain. 2. Stimulating, burning, nonpulsatile toothaches. 3. Constant, unremitting, nonvariable toothaches. 4. Persistent, recurrent toothaches over months or years. 5. Spontaneous multiple toothaches. 6. Local anesthetic blocking of the suspected tooth does not eliminate the pain. 7. Failure to respond to reasonable dental therapy of the tooth.

Therapeutic considerations in special patients.

Careful attention to patients' histories and their medical problems and consultation with their physicians should provide sound bases for selection of drugs. Antibiotic prophylaxis for patients with cardiovascular disorders is described for American Heart Association standards, but for other indications sound judgment based on the principles of antibiotic prophylaxis must be the rule. Patients with end-stage renal disease and severe liver impairment may be at risk with certain drugs. The most critical time for consideration of use of drugs during pregnancy is the first trimester. However, careful selection of drugs for use during the balance of the term can reduce the risk of harm to the mother and fetus.

Physical evaluation of the dental patient: current practices and opinions.

A survey of 560 graduates of the University of Kentucky College of Dentistry was performed to document the current methods of physical evaluation used by a group of practicing dentists and to sample their opinions about potential additions to the dental curriculum in physical evaluation, as advocated by the Council on Dental Education. The questionnaire was completed and returned by 59 percent of the practitioners. The results indicated that physical evaluation of dental patients was done primarily by using the medical history. Examination of blood pressure, other vital signs, and the head and neck were done infrequently. The clinical laboratory was reportedly utilized frequently. The respondents' attitudes were ones of general support for increasing the emphasis on physical evaluation in dentistry, but with varying opinions about appropriateness.

Effect of age on the digit blood flow response to sedative concentrations of nitrous oxide.

Twenty healthy male subjects [11 young, x̄ = 25.4 ± 0.8 (SEM) years old; 9 elderly, x̄ = 64.5 ± 0.7 years] volunteered for a study designed to investigate the effect of age on several cardiovascular parameters to inhaled N(2)O-O(2). The protocol was designed to mimic the administration of N(2)O-O(2) for sedation in the dental office, although no dental treatment was performed. Clinical criteria were used to judge the appropriate sedative level for each subject; no attempt was made to establish doseresponse relationships. Digit blood flow was measured by strain-gauge plethysmography, and heart rate, arterial blood pressure, respiratory rate, and skin temperature were monitored and recorded. N(2)O and CO(2) levels were monitored in end-tidal gas samples by gas chromatography; machine gauge readings were calibrated against known gas mixtures by the same technique.Under the conditions of this experiment both healthy young and healthy elderly subjects experienced a marked (200-300%) increase in digit blood flow during N(2)O inhalation, compared to that during air and 100% O(2) inhalation. There was no significant difference in the degree of flow increase between young and elderly subjects. Also, there were no significant differences in the response of these healthy young and healthy elderly subjects to sedative concentrations of N(2)O with regard to heart rate, arterial blood pressure, respiratory rate, skin temperature, or mean end-tidal CO(2) levels. The data indicate that N(2)O, in the concentrations routinely administered in the dental office for sedation, does not have a differential effect on the measured parameters in healthy elderly and healthy young males.

The effect of nitrous oxide and age on psychological and psychomotor performance.

Healthy older and younger males were compared on several psychomotor and cognitive measures before, during, and after N(2)O inhalation. Age did not appear to be a significant factor in determining response to N(2)O though on several measures younger subjects are superior to older under all conditions. N(2)O had a significant effect only on reaction time and facial recognition tasks. The relation of these findings to previous work is discussed.

The effects of nitrous oxide administration in the healthy elderly: N2O elimination and alveolar CO2.

Healthy young and elderly males were administered sedative concentrations of nitrous oxide/oxygen (N(2)O/O(2)) under a protocol designed to mimic that used in a dental operatory. Samples of end-tidal expired gas were taken at the end of 30-minutes inhalation of, and periodically for 70 minutes after withdrawal from, nitrous oxide/oxygen. Samples were analyzed to monitor the decline of alveolar nitrous oxide levels and any changes in alveolar carbon dioxide levels, to determine if there were any age-related differences. The fall in alveolar N(2)O following cessation of administration was rapid, and in a double-exponental manner as was expected. No age-related difference in N(2)O decline was observed. Alveolar carbon dioxide (CO(2)) levels were lower and more variable in the elderly group. Both groups exhibited elevated CO(2) levels at the end of the N(2)O period, and an unexplained rise in CO(2) at approximately 30 min post N(2)O.

Bacterial endocarditis. Survey of patients treated between 1963 and 1975.

Hospital records of forty-nine patients with a diagnosis of bacterial endocarditis at the University of Kentucky Medical Center Hospital from 1963 to 1975 were reviewed. Data collected and statistically analyzed resulted in the following conclusions: 1. Bacterial endocarditis affected males three to four times as often as females. 2. Morbidity was significant, with an average hospital stay of 4 weeks. 3. The mortality rate among the entire group of patients was 42.8 per cent. A significantly higher rate of 66.7 per cent was noted in patients with prosthetic heart valves. 4. The most prevalent predisposing factor was rheumatic heart disease. 5. There were five cases (10.2 per cent) in which dental procedures were the probable precipitating cause, once again pointing out the importance of detecting susceptible patients and proceeding with dental therapy only after adequate prophylactic measures. 6. The most frequently isolated microorganism was Staphylococcus aureus. 7. Chloramphenicol was the most effective in vitro antiboitic tested, with erythromycin a close second. Although it might appear that penicillin was not as effective, the concentration in actual usage may differ significantly from that in the tested discs. Penicillin, therefore, still remains the foundation for treatment in susceptible cases.

Disseminated intravascular coagulation and fibrinolysis as a cause of postextraction hemorrhage. Report of a case.

Presented is a case in which severe, prolonged hemorrhage, subsequent to simple dental extractions in an 85-year-old Negro man, was due to disseminated intravascular coagulation, with secondary fibrinolysis resulting from metastatic adenocarcinoma of the prostate gland. The difficulty and delay in diagnosis, selection of proper therapeutic regimen, and complications encountered during treatment are discussed.

Modified overdentures for the management of oligodontia and developmental defects.

A technique for the construction of complete dentures over unaltered natural teeth has been described and illustrated for three different situations. The procedure is straightforward and simple and varies only slightly from conventional overdenture construction. The technique offers several advantages for a patient who wishes to keep the remaining natural teeth unaltered but who requires significant functional or esthetic improvement. Since the teeth are unaltered, any type of future treatment may be considered at any time without being compromised. This is an important factor to consider for the young patient. The cost, when compared to the fabrication of a fixed or cast removable prosthesis, is significantly less, while still providing acceptable esthetics and function. The versatility of this procedure allows its use in a number of situations which are not amenable to more complicated treatment methods.